Stop! Check your initial assumptions: Frozen patient management in obstetrical practice

Ayala Kobo-Greenhut, Jawad Sakas, Racheli Magnezi, Izhar Ben Shlomo

Research output: Contribution to journalArticlepeer-review


At times, leaping from one patient management routine to an alternative one may be required to mitigate medical errors. "Frozen patient management" is the resultant situation, when, in the face of an obvious gap between the expected and the actual phenomena, leaping from current patient management to an alternative one is not considered or done. Frozen patient management can lead to a significant delay of the correct definitive intervention, be it surgical or pharmacological. The significance of this delay is especially important in time-dependent dynamic situations. In delivery ward, this may cost the life of either the fetus or the mother.In this study, we describe a sequence in which frozen patient management occurred in the delivery ward. Using "thinking protocol" (herein termed "de-freezing" questionnaire) made the team stop and consider a leap when gaps became apparent, and saved the mother's life.We believe that adopting the "de-freezing questionnaire" as a routine adjunct for all medical activities would lead to a timely change of treatment line, which, in turn, will save lives and unnecessary suffer.

Original languageEnglish
Article numbere9280
JournalMedicine (United States)
Issue number50
StatePublished - 1 Dec 2017

Bibliographical note

Publisher Copyright:
Copyright © 2017 the Author(s). Published by Wolters Kluwer Health, Inc.


  • De-freezing
  • Delivery room
  • Missed diagnosis
  • Patient management
  • Patient safety
  • Stagnant medical treatment


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