About this episode
The episode discusses a medication error during a woman's first pregnancy that led to a change in labor and delivery policy.
A 30-year-old woman experiencing her first pregnancy, presented to the Labor and Delivery unit. She was given the wrong drug and required an emergent C-section. The “five rights” of medication administration focuses on individual factors and not necessarily on system flaws. Many organizations are also promoting just culture, which encourages reporting near-misses and patient safety events, and focuses on psychological safety and promoting a non-punitive reporting culture.
Topics covered
- medication error
- patient safety
- labor and delivery
- just culture
- C-section
- healthcare policy
Keywords
- medication administration
- emergent C-section
- five rights
- system flaws
- psychological safety
Mentioned in this episode
Organizations: Labor and Delivery unit
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