Case 1:08­cv­01622­LJO­DLB   Document 158­12   Filed 10/27/09   Page 38 of 47 VSPW's Two Perinatal Death Cases Reviewed: Corrective Action Plan--1/25/08 1. Problem Identified Discussion of Plan Follow documentation Comments issues Motrin given in Was this a line 1. Training, VSPW's 1 .In 60 days, review all 1. This particular Motrin physician or the pregnancy regular OB provider medication orders for order was written by a OB? Why did the (Dr. Heinrich) will pregnant women and look for yard doctor who is no physician do this? prepare a lecture to motrin longer working at VSPW. Do they need educate/remind staff training on of medicines that are 2. Sheet signed by all 2. The sticker notification primary care of not to be used during providers that training was of pregnancy will be pregnant women pregnancy. received within 30 days placed inside the Unit 2. Place sticker in Health Record to protect chart to indicate the patient's pregnancy. This will confidentiality. be done at first OB visit. Also educate staff to look for OB portion when reviewing chart. The-Obstetric section of the Unit Health Record is clearly - designated by an orange tab. The providers will be trained to appropriately identify the OB patients by this tab. 3. Flag first order Case 1:08­cv­01622­LJO­DLB   Document 158­12   Filed 10/27/09   Page 40 of 47 II. Rhogam given on several occasions despite Rh positive (t Expensive and wasteful use of a medication Ill. No (3BS screen despite multiple visits with medical providers (Van Ibm) Current standards by CDC recommend universal screening. sheets—writing that pt is pregnant and due date for pregnant women. **These changes need to be discussed with pharmacy, nursing, Health Records and physician providers In 60 days, review all rhogam 1. Training of OB staff on proper use of orders for documentation on indication Rhogram and testing. 2. Educate on differentiating between Rh type and antibody screen. 3. Discussion with OB how to avoid ordering in RH+ women 1. Increase awareness In 60 days, all pregnant women will have a at LVN, RN, and documented screen provider level. Lecture and counseling regarding this particular case has already been done. 2. Send a letter to the OB providers at the community hospitals reuuestinz they treat This medication is only ordered by OB provider. CMO will discuss why this occurred with OB. In this particular case, patient/inmate's antibody screen was negative and her RE type was positive. It appears that the negative antibody screen was mistaken for Rh type. In this particular case inmate presented late in her pregnancy and was seen on multiple visits for various acute issues and, unfortunately, her GBS screen was overlooked. Case 1:08­cv­01622­LJO­DLB   Document 158­12   Filed 10/27/09   Page 42 of 47 1 IV. V. all patients as if they were positive if their status is unknown. 3. At OR intake make appointment for 35-37 weeks specifically for GBS screening. 4. Give custody or inmates either a copy of OB records or a check list of important tests that need to be done—CMO will discuss this further with custody and specialty coordinators Delay of Emergency What is the usual Usually takes 15-20 Reponse * delay? Can this be minutes for Ambulance took 25 improved? ambulance to arrive minutes with several phone calls S Send correspondence to local Letter will done by Health ambulance company that there Care Manager and also was a delay in this particular forwarded to Central case and to please investigate Region Medical Director why occurred and how to avoid in the future. This to be done within next 3 0-60 days Hospital physician Need to make OB 1. We will educate all In 60 days check with L&D was unable to get records readily clinical staff that and custody that records have chart information accessible for copies of the OB been obtained for patient when she community records are available was admitted (Van hospital providers, in the TTA 24 hours a Horn) day and they can be faxed to MCH when Case 1:08­cv­01622­LJO­DLB   Document 158­12   Filed 10/27/09   Page 44 of 47 the patient is sent. 2. Will give a copy to the patient to take during her transit to MCH or give a sealed copy to custody to take to MCH when patient si labor. __ We must not 1. Create a checklist In 60 days will evaluate and Currently inmates have VI. Contraceptive plan must be documented create barriers to of topics that must be document that this has been option of hormonal contraception-.not at intake visit (Van contraception for addressed at OB done condoms. During conjugal these women. It intake and include this Horn) visits partner has to bring must be discussed issue. in condoms if desired. If at length and 2. Educate staff and available to start in providers that this condoms are to be needs to be done at provided to inmates, will the facility need to implement intake and in a timely manner statewide or institutional policy VII. Intake Exam not Seen 12 times by 1. OB intake exam In 60 days will evaluate and done in a timely provider, but must be scheduled at document that has been done manner (Van Horn) unclear if intake first documentation was done. Is (positive test) of intake pregnancy. If an comprehensive inmate is presenting to enough? prison late in pregnancy, then it will be scheduled at prison reception H&P. 2. Educate staff and providers of __ Case 1:08­cv­01622­LJO­DLB   Document 158­12   Filed 10/27/09   Page 46 of 47 importance of this visit and the expectation that this will be scheduled in a timely manner