OB Case Studies for Application of QSEN Safety Competencies: Examination of
the Concept of a ‘Just Culture’ through Root Cause Analysis
Case Study #1: Magnesium Sulfate Overdose
A woman at 26 weeks gestation was transferred to a tertiary hospital in pre-term labor. Despite
intravenous (IV) MgS04 therapy, labor proceeded quickly. The woman reported feeling
“something coming out.” She was rushed back to the surgical suite and the perinatal and
neonatal teams were hastily assembled. Confusion and hurried activity prevailed as the baby
was delivered and resuscitated. Following delivery of the placenta, the physician ordered 20
units of oxytocin added to the IV fluids for rapid infusion. One of the nurses added the oxytocin
to the mainline fluids, which were infusing at a keep-open rate. The other nurse used the roller
clamp to discontinue the MgS04, turned off the pump and removed the line from the pump.
She then proceeded to open the line, with what she presumed was oxytocin, to infuse rapidly
using the roller clamp. The woman was transferred to an LDR room for recovery care.
Thirty minutes later, during the first postpartum assessment, the patient was found
nonresponsive and not breathing. Cardiac arrest followed quickly. A full code was called during
which it was discovered that the IV MgS04 was wide open and the line with the oxytocin was
clamped shut. Subsequent analysis revealed that the nurse had inadvertently opened the line
to the bag with MgS04 instead of the line to the bag with the oxytocin after delivery of the
placenta. Despite resuscitative efforts, the woman did not regain consciousness and remains in
a vegetative state.
Case Study #2: IV Antibiotics?
A woman with a positive Group B Streptococcal screen (GBS) and a history of precipitous births,
was admitted in active labor to a busy labor unit. Penicillin G 5 million units for GBS prophylaxis
was ordered. The nurse rapidly retrieved the pre-mixed medication in the IV solution from the
automated drug dispensing system. The drawer for premixed IV solutions contained several
different types of IV solutions all identified with drug names in a light dot-matrix printer font on
a white label. The retrieved medication was administered IV to run over 15 minutes.
Approximately five minutes after the medication was initiated, the woman had a grand mal
seizure, then a cardiopulmonary arrest. The medication was discontinued. Anaphylactic shock
related to an allergic reaction to penicillin was suspected. The resuscitation was difficult and
prolonged, with intubation and ventilator support required. After admission to the ICU, it was
noted that the medication administered was not penicillin, but rather a solution of fentanyl and
Marcaine used in pumps for epidural anesthesia during labor. The woman and her fetus made a
full recovery after 36 hours in the ICU and the baby was born apparently healthy.
Case Study #3: Nurses Administering Boluses of Medication via Epidural Catheter During
Labor
A woman in labor at six centimeters with an epidural catheter in place began complaining of
severe pain. Her nurse called the anesthesia provider to evaluate the patient and to administer
a bolus of medication. The anesthesiologist was busy in the OR. He asked the nurse to give the
woman the bolus and promised to check on the patient in 45 minutes after his OR case was
completed. The nurse was aware of the unit policy and recommendations from the Association
of Women’s Health, Obstetric and Neonatal Nurses (AWHONN Position Statement, 2001) that
epidural boluses could only be given by qualified anesthesia providers but didn’t want her
patient to have to wait and suffer needlessly. In several previous similar situations, she had
given boluses via epidural catheter to women in labor and no adverse outcomes had occurred,
so she gave the medication. Approximately two minutes after the bolus had been administered;
the patient reported shortness of breath. One minute later, the woman had a complete
cardiopulmonary arrest. A code was called. The anesthesiologist was paged stat but was
involved in a case with general anesthesia in the OR and unable to come to the unit for 12
minutes. The nurses attempted using a bag and mask to maintain respirations while waiting for
the code team. Eventually, the woman was resuscitated but suffered an irreversible brain injury
due to anoxia. An emergent cesarean birth was performed; the baby was born depressed and
hypoxic. The woman remains in a persistent vegetative state, and the baby is neurologically
damaged. Epidural catheter migration was the suspected cause of the high block and
respiratory paralysis. Prior to this accident, anesthesiologists routinely asked nurses to give
labor epidural boluses so they could cover the OR as well as the labor and delivery unit
simultaneously, thereby avoiding calling in another anesthesiologist.
Case studies adapted from:
Simpson, K. R. and Knox, G. E. (2003). Adverse Perinatal Outcomes: Recognizing, Understanding
& Preventing Common Accidents. AWHONN Lifelines, 7(3), 224-235.