As more hospitals turn to centralized fetal heart rate monitoring, they should be aware of the unanticipated, and sometimes problematic, consequences that can occur, says a case study of an event that went undetected with centralized monitoring. The case study appears in the January 2015 WebM&M from the Agency for Healthcare Research and Quality. In the case, the baby's abnormal fetal heart rate tracings, which likely would have prompted an urgent cesarean section, were unnoticed for at least 90 minutes before the baby's delivery. The responsible obstetrician was busy with another childbirth at the time. The hospital used a centralized approach to monitor fetal heart rate tracings from its 16 labor and delivery rooms. Hospitals have introduced centralized monitoring to watch patients simultaneously from a single location. In the case, the infant suffered brain injury and other complications from inadequate oxygenation during childbirth. The two nurses assigned to watch the centralized monitor at the time of the baby's delivery commented on the difficulty in identifying abnormal tracings from the 16 window displays on a single 40-inch monitor at the nurses' station. To get a complete picture of a particular case, the window for each tracing must be expanded on the screen. Studies have found that a person's ability to detect abnormalities decreases as the time at the monitoring task progresses and as the number of monitoring tasks increases. Among the author's recommended strategies to improve centralized fetal heart rate monitoring are providing ongoing education and training to staff to identify subtle abnormalities, having more than one person monitor the displays, and limiting the duration of the monitoring shift. Technologic solutions to provide warnings generated by computerized analysis of the tracings have reduced vigilance failures but have not eliminated them, the authors note. Any prevention measures must be supported by a safety culture in the labor and delivery unit, where a commitment to safety prevails. Other cases in the same issue examine a laparoscopic surgery event and a rushed heart bypass procedure.

HRC Recommends: Hospitals that use centralized approaches to monitor electronic fetal heart rate tracings should ensure that measures, such as those suggested in the WebM&M article, are in place to maintain the vigilance of those assigned to monitor the tracings. Risk managers should share the case study with their staff in their labor and delivery units to underscore the importance of providing a sufficient number of well-trained and vigilant staff, free of distractions, at the centralized monitoring station.