In 2010 a woman arrived at a California Medical Center at 2 AM for a full term delivery. The woman was in good health. Her membranes were artificially ruptured at 11:26 AM and her baby was delivered vaginally at 3:18 PM. Unfortunately, after the delivery the patient continued to bleed. After an hour, the patient was moved to the operating room. The bleeding source could not be located and the bleeding continued for another 41 minutes until a senior obstetrician was called. Although the doctor indicated that the Rapid Response Team (RRT) was not needed, it arrived shortly after but was refused entry to the operating room until after a breathing tube had been inserted. Although Code Blue resuscitative procedures were continued for 72 minutes, the patient died due to excessive blood loss.
This tragic incident can be examined in a visual root cause analysis, or Cause Map, using the information released by the California Department of Public Health. The first step to performing a root cause analysis is to determine which goals were impacted. In this case, the patient safety goal was impacted due to the death of a patient. In cases involving death or injury to a patient, employees can also be impacted in what is known as a second victim. The death of a healthy patient associated with a normal delivery is considered an “adverse event” per the California Department of Public Health and a “never event” as defined by the National Quality Forum, which can be considered an impact to the compliance goal. The center was fined $50,000, an impact to the organizational goal. Additionally, the delay in life saving measures to the patient is an impact to the patient safety goal.
Beginning with an impacted goal, asking “Why” questions allows the development of the cause-and-effect relationships that led to the incident. In this case, the patient died from excessive blood loss and a delay in life saving measures. The blood loss started as damage from delivery, but was unable to be stopped and treatment of the bleeding was delayed. All three of these causes contributed to the total amount of blood loss experienced by the patient. There was a delay moving the patient to the operating room (OR) and a delay calling for assistance from a senior obstetrician (OB). Additionally, there was delay in treatment by the RRT, which was initially not allowed to enter the OR.
As a result of this incident, the medical center has reviewed and revised its policies regarding post-delivery hemorrhage and response. Specifically, when a patient suffers more than 750 cc’s of blood loss after vaginal delivery (this patient lost more than 1500 cc’s), she is transferred to the main OR. An OB Hemorrhage Toolkit, including checklist, has been adopted in Labor & Delivery, and the hospital has joined a maternal care collaborative. According to the CEO of the Medical Center, “We have reviewed these situations with everyone involved . . . to learn from them, improve patient care, update our policies and make sure nothing like these incidents can happen again.”
To view the Timeline, Outline and Cause Map, please click “Download PDF” above. Or click here to read more.