Placental abruption | Labor and delivery unit | Communication via personal cell phones found ineffective for emergencies |
Eclamptic seizure | Antepartum | Attendings not receiving code notification |
Eclamptic seizure | Obstetric emergency room | Magnesium not stocked in Pyxis |
Eclamptic seizure | Postpartum | Wrong number for code operator; lorazepam not stocked in Pyxis |
Severe hypertension | Antepartum | Code button deactivated |
Precipitous preterm delivery | Antepartum | Unknown location of warmer; unable to override elevator |
Precipitous delivery | Obstetric emergency room | Stat pack inadequate |
Postpartum hemorrhage | Operating room | Massive transfusion protocol order set via telephone communication improved response time |
Cord prolapse | Alternative birth center | Requires key to access; bed does not fit through front door |
Car delivery | Garage | “Code stork” confused with “code stroke” |
Malignant hyperthermia | Operating room | Resuscitation box disorganized |
Fire | Operating room | Location of oxygen shutoff unknown |
Malignant hyperthermia | Operating room | Optimal medication not available at Ochsner Baptist |