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Melissa S. Wong, MD; Angelica Vivero, MD; Ellen B. Klapper, MD; and Kimberly D. Gregory, MD, MPH; July 2019
First admitted to the hospital at 25 weeks of pregnancy for vaginal bleeding, a woman (G5 P2 A2) received 4 units of packed red blood cells and 2 doses of iron injections. She was discharged after 3 days with an improved hemoglobin level. At 35 weeks, she was admitted for an elective cesarean delivery. Intraoperatively, an upper uterine segment incision was made and the newborn was delivered in good condition. Immediately after, a subtotal hysterectomy was performed. The anesthesiologist noted that the patient was hypotensive; blood was transfused. A rash developed surrounding the transfusion site and widespread ecchymosis appeared as she became more unstable. Although physicians attempted to stabilize her with fluids and medications and cardiopulmonary resuscitation was performed for 60 minutes, the patient died.
Journal Article > Study
Beaulieu MJ. MCN Am J Matern Child Nurs. 2009;34:18-23.
This study discovers that using selected failure to rescue process measures may help identify areas for improvement in perinatal care.