Perinatal Case Study

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A case of preventable maternal death

The following case study illuminates the fundamental issues of patient Safer Culture that can lead to tragic maternal outcomes.

Keoni was a vibrant and intelligent black woman who traveled extensively, raced cars, and spoke five languages. She and her husband Max, her college sweetheart, had a 19-month-old son. At age 39 she underwent fertility treatments and conceived a second child. Keoni was in excellent health and never missed a prenatal appointment.

The couple chose to deliver at a world-renowned medical center. On April 12, 2016 Keoni, accompanied by Max, was admitted for an elective repeat cesarean section. The surgery was over within an hour, and Keoni and her newborn were transferred to the PACU.

APRIL 12, 2016: SEQUENCE OF EVENTS

Approximately 2 hours post-surgery, (4:30pm), Keoni was still in the PACU when her nurse noted bright red blood draining from the Foley catheter. Keoni’s fundus (the top of the uterus) had risen well above the level of the umbilicus. The PACU nurse called the resident “to evaluate the rising fundus and note concern for excessive bleeding.” The resident told the nurse to replace the Foley catheter and called Keoni’s physician to make him aware of her condition. The catheter was removed and replaced, but eight minutes later the nurse noted frank red blood draining from the new catheter.

Four hours post-surgery (6:30pm) the nurse called the resident noting Keoni had no urine output. The resident performed another bedside ultrasound, which showed the hematoma had enlarged. Keoni and her husband were told by the resident “although the hematoma appeared stable, there was concern regarding blood in the Foley catheter with no urine output.” The resident made Keoni’s physician aware of her condition.

Five hours post-surgery (7:30pm), the OB resident saw Keoni again. She had little to no urine output despite fluid boluses, and there was still a significant amount of blood in the catheter. A CBC showed her hemoglobin and hematocrit dropping and her heart rate was tachycardic in the 120’s. Keoni’s quantitative blood loss (QBL) was 1500cc’s. The resident’s note read, “this suggests symptomatic acute blood loss anemia” and the decision was made to transfuse Keoni with 2 units of packed red blood cells. Also, the decision was made to proceed with a CT urogram to evaluate the kidneys/ureters/bladder, given the frank blood in the Foley catheter and it was noted that the STAT CT had not arrived. The resident contacted Keoni’s physician with an update on the situation.

Six hours post-surgery (8:30pm) Keoni’s private physician arrived at her bedside in the PACU. Keoni’s status was reviewed with him: “bloody urine”, “abnormal hemoglobin”, “tachycardia”, “and possible hematoma”. The PACU nurse received no new orders.

Nine hours post-surgery (11:30pm) Keoni feels “a little groggier than before”. Her vital signs included a heart rate of 120 and her blood pressure was 90/70. Keoni’s physician was at the bedside and stated that he “wishes to continue expectant management at this time”. Shortly thereafter Keoni’s vital signs dropped significantly and the Massive Transfusion Protocol (MTP) was initiated Keoni was taken to surgery emergently and 3 liters of blood was found in her abdomen.
Approximately eleven hours post-surgery, at 2:22 am, Keoni was pronounced dead. Autopsy showed the cause of as “hemorrhagic shock, due to acute hemoperitoneum” secondary to a nicked bladder during the cesarean section.

ANALYSIS: INEFFECTIVE SAFER CULTURE LED TO A DEVASTATING OUTCOME

Underlying assumptions, values, and norms (the culture) of this labor and delivery department came through in the health care provider’s behaviors and influenced the result: an avoidable death. Preventing a recurrence of this tragic event invites all of the health care providers and patient representatives to review the factors affecting this culture and evaluate the enacting behaviors that were their downfall:

Cohesion
Although we don’t know what hospital policies were in place, we do know that Keoni was the victim of “failure to rescue” and “failure to escalate.” Lack of cohesion was observed as the academic physicians, private physician and nurses failed to work as a team with the husband to recognize the dangers and provide immediate care. At the first frank blood in the foley catheter, the resident should have notified the attending. When the resident and attending failed to write orders or change their plan of care, the nurse with a strong sense of control and solid escalation policy should have gone up the chain of command.
Psychological safety
The process of junior physicians and nurses not speaking up and intervening to escalate her condition to another higher-ranking physician to rescue Keoni exemplifies lack of psychological safety. Failure of her primary obstetrician to recognize the imminent danger of his patient despite multiple signs and symptoms presented played a role in Katie’s spiraling postpartum deterioration.
Sense of control, Policy/organizational process
Hours into her crisis, providers may have lacked a sense of control, which led to hesitancy to take additional actions. A lack of policy or organizational process may have existed in how to escalate her care by the other healthcare providers in order to get her back to the OR. Eventually some individuals were motivated to respond but unfortunately, it was too late.

ALTERNATIVE ENDING: AN EFFECTIVE SAFER CULTURE COULD HAVE CHANGED THE OUTCOME

When the nurse noted that Keoni had bright red blood draining from her Foley catheter and a rising fundus, she called the resident, who immediately came to evaluate the patient. In consultation with the nurse, they decided to replace the Foley catheter and called her private physician. (Communication and Information Exchange; Teamwork and Collaboration.)
The nurse assessed that Keoni continued to have frank blood in her Foley catheter and was experiencing a rising fundus, so she contacted the private physician, who came in to see the patient (Sense of Control.)
The nurse, questioning an order for uterotonics when the bleeding did not appear to be uterine in origin, escalated to her charge nurse (Psychological Safety) who followed the hospital policy for escalation to notify the chief resident (Policies and Resources for Safety.) They estimated blood loss to be high and were monitoring Keoni’s blood pressure and heart rate every 15 minutes. Keoni and Max were given a complete overview of the risks of Keoni’s potential bleeding. After two hours, she was reassessed by her primary physician who consulted with a team of OB specialists about next steps (Cohesion). Labs and a stat CT was ordered, two units of PRBCs were given, with type and cross match for two more. If her condition worsened in an hour, they recommended she be taken back to surgery.
Keoni’s status continued to decline and she and Max were given a complete overview of her condition. The team discussed with Keoni and Max the need for surgery and consents were signed (Communication and Information Exchange; Teamwork and Collaboration.)
Nurses continued monitoring her fundus, IV fluids were increased and Keoni was prepped for the operating room. In surgery, a tear in her left ureter was identified and was repaired. She underwent evacuation of hematoma and bleeding was controlled. She returned to the post-anesthesia care unit for monitoring. She recovered from anesthesia within a couple of hours and was able to hold her infant in 4 hours. The doctor disclosed to the husband and patient, the unexpected finding of a ureter tear causing the bleeding and promised to keep checking in with them over the next few weeks (Incident Reporting; Fair Rewarding and Punishing.)
After surgery, the labor and delivery staff held a debrief to discuss the events of the labor and delivery situation and post-recovery management (Leadership Commitment and Prioritization of Safety.) It was discovered that the nurse had put the CT order in for the am and not STAT (Individual Commitment and Prioritization of Safety.) The radio buttons were very similar in nature. By disclosing this information, IT was consulted to change their appearance in the order sets (Incident Reporting; Fair Rewarding and Punishing.)

On April 16, 2016, Keoni, Max and their newborn son were discharged home