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and Introduction Abstract Intrapartum electronic fetal monitoring (EFM) interpretation and management continue to be a common issue in litigation involving adverse outcomes in term pregnancies. This article uses a case study approach to illustrate system errors related to intrapartum EFM. Common system errors related to use of intrapartum EFM include knowledge deficits, communication failures, and fear of conflict. Strategies for reducing error and the promotion of a patient safety approach to risk management in EFM are discussed, with an emphasis on the importance of a true team approach to EFM education, interpretation, and management. Introduction Electronic fetal monitoring (EFM) is currently the most widely used technology in intrapartum care in the United States, despite questions of efficacy.[1] Although arguments for the abandonment of continuous EFM in low-risk pregnancies continue to be proffered and deserve a thoughtful review, this article addresses the risk management issues associated with intrapartum use of EFM.[2] Allegations regarding the interpretation and management of EFM tracings dominate obstetric litigation related to neurologically impaired infants. In addition, obstetric litigation continues to account for a disproportionate share of medical malpractice indemnity payments.[3] Simpson and Knox have identified several common plaintiff's theories, or allegations, related to EFM, including 1) failures in the assessment and treatment of nonreassuring fetal heart rate (FHR) patterns, 2) communication failures, 3) lack of appropriate response by clinicians, and 4) failure to use chain of command to resolve clinical disagreements.[4] Allegations of medical, midwifery, or nursing error made by a plaintiff in a specific case may or may not be accurate. But there is no doubt that medical errors occur, and their occurrence is a significant problem.[5] Research in the arena of medical error tells us that when the allegations are valid (i.e., when errors occur), they are more likely the result of a complex multiplicity of factors, versus the performance failures of single individuals.[6] This approach of examining error is called a systems approach, and it allows recognition of both active failures, which are failures of clinicians directly involved in patient care, and latent failures, which are failures in areas such as administration, design, or implementation.[7] For example, the failure of a clinician to recognize an abnormal FHR pattern may be due to lack of knowledge (active failure) but may be compounded by fatigue due to lengthy call schedules (latent failure), a lack of training in the clinician's original education program (latent failure), or lack of skills assessment by the employer or credentialing body (latent failure). Thus, error prevention is not simply the removal or retraining of the individual clinician involved, but rather, a restructuring and reworking of the system that created the conditions under which error became not just a possibility (there will always be errors in any human endeavor) but a probability, a "more likely than not" scenario. Training and education in EFM vary widely for certified midwives (CMs), certified nurse-midwives (CNMs), physicians, and nurses.[79] This fact, coupled with the continued predominance of EFM issues in obstetric negligence claims, make FHR interpretation, management, and communication critical areas of concern for clinical practice as well as risk management. The following case study and analysis serve as an example of common errors in EFM and how a systems approach can provide solutions for future error prevention. The case facts and outcome are presented first, followed by a discussion of the fetal monitoring issues, system errors, and risk management strategies applicable to clinical practice. Case Presentation Page 1 of 11 System Errors in Intrapartum Electronic Fetal Monitoring 11/19/2007 file://C:\Documents and Settings\mdwyer\Desktop\System Errors in Intrapartum Electronic Fetal Monit... A 24-year-old primigravida was admitted at term in latent labor during the early morning hours by the CNM on call. The patient had an unremarkable antenatal course and no significant risk factors. Figures 1 to 14 reflect pertinent portions of the FHR tracing; the shaded area in each figure indicates the range of normal baseline rate from 110 to 160 beats per minute (bpm). Figure 1. Patient's admission tracing. Arrows represent RN noting fetal movements.