1. Morbidity and Mortality Conference
Joshua Kanik, MD
Family Medicine Resident
NEIMEF
2/26/14

2. Case: M. H. Brief HPI
23yo G2P1001 presented to clinic at 9w 1d for initial OB visit.
She had not had a period since Mirena placed 6 years ago
Mirena removed approximately 10 month prior to pregnancy.

3. Case:
PMH - Depression
OB/Gyn - Menarche at age 13, regular cycle until Mirena placed 6 yrs ago. No gyn surgery. No h/o abnormal PAP.
FH - No known hx
SH - Single, unemployed, smoker, abstains from alcohol, Denies drug use.
Medications - None
Allergies - NKDA

4. Case: Physical exam Vitals - Afebrile, 260 lbs (BMI 45),107/63
Pelvic exam:
EGBUS: without lesion
Vagina: no significant discharge or lesion
Cervix: pale, no blood, without lesion or discharge, closed
Uterus: Gravid size approximately 8-9 weeks
Adnexa: without masses or tenderness

5. Timeline of Events Date/Time Clinical Status/ change in status 10/8/13
Initial OB ultrasound indicating 9w 1d
Initial OB visit Normal except PAP returned showing LSIL
10/27/13 sd
Transvaginal Ultrasound revealed spontaneous abortion w/ POC
No record of US result in ED report
Diagnosed with UTI. Prescribed Levaquin.
12/11/13
Follow up prenatal visit. (18wk)
Denied vaginal bleeding or diagnosis of UTI
No mention of ED visit or Transvaginal Ultrasound
Exam: FH measured at twice with doppler.
12/23/13
OB ultrasound in office unable to find fetus, sent to CMC for
transvaginal US.

6. Adverse events/outcomes triggering case presentation
Yes No
Unexpected death X
Medical or surgical complication
Delay in care
Delay in Diagnosis
Prolonged medical care in setting of poor prognosis
Other:

7. Review of Package Insert Literature:
Artifact in Fetal Heart Rate.
FHR measurement techniques have limitations that can lead to misrepresentation of FHR.
Doubling - The autocorrection algorithm can display a doubled fetal OR maternal heart rate if duration of diastole and systole are similar.

8. Review of Package Insert Literature:
Artifact in Fetal Heart Rate.
Halving - With fetal tachycardia and interference from fetal or maternal arteries the autocorrelation algorithm may only recognize every other beat
Switching or “Maternal Insertion”- Alternating between fetal and maternal heart rate, simulating decels, Or the maternal HR may simulate FHR while pushing or during contractions. 8

9. Factors contributing to adverse outcomeY N
Communication: e.g., inadequate handoffs; incomplete clinical information X
Coordination of care: e.g., involving multiple services and/or care sites
Volume of activity/workload: e.g., increased clinical volume and /or perception of workload
Escalation of care: e.g., delay or failure to involve more senior physician or nurse
Recognition of change in clinical status: e.g., delay or failure to recognize changing clinical signs +/or symptoms
Other factors:

10. Root Cause Analysis Fishbone Diagram
People
Equipment
Procedure
Environment
Policy
Other
Adverse Outcome
Causes:
Causes:
Causes:
Patient, Physicians
(ER, Rad, PCP)
_______________ _____________
Doppler artifact
Multiple points of care
Forwarding notes to PCP
Poor communication
Causes:
Causes:
Causes:

11. Root Cause Analysis Fishbone Diagram
People
Equipment
Procedure
Environment
Policy
Other
Outcome
Solutions:
Solutions:
Solutions:
Communication
_______________ _____________
Understanding dopplers shortcomings
Fewer points of care.
Forwarding notes to PCP
Educating pt
Solutions:
Solutions:
Solutions:

12. Comments & Discussion