Everything hung on a fine thread when a woman came in with the ambulance to the Södertälje hospital after a home birth on a summer night last year. The woman needed emergency medical care due to hemorrhage during delivery.
at the same time that the patient was transferred to the surgical ward went the alarm for immediate caesarean section by another woman. Parts of the surgical team then had to move to another operating room. The child that was born was very included and needed to be dealt with urgently.
” That I reported was the risk of the hemförlösta the mother ran to not be able to be taken care of quickly enough. The woman who came in as an emergency after hemförlossningen needed to be dealt with immediately, and had also need of blood transfusion, ” says Michael Gårdebäck.
iatrogenic harm or the risk of iatrogenic harm is the caregiver required to establish a notification in accordance with lex Maria.
In the notification for the event described how the hospital with very little staffing during the several hours had to deal with two operations and also emergency care for a child with very limited resources.
Michael Gårdebäck is chefläkare at Södertälje hospital, but he was also the director of the anesthesia when the incident occurred.
” We came to ourselves that we can’t have it like this in the emergency hospital. We had three serious patients to take care of immediately, and just had a narkossjuksköterska and an anesthesiologist.
the hemförlösta the woman serious iatrogenic harm that could have occurred due to a delay in operation. At the hospital consisted anestesiresurserna at the time of a team with a narkossjuksköterska and an anaesthetist, a theatre nurse and an assistant nurse. An anesthesiologist had bakjour in the home with a 30-minute presentation time at the hospital.
Kejsarsnittet was performed by the obstetrician, and the bleeding woman was taken care of by an obstetrician with bakjour that same night found himself in the hospital. The conclusion is that the organisation had not sufficiently prepared to deal with several emergency situations at the same time, and in order to ensure patientsäker care.
had they employed even in the past thought that the bemanningssituationen was brittle.
” Yes, we had long felt it and we had also expressed this to management. I said that was unacceptable. Here we got a living proof. It was crystal clear that one could point to a risk. It was very clear. We sorted it out, but it was close.
the hospital resources and took steps to increase the staffing, in particular, of narkossjuksköterskor.
– the First step is to have the money to hire, and it has been made. The next step is to employ. The objective is that we shall have two narkossjuksköterskor in service at the same time around the clock.
A separate lex Maria-notification relating to the child, who suffered lack of oxygen during birth. According to chefläkaren is the event not related to lack of resources.
Read more: Child died at childbirth – Sös lex Maria-sign