Beth Israel danger zone

An article in the current Journal of the American Medical Association (A 38-Year-Old Woman With Fetal Loss and Hysterectomy) describes a tragic case of a healthy woman having her first child at Beth Israel Deaconess Medical Center (BIDMC) in Boston. Due to a series of system failures, the baby was stillborn and the mother severely injured.

The incident, which occurred in November 2000 was a “sentinel event” for the hospital and triggered a series of reforms. My wife had a similar though ultimately less serious incident at the same hospital a month earlier when our daughter was born. My wife also had a uterine rupture and an emergency C-section. The baby was born with a 1 Apgar score at 1 minute and was rushed to the ICU. (Both mom and daughter are fine now.) Some of the problems described in the article applied to our case as well.

“Mrs. W,” the mother in the JAMA article says,

We trusted a lot. We were at what I thought was the best possible hospital… Looking back, had I just gotten up and yelled out in the hallway, right outside the door, I feel like that would have made something different happen.

She’s probably right. In fact back when my brothers (who are twins) were born in another Boston teaching hospital, my father did get up and yell in the hallway and apparently it worked.

The article describes six things that went wrong in Mrs. W’s case:

  1. Poor communications –including no clinical plan
  2. Lack of mutual performance cross monitoring –where the team double checks one another
  3. Inadequate conflict resolution
  4. Poor situational awareness
  5. High MD workload and no contingency planning
  6. Attending physician on duty for 21 hours, experiencing “vigilance fatigue” –the failure to monitor a serious problem intensively enough after a while

In our case back in 2000 we had a more experienced OB, a less busy night, less trust in the system, the experience and confidence to speak up, and some luck.

Things really do seem to have changed since that time.

When I blogged last month about the experience of having our newest baby at “a prestigious teaching hospital” I was also talking about BIDMC. As I wrote at the time I noticed that a lot of re-engineering had been done, including performing scheduled C-sections in the regular OR to free up the OB floor’s OR for emergencies, and adding a pre-op and post-op checklist that encouraged cross-checking, debriefing, etc. The checklists closely tied to the 6 points above. I had no idea at the time about what triggered it all.

August 17, 2005

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