GROUP ACTIVITY:

CASE STUDY: WRONG MEDICATION IN THE LABOR ROOM A 25 year old primipara at 32 weeks gestation in the emergency department with severe back pain. She was triaged and sent to the busy, understaffed labor ward. The fetal monitoring strip showed contractions every 8-10 minutes. The obstetrician examined the client and recommended a continuing infusion with tocolytic drugs to decrease the uterine activity and avoid the preterm birth of the infant. All nurses and midwives are busy with other clients giving birth and a student midwife was asked to prepare the infusion. She did not know the case history and was anxious to ask her clinical instructor. Despite the women being obviously pregnant at 32 weeks, the student failed to assess the fundal height. The student prepared and applied an infusion with oxytocin instead of tocolytic drug. The error was not recognized for hours and the next day the client gave birth to a premature baby who had to be transferred to the neonatal intensive care unit due to severe breathing problems.
DISCUSS THE CASE BY EXAMINING THE FOLLOWING FACTORS: 1. Student factors 2. Patient factors 3. Mentor factors 4. Organizational factors 5. Environmental factors HOW MIGHT THIS ADVERSE EVENT/S BE AVOIDED?