Prolonged DKA in Pregnancy: A Case of Communication Breakdown. Sarah Marshall, MD and Nina M. Boe, MD | August 30, 2023

https://psnet.ahrq.gov/web-mm/prolonged-dka-pregnancy-case-communication-breakdown In this WebM&M Spotlight Case with CE/MOC, a 31-year-old pregnant patient with type 1 diabetes on an insulin pump was hospitalized for euglycemic diabetic ketoacidosis (DKA). She was treated for dehydration and vomiting, but not aggressively enough, and her metabolic acidosis worsened over several days. The primary team hesitated to prescribe medications safe in pregnancy and delayed reaching out to the Maternal Fetal Medicine (MFM) consultant, who made recommendations but did not ensure that the primary team received and understood the information. The commentary highlights how breakdowns in communication amongst providers can lead to medical errors and prolonged hospitalization and how the principles of team-based care, communication, and a culture of safety can improve care in complex health care situations.