Presentation
On January 7, a 32-year-old woman came to her ob-gyn to begin prenatal care. During this first visit, an ultrasound was performed that estimated her delivery date to be August 26.
Physician action
A second ultrasound was performed on January 21 at nine weeks gestation. This ultrasound estimated the patient’s due date to be August 22.
Due to an error made by the ob-gyn’s medical assistant, the patient’s due date was changed in the electronic health record (EHR) to August 7. Based on this due date, the ob-gyn scheduled a planned induction for July 30. Had the obgyn known about this error, she would not have scheduled the induction for July 30.
The patient was admitted to a local hospital for an elective induction of labor on July 30. After an unsuccessful 20-hour induction, the ob-gyn delivered the baby by cesarean delivery at 7:58 p.m. on July 31. The baby weighed 7 pounds,12 ounces and had one- and five-minute APGAR scores of 6 and 8. Cord blood gas was 7.35/36/44/19/-4.9.
Following the delivery, the baby went into respiratory distress and was transferred to the NICU. Records from the NICU indicated the baby’s gestational age at delivery was 36 weeks. While in the NICU, he required intubation and ventilator support for congenital pneumonia and respiratory distress syndrome. The baby received antibiotics for pneumonitis from July 31 to August 7. He also required a blood transfusion to correct hyperbilirubinemia.
A cardiac echocardiogram performed on August 2 indicated that the baby had a patent foramen ovale that did not close the way it should during birth. He was also tested for severe combined immunodeficiency (SCID), but the results were negative.
The baby was discharged home from the NICU at eight days of life. He was seen two days later by a pediatrician who stated that the baby was “a healthy, well-developed 10 days infant.” At the time this lawsuit was filed, the child had not suffered any long-term or permanent injury as a result of the respiratory complications.
Allegations
A lawsuit was filed against the ob-gyn and her medical assistant. The allegations included incorrectly re-assigning the baby’s gestational age late in the third trimester instead of relying on an earlier ultrasound. This led to a premature delivery of almost four weeks. As a result of the incorrect dates, the baby spent eight days in the NICU and went through extensive testing before being discharged.
Legal implications
The plaintiff’s expert ob-gyn stated that the gestational age of the baby at the time of delivery was approximately 36 weeks. She concluded that the premature induction of labor was likely responsible for the baby’s respiratory distress and pneumonia.
Two ob-gyns who reviewed this case for the defense criticized the ob-gyn for not establishing an accurate due date, resulting in the premature delivery of the baby. They also expressed concern about the induction and “invalid” reasons for the cesarean delivery. Those reasons were the mother’s gestational diabetes and that the baby was large for gestational age.
Regarding the due date error, an estimated delivery date calculator was programmed into the ob-gyn’s EHR. A mistake was made when the medical assistant changed the due date to August 7. In the EHR, any attempt to change a due date results in a warning box appearing that asks the user if they want to change the due date. The medical assistant did indicate that she wanted to change the date, though she had no explanation for or recollection of doing this.
Because of this mistake, the ob-gyn thought the baby was 38 weeks and 6 days, which is why she scheduled the induction.
Disposition
This case was settled on behalf of the ob-gyn.
Risk management considerations
A majority of the complications in this case might have been prevented by anticipating the shortcomings in this ob-gyn’s EMR system and setting precautions for them. Specifically, the warning box for changing delivery dates could have been flagged as a potential source of alert fatigue and the staff (i.e. the medical assistant in this office) should have been made aware of this fact.
Keeping a record of patient data and learning from this error to implement better risk management framework moving forward would prove to be very beneficial for the ob-gyn’s practice.
