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Fortis B, Bell L. Pro Publica. September 12, 2023.
Rockville, MD: Agency for Healthcare Quality and Research; August 22, 2023.
West S. KFF Health News. August 24, 2023.
Desjardins L. PBS NewsHour. August 29, 2023.
A 31-year-old pregnant patient with type 1 diabetes on an insulin pump was hospitalized for euglycemic diabetic ketoacidosis (DKA). She was treated for dehydration and vomiting, but not aggressively enough, and her metabolic acidosis worsened over several days. The primary team hesitated to prescribe medications safe in pregnancy and delayed reaching out to the Maternal Fetal Medicine (MFM) consultant, who made recommendations but did not ensure that the primary team received and understood the information.
This case describes a 27-year-old primigravid woman who requested neuraxial anesthesia during induction of labor. The anesthesia care provider, who was sleep deprived near the end of a 48-hour call shift (during which they only slept for 3 hours), performed the procedure successfully but injected an analgesic drug that was not appropriate for this indication. As a result, the patient suffered slower onset of analgesia and significant pruritis, and required more prolonged monitoring, than if she had received the correct medication.
Kwon S. KFF Health News. August 8, 2023
Rockville, MD: Agency for Healthcare Research and Quality; July 2023.
Burton S. New York Times and Serial Productions. June 30-July 27, 2023.
Simmons-Duffin S. Health Shots. National Public Radio. July 20, 2023.
Board on Health Care Services, National Academies of Science, Engineering, and Medicine. Arnold and Mabel Beckman Center, Irvine, CA. July 27, 2023.