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Near Miss With Neonate | AHRQ Patient Safety Network

Near Miss With Neonate | AHRQ Patient Safety Network

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Near Miss With Neonate
A pregnant woman was admitted for induction of labor for postterm dates. Prior to artificial rupture of membranes (AROM), the intern found a negative culture for group B streptococcus in the hospital record but failed to note a positive culture in faxed records from an outside clinic. Another physician caught the error, ordered antibiotics, and delayed AROM to allow time for the medication to infuse. Jennifer Malana, MSN, RN, and Audrey Lyndon, PhD, RN, both of UCSF, outline the risks of group B strep in neonates along with guidelines for screening and treatment.



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  • Published October 2016

Near Miss With Neonate

    The Case

    A 37-year-old pregnant woman was admitted to the hospital for scheduled induction of labor for postterm dates. Early the next morning, intravenous oxytocin was administered to induce labor.
    When the obstetrics team rounded on the patient several hours later, AROM (artificial rupture of membranes) was recommended to accelerate labor. The intern reviewed the patient's chart and noted that a culture done from a vaginal and rectal swab at 36 weeks was negative for group B streptococcus (GBS)—a bacteria that sometimes colonizes the gastrointestinal and genital tracts of pregnant women. If documented at any time during pregnancy, the infant is at increased risk of infection at the time of delivery. The intern failed to note that faxed records from a clinic outside the hospital system included another culture—a urine culture positive for GBS. This test had been ordered at an office visit earlier in the patient's pregnancy. Given this positive culture, to prevent transmission of GBS infection to the infant, the patient should have been started on intravenous antibiotic prophylaxis before the membranes were ruptured.
    The senior resident on the team happened to review the faxed records and noted the positive urine culture. She immediately ordered antibiotics and delayed AROM for several hours to allow time for the medication to infuse. Luckily, the senior resident's "catch" made this case a near miss, and the patient ultimately delivered a healthy infant and experienced no adverse consequences.

    The Commentary

    by Jennifer Malana, MSN, RN, and Audrey Lyndon, PhD, RN
    The case presented illustrates multiple ways in which critical patient information may be lost during transitions of care. In obstetrics, information management issues have the potential to affect the safety of both the mother and the neonate. In this particular case, overlooking the urine culture positive for group B streptococcus (GBS) could have triggered a cascade of inadequate care with potentially devastating effects on the health of the neonate. Fortunately, the result was caught in time by the senior resident, a classic case of a near miss.
    To identify risk factors prior to the onset of labor, GBS screening is conducted as part of a woman's routine prenatal care. Approximately 25% of the pregnant population in the United States carries GBS.(1) Adult GBS carriers are asymptomatic and generally experience no adverse effects. However, for the neonate, GBS colonization can result in fatal infection if not treated appropriately during the intrapartum period.(1,2) For neonates who survive early-onset GBS disease, long-term adverse outcomes may include permanent loss of hearing or vision and cerebral palsy.(3)
    In the 1970s, neonatal death rates due to early-onset GBS infections were as high as 50%.(4) Current data indicate that approximately 1000 neonates contract early-onset GBS disease every year in the US, with fatalities occurring in 4%–6% of those infected.(1,2,4) This drastic decrease in mortality is largely due to interventions such as early prenatal screening of GBS and initiation of intrapartum antibiotic administration.
    Current recommendations for GBS screening focus on early identification of GBS colonization, use of prophylactic intrapartum antibiotics for patients at risk for GBS transmission to neonates, and specific guidance on antibiotic selection.(5) The Centers for Disease Control and Prevention (CDC), the American Congress of Obstetricians and Gynecologists (ACOG), the American Academy of Pediatrics, and the American College of Nurse-Midwives have all endorsed prenatal GBS screening as a standard part of patient care.(6) Despite CDC guidelines and algorithms designed to help clinicians navigate GBS management more effectively, there are situations in which errors occur and guidelines are not followed appropriately. A recent study demonstrated that knowledge gaps among providers led to inconsistencies in CDC guideline implementation and clinical care.(7)
    According to the CDC, a GBS positive urine culture at any time during pregnancy automatically requires administration of intrapartum antibiotic prophylaxis, and no further testing is indicated.(8) Thus, the decision to screen the woman in this case for GBS with a vaginal and rectal swab after a transition in care, despite a documented positive urine culture for GBS, represented an error. This retesting may have been due to a lack of knowledge on the part of the provider who performed the second screening test or the result of communication gaps associated with the transition of care.
    The CDC GBS guidelines are fairly straightforward; they indicate that repeat screening at 36–37 weeks was not needed in this patient because of the previous positive urine GBS culture. In this situation, using the CDC's electronic algorithm to determine appropriate action at relevant points of care (both an application and a website are available to the public) could have prevented the unnecessary repeat GBS screening. This free, easily accessible electronic resource provides an efficient means for providers to determine appropriate GBS screening for patients and necessary follow-up care.(9) In addition, the CDC app gives providers access to up-to-date guidelines and easy clinical management tools. One strategy that might improve both clinical education and patient safety would be to instruct trainees to evaluate their own plan of care against the algorithm and guidelines listed in the GBS app.
    In this case, communication gaps and a lack of interprofessional teamwork may also have contributed to this near miss. Best practice recommendations from ACOG include standardization of antenatal records to ensure that clinically important information, such as GBS carrier status, is cohesively maintained regardless of method of documentation (i.e., paper versus electronic).(10) This recommendation does not address the potential for error in transitioning patient care from outside clinics or health care systems to the location where intrapartum care occurs. In the case presented, vital GBS screening information was overlooked in prenatal records that came from an outside clinic.
    One way to support clear communication during transfer of care is to use patient problem lists to document current health issues, including GBS status, within the electronic health record. For health systems that are still using paper records, a current problem list placed at the front of the patient's paper chart could serve the same purpose. Other documentation processes, such as preadmission evaluation prior to anticipated birth or planned transfer of care by the accepting facility, or the use of an inpatient admission checklist could also facilitate completeness of critical patient history and laboratory findings.(11,12)
    In this case, the primary discussion of the management plan focused on the two residents; however, many members of a health care team affect the safety of patient care. Nurses typically conduct a review of medical records and a full patient assessment during admission for labor and delivery. An interdisciplinary discussion of the management plan and joint review of records by both the nurses and the physicians involved, or the use of a standardized handoff between the intern and the nurse at the time of admission, might have prevented the error.(12-14)

    Take-Home Points

    • Use patient problem lists within the prenatal health records to clearly identify key pieces of information that are essential to patient care.
    • When feasible, the use of a standardized preadmission process, such as a checklist, to streamline information transfer between prenatal and intrapartum care may help prevent errors. An admission checklist can further help to ensure that all necessary clinical information has been obtained and documented.
    • Use technological resources, such as the CDC apps or website, to confirm current working knowledge of group B streptococcus guidelines.
    • Ensure optimal communication between all members of a patient's care team.
    Jennifer Malana, MSN, RN
    Clinical Nurse
    University Birth Center
    UC Davis Health System
    Doctoral Student
    Department of Family Health Care Nursing
    University of California, San Francisco
    Audrey Lyndon, PhD, RN
    Associate Professor
    Department of Family Health Care Nursing
    University of California, San Francisco

    References

    1. Group B Strep (GBS): Fast Facts. Atlanta, GA: Centers for Disease Control and Prevention.[Available at]
    2. Group B Strep Infection in Newborns. Atlanta, GA: Centers for Disease Control and Prevention. [Available at]
    3. Group B Strep (GBS): Clinical Overview. Atlanta, GA: Centers for Disease Control and Prevention. [Available at]
    4. Early-onset Group B Streptococcal Disease Prevention: For Clinicians. Atlanta, GA: Centers for Disease Control and Prevention; November 2010. [Available at]
    5. Group B Strep (GBS): Overview of 2010 Guidelines. Atlanta, GA: Centers for Disease Control and Prevention. [Available at]
    6. Group B Strep (GBS): 2010 Guidelines for the Prevention of Perinatal Group B Streptococcal Disease. Atlanta, GA: Centers for Disease Control and Prevention. [Available at]
    7. Edwards RK, Tang Y, Raglan GB, Szychowski JM, Schulkin J, Schrag SJ. Survey of American obstetricians regarding group B streptococcus: opinions and practice patterns. Am J Obstet Gynecol 2015;213:229.e1-229.e7. [go to PubMed]
    8. Indication and nonindications for intrapartum antibiotic prophylaxis to prevent early-onset group B streptococcal (GBS) disease. Atlanta, GA: Centers for Disease Control and Prevention; November 2010. [Available at]
    9. Group B Strep (GBS): Prevent Group B Strep App for Obstetric and Neonatal Providers. Atlanta, GA: Centers for Disease Control and Prevention. [Available at]
    10. Committee on Patient Safety and Quality Improvement. Committee Opinion No. 629: Clinical guidelines and standardization of practice to improve outcomes. Obstet Gynecol. 2015;125:1027-1029. [go to PubMed]
    11. American College of Obstetricians and Gynecologists Committee on Obstetric Practice. ACOG Committee Opinion No. 485: Prevention of early-onset group B streptococcal disease in newborns. Committee Opinion No. 485. Obstet Gynecol. 2011;117:1019-1027. [go to PubMed]
    12. Fuhrmann C. First stop: pre-admission for your delivery. J Obstet Gynecol Neonatal Nurs. 2011;40(suppl 1):S7. [Available at]
    13. Ranji S, Wachter RM, Hartman EE. Patient Safety Primer: Handoffs and Signouts. [Available at] Updated July 2016.
    14. Starmer AJ, Sectish TC, Simon DW, et al. Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA. 2013;310:2262-2270. [go to PubMed]




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