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System Errors in Intrapartum Electronic Fetal Monitoring: A Case Review


  • Lisa A. Miller CNM, JD

    Corresponding authorSearch for more papers by this author
    • Lisa A. Miller, CNM, JD, teaches multidisciplinary fetal monitoring programs nationally and is president of Perinatal Risk Management and Education Services. She is in clinical practice as a certified nurse-midwife at Saint Anthony Hospital in Chicago, Illinois.

Lisa A. Miller, CNM, JD, 2014 West Cullom, Chicago, IL 60618. E-mail:


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.