Drawing on Tragedy to Make the Case for Patient Safety

SAN DIEGO — Piece by piece, Capt. Ryan Carron’s life was clicking into place. An accomplished naval aviator, he had recently gotten married and moved to a new home. And he and his wife were expecting their first child, a son.

Then things took a tragic turn that led him to become a champion of patient safety, an experience he recounted here at the Triological Society Combined Sections Meeting.

At regular check-ups for the pregnancy, their obstetrician-gynecologist told them everything was going “fine,” said Capt. Carron, a Navy Helicopter Wing Commander. The doctor discovered placenta previa, in which the placenta blocks the cervix, but it was early in the pregnancy and they were told later that it had resolved on its own.

The baby was big, estimated at eight pounds several weeks before the due date, but the healthcare team didn’t see this as worrisome. As the due date came and went, there were some light discharges the team also said not to worry about. Finally, two weeks after the due date, a planned induction was scheduled for a Friday. When the birthing center became full, the delivery was pushed to Saturday.

It was a scheduling change that ended up having profound consequences, Capt. Carron said.

They were again told all was normal when their doctor performed artificial rupture of the membrane and labor was induced with oxytocin (Pitocin). Along with bleeding, his wife experienced “stabbing pain.” The doctor, they didn’t realize until later, then went home, 12 miles away.

Eventually, Capt. Carron’s wife found herself in a pool of blood and was allowed to go to the bathroom. When she got back, they couldn’t find the baby’s heartbeat. Another nurse who was called in couldn’t, either. The doctor was called and showed up 20 minutes later in a track suit.

The baby, born with no heartbeat, was revived but couldn’t breathe on his own and was transferred to a hospital with a neonatal intensive care unit. Named Kenneth and called “Kenny,” he died five days later.

Aviation safety systems are being applied right now in some degree to medicine. These human performance enhancers and control mechanisms just need to be accelerated if we want to make a true difference in patient safety. —Capt. Ryan Carron

One Mistake after Another

Capt. Carron recounted the litany of warning signs that were missed and ways the system failed.

For instance, his wife was allowed to get out of bed while in labor on oxytocin. While hospital procedures required the doctor to be “on hand” during labor, there was no clear definition of what that meant. Any amount of blood was supposed to be reported to the obstetrician-gynecologist, but it wasn’t.

The Carrons’ nurse didn’t have documented fetal heart rate monitoring training. In a lapse of situational awareness, a physician was never called in, although the room was right upstairs from the ER.

And when an internal investigation was done, the nurses who were the closest witnesses to the whole episode were never interviewed.