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Wednesday, March 28, 2007

Beth Israel wins prize for reducing medical errors

By Liz Kowalczyk, Globe Staff

The state's largest health insurer has awarded Beth Israel Deaconess Medical Center a $100,000 prize for its "groundbreaking approach to reducing medical errors" after the death of a newborn in 2000.

The hospital's department of obstetrics and gynecology is the first recipient of Blue Cross and Blue Shield of Massachusetts' Health Care Excellence Award, which will be presented to physicians at a health care conference in Boston on Monday.

Blue Cross president Cleve Killingsworth said in a statement that the hospital "successfully changed its culture and achieved significant results" through an initiative that borrowed team work and communication improvements from military and commercial aviation. More than 40 hospitals and other health care organizations competed for the award.

In August 2005, Dr. Benjamin Sachs, chief of obstetrics and gynecology at Beth Israel Deaconess, described numerous judgment errors and miscommunications in the baby's case in an article in the Journal of the American Medical Association. His report highlighted how medical mistakes occur, often because of an accumulation of smaller miscues, and the changes his department adopted in the aftermath.

The case, which occurred in November 2000, became a "burning platform," he wrote, resulting in "a major reorganization of the way care is provided." The hospital used "crew resource management" techniques to train the staff in teamwork and conflict resolution, and limited obstetricians' workloads. The obstetrics department also made major changes in the way it monitored patients. Rather than doctors and nurses knowing the medical situations only of patients directly under their care, the entire department now is knowledgeable about all patients.

Since then, fewer mothers and their babies have suffered complications during childbirth, and legal claims also have declined, though it's not certain that the changes caused the drop. Between 1999 and 2005, the department experienced a 35 percent reduction in "adverse events" among patients and a 50 percent decline among high-risk patients, Sachs said.

The mother in the 2000 case, referred to in the article as Mrs. W, suffered massive blood loss, required an emergency hysterectomy, and spent three weeks in the hospital. In the article, Sachs apologized to the family, taking the unusual step of admitting mistakes and apologizing for them in a public forum.

The $100,000 award will pay for obstetrics nurses to attend a national patient safety conference in May, development of an online continuing medical education course in crew resource management, and research in patient safety.

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