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Ho AM, Dion PW, Cheng CA, Karmakar MK, Cheng G, Peng Z, Ng YW. A mathematical model for fresh frozen plasma transfusion strategies during major trauma resuscitation with ongoing hemorrhage. Can J Surg Dec 2005; 48: 470-8.

BACKGROUND: Randomized controlled trials of how best to administer fresh frozen plasma (FFP) in the presence of ongoing severe traumatic hemorrhage are difficult to execute and have not been published. Meanwhile, coagulopathy remains a common occurrence during major trauma resuscitation and hemorrhage remains a major cause of traumatic deaths, suggesting that current coagulation factor replacement practices may be inadequate. METHODS: We used a pharmacokinetic model to simulate the dilutional component of coagulopathy during hemorrhage and compared different FFP transfusion strategies for the prevention or correction, or both, of dilutional coagulopathy. Assuming the rates of volume replacement and loss are roughly equal, we derived the hematocrit and plasma coagulation factor concentration over time based on the rate of blood loss and replacement, the hematocrit and coagulation factor concentration of the transfusate, and the hematocrit and plasma factor concentration at the time when FFP transfusion begins. RESULTS: Once excessive deficiency of factors has developed and bleeding is unabated, 1-1.5 units of FFP must be given for every unit of packed red blood cells (PRBC) transfused. If FFP transfusion should start before plasma factor concentration drops below 50% of normal, an FFP:PRBC transfusion ratio of 1:1 would prevent further dilution. CONCLUSION: During resuscitation of a patient who has undergone major trauma, the equivalent of whole-blood transfusion is required to correct or prevent dilutional coagulopathy.

Weinstein L. A multifaceted approach to improve patient safety, prevent medical errors and resolve the professional liability crisis. Am J Obstet Gynecol
Weinstein L. A multifaceted approach to improve patient safety, prevent medical errors and resolve the professional liability crisis. Am J Obstet Gynecol 194: 1160-7.

The current professional liability crisis is the third in the last 30 years. Similarities of the 3 crises
are the rising cost of professional liability insurance and a diminishing number of sources available
to purchase coverage. Proposed tort reform with caps on noneconomic damages and attorney
contingency fees is a back end approach and will do little to solve this crisis or prevent future
ones. The current situation can only be solved by placing an increased emphasis on improving
patient safety and elimination of all preventable medical errors. A national electronic medical record
must be developed and rapid response teams need to be available in most hospitals. The protective
devices of privileged communication and peer review are counterproductive and must be
eliminated. Full and prompt disclosure of any medical error or injury needs to be made. Physicians
must be taught proper communication skills and the importance of teamwork. Providers
with frequent patient, nursing or medical staff complaints must be critically reviewed. The present
system of risk management needs to move from a reactive position to a role of being proactive for
both patient and physician. Claims management should offer the patient early compensation
when appropriate and pursue a vigorous defense when medical care is adequate. Experts should
be identified who will render fair, unbiased reviews of medical care with all of their findings being
disclosed. Similar experts need to devise clear, concise, evidenced based standards of care for
common medical conditions.

Swanton, R, et al. A National Survey of obstetric early warning systems in the United Kingdom. Intern J Obstetric Anesthesia 18: 253-257.

Background: Despite recommendations in the two most recent Confidential Enquiries into Maternal and Child Health
(CEMACH) reports, and improvements in patient care using early warning scoring systems (EWS) in the general adult population,
no validated system currently exists for the obstetric population.
Methods: We performed an Obstetric Anaesthetists’ Association (OAA) approved postal survey of all UK consultant-led obstetric
anaesthetic units in November 2007 to assess opinions on the value and of such a system and how it could be implemented, and
invited comments and samples of systems already in use.
Results: The response rate was 71%. Of those who replied a median usefulness score of 80% for a standardised national obstetric
EWS was demonstrated. Eighty-nine percent of units thought it would be possible to implement a system, and although 96% of
UK hospitals already use a non-obstetric EWS, only 23% of respondents thought this to be relevant to obstetric physiology and
disease. Nine units returned copies of their obstetric EWS. Using extracts from some of the submitted versions we have designed
and implemented a system locally and submitted it to the OAA for consideration.
Conclusions: The survey results support CEMACH recommendations for a nationally agreed obstetric EWS.
c 2009 Elsevier Ltd. All rights reserved.
Keywords: Obstetric Early Warning Systems

PMAD. A new way to think about quitting smoking.
Brees C, Hensleigh PA, Miller S, Pelligra R. A non-inflatable anti shock garment for obstetric hemorrhage. Int J Gynaecol Obstet 87: 119-124.

OBJECTIVES: Maternal death from hemorrhage in low resource settings is frequently due to long delays in transportation to referral centers and/or in obtaining blood and surgical interventions. This case series was designed to demonstrate the feasibility, efficacy and safety of the non-inflatable anti-shock garment (NI-ASG) for resuscitation and hemostasis in the initial management of obstetric hemorrhage and shock. METHODS: Fourteen cases of obstetric hemorrhage and hypovolemic shock at Memorial Christian Hospital, Sialkot, Pakistan were managed with a specific clinical protocol based on using NI-ASG as the primary intervention. RESULTS: The NI-ASG was used to resuscitate and stabilize women with hypovolemic shock from 18 to 57 h. Thirteen patients survived without evidence of morbidity, but one had prolonged shock followed by multiple organ failure and death. CONCLUSIONS: This study confirmed that the NI-ASG quickly restored the vital signs of most women in severe hemorrhagic shock and stabilized them while awaiting blood transfusion.

Waring, JJ. A qualitative study of the intra-hospital variations in incident reporting. International Journal for Quality in Health Care 16: 347-352.

Objective. To determine the relationship between variations in hospital incident reporting and the corresponding attitudes and
participation of medical professionals.
Methods. An in-depth qualitative case study using semi-structured interviews with hospital managers and clinicians. Twelve
participants were theoretically sampled based on their involvement with clinical risk management and patient safety. Twentyfive
medical physicians and four risk leads were selected from the specialist hospital departments of Obstetrics, Anaesthesia,
General Surgery, Acute Medicine, and Rehabilitation. The data were analysed to develop a descriptive account of the intrahospital
variations in reporting and the associated attitudes of physicians.
Setting. The research was conducted in a single acute National Health Service Hospital Trust in the English Midlands.
Results. The qualitative data revealed significant variations in the intra-hospital organization of incident reporting between
medical specialities that corresponded with the attitudes and participation of medical staff. Specifically, it was found that medical
doctors were more inclined to report incidents where the process of reporting was localized and integrated within medical
rather than managerial systems of quality improvement. Underlying these variations, it is suggested that medical reporting is
more likely when physicians have greater control or ownership of incident reporting, as this fosters confidence in the purpose
of reporting, in particular its capacity to make meaningful service improvements whilst maintaining a sense of collegiality and

Mayberry LJ. A Quality of Health Outcomes Model for guiding obstetrical practice . J Nurs Scholarsh 33: 141-6.

PURPOSE: To describe the application of the Quality of Health Outcomes Model, introduced by the American Academy of Nursing Expert Panel on Quality of Health Care, to obstetrical care, particularly second-stage labor. ORGANIZING FRAMEWORK: The model is different from the more linear structure-process-outcome frameworks used in the past to a dynamic conceptualization of reciprocal relationships among the system, intervention, client, and outcome components. Analysis of these components can provide a comprehensive picture of the complexity of patient care decision making in hospital labor and delivery units. CONCLUSIONS: Research findings indicate that interventions such as cesarean delivery and epidural analgesia may result in several significant quality of health outcomes for women that should receive increased attention. Uses of this model for shaping best practices among physicians and nurses and for setting directions for priorities in future interdisciplinary research and health policy are discussed.

Coetzee EJ, Dommise J, Anthony J. A randomised controlled trial of intravenous magnesium sulphate versus placebo in the management of women with severe pre-eclampsia. British Journal of Obstetrics and Gynaecology 105: 300-303.
Oboro VO, Tabowei TO. A randomised controlled trial of misoprostol versus oxytocin in the active management of the third stage of labour. J Obstet Gynaecol 2003; 23: 13-6.

Our objective was to compare oral misoprostol with intramuscular oxytocin in the prevention of postpartum haemorrhage. Four hundred and ninety-six women were randomised to receive either 600 microg misoprostol orally or 10 IU oxytocin intramuscularly after delivery. There were no significant differences between the misoprostol and oxytocin groups with regard to the incidence of postpartum haemorrhage (1% vs. 0% respectively, relative risk (RR) 3.02, 95% confidence interval (CI) 0.32-28.88) or drop in haemoglobin concentration (0.71 g/dl vs. 0.68 g/dl, respectively, P = 0.699). The length of the third stage of labour and the percentage of women requiring manual removal of placenta, further oxytocics or blood transfusion were also similar. Shivering was significantly higher with misoprostol (57% vs. 14%; RR 4.06, CI 2.93-5.62), but there were no differences in other side effects. We conclude that oral misoprostol can replace intramuscular oxytocin in reducing postpartum haemorrhage in low-risk women, in developing countries, especially as it is administered orally and it is thermostable in tropical conditions.