From Tragedy to Safer Care: A stillborn baby

Seven years ago, a series of errors befell Mrs. W. while she was an obstetric patient at Beth Israel Deaconess Medical Center in Boston, and her 9-month old fetus was stillborn. Mrs. W. herself needed a hysterectomy, and 18 days of subsequent hospitalization in the intensive care unit.

According to the Chief of Obstetrics in the Journal of the American Medical Association article, staff made several errors in her care. After she started labor, doctors discharged Mrs. W. back home, though her blood pressure should have led doctors to keep her in the hospital. When she was re-admitted at midnight, a few hours later, doctors did not consider that preeclampsia could be involved. Doctors ordered lab tests, but the tests were never sent, due to miscommunication. When the fetus' heart rate exhibited a worrisome "non-reassuring" pattern of "late decelerations," a C-section should have been promptly performed at 5:30 am.

Several factors contributed to the errors. The attending physician had been on call for 21 hours, and fatigue may have led the doctor to stick to a diagnosis despite evidence to the contrary. There were an unusually high number of women giving birth there at that time. Residents were afraid to speak up to the more senior doctors. At age 38, Mrs. W was relatively old for a first-time birth. The hospital had been experiencing severe financial difficulties, which might have affected nurse staffing levels. The crisis occurred in the early morning. Mrs. W. did not know about the drug used to induce her labor.

In the words of Mrs. W's husband, "That night, I saw residents who were afraid. They were either unable or unwilling to get the doctor, when clearly things weren’t going the right way."

As a result of the multiple tragic errors in her care, doctors and other staff aggressively have since acted to safeguard their system of care to prevent similar errors. Indeed, they were able to reduce errors by about 25%.

This improvement led the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to honor the hospital last week with the John M. Eisenberg Patient Safety and Quality Award.

I hope the improvement will be permanent. Two factors, however, will make this doubtful. First, hospital policy continues to have attending physicians on call for 24-hour shifts, despite the Chief's clear attribution of overwork and fatigue as significant contributing factors. Second, the Chief is leaving the hospital, and it is unclear whether his successor will as strongly advocate team communication ("crew resource management," from the aviation industry).

Dr. Sachs' advice to patients and their spouses, patient advocates: Ask the attending physician, "What's going on, and what are the plans?"


Read one of our stories by a pilot who is expert in crew resource management, or read more from the discussion among doctors in the August 17, 2005 issue of the Journal of the American Medical Association.