What can be learned from reviewing these 2 cases?
Fortunately, both of these women survived even though they had severe morbidity that could have had a permanent impact on their health. What is learned from reviewing these cases could improve the care of subsequent women.
Case 1 (preeclampsia/eclampsia)
Problem 1: The team did not know how to manage severe hypertension. They repeatedly used the wrong doses of labetalol at the wrong intervals. The patient could have had a stroke, but did not. Next time, the team might not be so lucky.
Potential improvements: educate nurses and physicians about the nationally available guideline for treatment of severe hypertension, have the guideline available, create an order set, and practice with simulation and drills.2
Problem 2: The patient should have received IV magnesium sulfate much sooner. If the diagnosis was correct, why was magnesium not started?
Potential improvements: reeducate staff about need for magnesium to reduce eclampsia in women with severe preeclampsia, determine why this patient did not receive it sooner (ie, pharmacy delay, order delay, communication delay), and correct that issue.
Case 2 (placenta accreta)
The care in this case was excellent. Communicating this to staff is important feedback to reinforce their first-rate approach to planning and documentation.
Problem: The patient’s initial cesarean delivery. What was the indication? Was it necessary? Questioning the indication for the initial cesarean at the review committee reminds physicians of the risks of cesarean delivery, including the risk of subsequent placenta previa and placenta accreta, and ultimate need for hysterectomy that occurred in this case.
Based on their review of this case, the committee may decide to recommend evaluation of the nulliparous, term, singleton, vertex cesarean delivery rate and the incidence of placenta accreta at their institution. The committee may decide to focus on better patient and physician education about the delayed risks of cesarean delivery.
These cases both illustrate the power of careful review of cases with SMM. In the first case, clear opportunities for improvement existed and likely reflected both provider and system issues. In the second case, the care was excellent, but the presence of placenta accreta reminds us that the patient would not have had this morbidity if she had not had a prior cesarean delivery.