iI recently read an essay in Nursing for Women’s

Health (Stichler, 2007) about the birth of twins

from the perspective of the family. The au-

thor—a nurse as well as the twins’ grandmoth-

er—closed the article with this statement: “I

am grateful for nurses who are called to touch

our lives and heal our hearts. I am proud to be

a nurse!” I, too, am the grandmother of twins

who arrived after much hopefulness and failed

attempts at pregnancy. As a clinician, my heart

identifi es with the author’s refl ection on nurses

who touch our lives.

It was ironic that I read this essay at the

same time I was contemplating how to record

my own family experience. My daughter-in-law,

Ginger, was a 29-year-old primigravida. She

entered the hospital for an elective cesarean

section at 37 weeks’ gestation after a pregnancy

that had been basically unremarkable. On the

day of delivery, Whitney and Weston arrived,

weighing 5lb 3oz and 5lb 4oz, respectively. I

watched as my son, Matt, readily took on the

role of “Daddy.” He exuded a confi dence and

calmness that defi ned his strength and char-

acter. He reported to us that the babies were

perfect, crying vigorously, pink and had

Apgar scores of 9/9.

Our family, Ginger’s family and several

friends eagerly waited for a summons to meet

My anxiety started

to bubble up

and an alarm of

uncertainty began

to sound in my

head.

88 © 2008, AWHONN http://nwh.awhonn.org

(continued on p. 86)

Marcia Hodges, MSN, RNC

Expectations Unmet

When Patient Safety Takes a Back Seat

Marcia Hodges, MSN,

RNC, is a clinical special-

ist in perinatal sales at

GE Healthcare in Jacksons

Gap, AL.

Address correspondence to:

marcia.hodges@ge.com.

DOI: 10.1111/j.1751-486X.2007.00282.x

the new babies. I explained to them that the fi rst

hour of recovery was a very important time to

assess the mother and we shouldn’t even expect

to see them for at least an hour.

Two hours later, Matt met with the anxious

family members to update us. He remarked that

Ginger was very sleepy and he had promised

her that she would be able to have time with

her babies alone prior to any family members

or visitors being admitted to the room, and he

wanted to honor that promise. Ginger hadn’t

been able to sleep well over the past several

weeks, and we could certainly understand her

need to “catch up” now that she was more than

10 lbs. lighter and without the activity of two

fetuses inside her. Matt was animated as he

described the babies to us; Whitney looked like

Ginger, and Weston like him. He said they were

bald and small but perfect and quietly sleep-

ing under the warmers. We couldn’t wait to see

them, but we would.

Another hour passed and we still weren’t in-

vited to the room. My anxiety started to bubble

up and an alarm of uncertainty began to sound

in my head. I’ve recovered many patients over

the years and this seemed to be an extended

period of recovery, even for a patient who was

sleepy and had delivered multiples.

After four and a half hours, I couldn’t take

it any longer. I walked down to Ginger’s room

with the entourage in tow and knocked on the

door. My son met me at the door and let us in

and proudly took everyone over to the warm-

ers. I glanced at the infants and wanted to join

the inspection, but I became overwhelmed with

fear when I looked at Ginger. I walked over to

the side of her bed and saw that she was lying

with her head fl at and her color was very pale.

In fact, she was almost the same hue as the

white sheet underneath her. When I tried to talk

to her, she didn’t respond but only fl uttered her

eyelids as if she couldn’t open them. I glanced at

her blood pressure monitor and saw a read-

ing of 80/40. There was no urine output in her

catheter bag and her skin was cool to the touch.

What happened next is that I became that

irrational family member that I’d encountered

in my experience as a nurse and a manager, but

I felt justifi ed. I noticed that the hospital bed-

side monitoring system provided the ability for

the nurse to document medications and view

the fetal monitor strip while the patient was

in labor, but the nursing documentation was

completed in a paper chart that was positioned

outside the room on a wall chart. Because the

nurse was outside the room charting, I asked

her to come to the bedside and said, “What’s

going on here? Ginger is unresponsive with no

urine output and is pale and hypotensive! Has

anyone checked her bleeding or her hematocrit

or notifi ed the physician?”

The nurse didn’t appear very impressed with

my assessments but stated, “She’s been very

sleepy.”

I continued, “This is more than very sleepy.

This is a patient who’s lost too much blood and

may still be hemorrhaging.”

The nurse then asked all of us to leave

the room. We complied, but I didn’t leave the

nurse’s desk, even though I could tell by the

busyness and the lack of eye contact with me

that I wasn’t a welcome guest.

Thirty minutes later, the nurse approached

me and said, “We’ve given Ginger Hespan, we

now have two units of blood infusing, we have a

physician at the bedside and we are concerned.”

“I’m very glad to see concern!” I replied.

Ginger slowly started to recover but didn’t

have the strength to sit up or even hold her

infants until the next day. There were many

apologies from nurses and the physician, but

no one gave a satisfactory answer as to why it

took a visitor to illicit immediate care or if there

was any concern to her condition prior to this.

Ginger’s hematocrit the next morning was 19.

I’ve tried to refl ect on this situation with an

open mind, coupled with my years of experi-

ence. The unit wasn’t extremely busy the day of

this delivery and the nurse assigned to Ginger

didn’t have any additional patients to care for.

I do know that this situation would never have

progressed for this length of time at my smaller

regional hospital. After one hour of recovery

following a cesarean section, the physician

would have been notifi ed if the patient didn’t

meet certain recovery care standards.

I was left with several questions. Did the

nurse adequately assess her patient? Did she

meet competency requirements to care for her

patient? Was the physician notifi ed prior to the

questioning by the family? Was the nurse fo-

cused on meeting her documentation require-

ments and tasks and, therefore, did she fail to

actually be aware of what was occurring with

Did the nurse

adequately assess

her patient?

Did she meet

competency

requirements

to care for her

patient?

86 Nursing for Women’s Health Volume 12 Issue 1

(continued from p. 88)

her patient? What could be the root causes of

this unacceptable outcome?

One thing I identifi ed in this scenario was

that the nurse had to leave the room to chart

due to two separate charting systems. Technol-

ogy has changed our way of practicing and has

actually allowed us as clinicians to be more ef-

fi cient. It can assist us to provide complete, con-

sistent care, but it mustn’t drive our practices.

For instance, if the nurse could have completed

her nursing documentation in the room while

at the bedside, perhaps this would have assisted

her in really “seeing” the patient and providing

timely interventions. Are some of our hospital

practices or the fear of litigation or our dispa-

rate systems prompting nurses to spend time

documenting, many times in multiple places

and taking them away from the bedside?

The second thing I learned from this experi-

ence is that I have a responsibility as a profes-

sional to request a meeting with the director of

this unit and express my concerns in a non-

judgmental manner. How can I hold the nurse,

physician or hospital accountable if they’re not

aware of my disappointment in this experience?

If I truly value patient safety, I must present the

facts as I see them and respect the fact that no

nurse, physician or manager would ever want

to provide fractured, suboptimal care for their

patients. That’s what we’re all about. Evaluat-

ing near misses and root causes of less than

optimal care will only help us identify those

areas and interventions that will truly bring us

to improved outcomes.

There’s always a feeling of regret when

medical outcomes don’t meet our expectations.

I felt this as a nurse manager when I had to

review cases in my own unit, but I experienced

the disappointment at a deeper, more personal

level when my own family was involved. Many

times these situations illicit anger, lawsuits and

fi nger-pointing. My professional experience has

led me to believe that most unwanted outcomes

are process related. I don’t know of one nurse or

physician who approaches his or her work with

the idea of creating harm or providing inad-

equate care due to lack of concern or unprofes-

sional behavior.

I agree with the author of the previously

mentioned article. I, too, am proud to be a

nurse and I want to take every opportunity

to do my part to help nurses of today meet

head-on the challenges they have and to help

identify risks that could affect perinatal patient

safety. By doing so, I hope to help them fi nd

fulfi llment in being the best nurses they

can be. NWH

ReferenceStichler, J. F. (2007). When birth is not as planned:

Joy and fear interwoven. Nursing for Women’s Health, 11, 217–220.

February | March 2008 Nursing for Women’s Health 87

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Evaluating near

misses and root

causes of less

than optimal care

will only help us

identify those areas

and interventions

that will truly bring

us to improved

outcomes.