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BOSTON, Aug. 17-In an extraordinary public apology, Beth Israel Deaconess Medical Center here, a Harvard teaching hospital renowned for its obstetric care, revealed with remarkable candor its series of blunders that led to a tragic event one night not long ago.

It was in November 2000, when a 38-year-old pregnant woman and her husband, in excited anticipation of the birth of their first child, arrived at Beth Israel Deaconess.

In today's issue of the Journal of the American Medical Association, Benjamin Sachs, M.B., (see photo) the hospital's chief of obstetrics and gynecology and a professor at Harvard Medical School, and colleagues recounted the errors, miscues, and lost opportunities that led to the death of the child, an emergency hysterectomy for the mother, a lengthy hospitalization, and a long, slow recovery.

"There was panic in the air, panic in the room," the patient, identified only as Mrs. W, recalled of the events of that night. "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."

It was too late to save the W's child, a boy, but something did happen at the hospital. The hospital's senior staffers detailed how they have overhauled the system and introduced the concept of team training and responsibility sharing to help prevent future disasters.

"Every single hospital in the United States unfortunately experiences medical errors every day, and some of those medical errors lead to tragic outcomes," said Dr. Sachs in an interview. "Historically in medicine, we have kept these kind of cases under wraps, under peer-review, strict confidentially. We don't discuss them in detail because we're worried about lawsuits, and the end result is that we never learn from our mistakes in the way that we should."

Traditionally, being a physician meant never having to say you were sorry, but when clinicians make errors that's exactly what they should do, says Dr. Sachs.

"We need to be more open with the public about health care, what we can and can't do, and that errors are occurring, and work with the public to try and make them gain more confidence in healthcare as well as encourage us to change," he said. "So the first is open disclosure, saying 'I'm sorry,' and I think its okay for people to say 'I'm sorry.' Another issue is the obligation, in mind, for early financial settlement."

In an immediate analysis of the case, Dr. Sachs and other Beth Israel Deaconess physicians determined that the hospital was at fault, and Dr. Sachs argued successfully for a quick settlement with the family, reported to be in the range of $2 million.

When she saw her obstetrician in the 40th week of gestation showing no sign of labor at term, Mrs. W's blood pressure was 126/78 mm Hg, but in a short time it rose to 144/85 mm Hg. She had trace proteinuria, a creatinine level of 0.8 mg/dL (70.7 μmol/L), and a uric acid level of 6.3 mg/dL. At 41 weeks, her obstetrician decided to admit her for labor induction.

On the night the induction was scheduled, she arrived at the hospital with her husband and sister after driving several hours from home. Her obstetrician was not on call that night, and so was not present for the events that took place. On admission, her cervix was closed and only 50% effaced, and her blood pressure was slightly elevated at 124/90 mm Hg. She was given misoprostol (25 μg, vaginally) for induction of labor and sent home that evening at 10 p.m. In retrospect, Dr. Sachs said, she should have been admitted for monitoring, based on her blood pressure.

On her way home, Mrs. W experienced more contractions, and the family turned around and came back to the hospital, where she was admitted at midnight in active labor, breathing uncomfortably with contractions, vomiting, and with a blood pressure of 174/104mm Hg.

Her cervix was still soft and closed, and the fetal heart rate was in the 130s, with no decelerations accompanying contractions. At 1:30 a.m., her membranes ruptured, and she was having contractions one to two minutes apart. By 3:30 a.m., her cervix had dilated to 2 cm and was 90% effaced. The fetus' heart rate was 120/min, and contractions were every one to two minutes.

When the mother was given a test dose for epidural anesthesia (3 mL of 1%-5% lidocaine), her blood pressure dropped to 53/33 mm Hg, and the fetal heart rate dropped to 80/min, but both subsequently recovered.

At 4:30 a.m., the delivery team noted an unusual saltatory, or sawtooth pattern, to the fetal heart rate, with occasional late decelerations. At that time, an ob-gyn resident evaluated Mrs. W for pre-eclampsia and ordered laboratory tests, but the tests were never completed because of "miscommunication."

The resident also relayed her concerns to the attending physician, who had been on call for 21 hours at the time, and may have been suffering from impaired judgment due to "vigilance fatigue," which Dr. Sachs defined as "sticking to a diagnosis despite evidence to the contrary." The resident did not go over the attending's head with her concerns.

Although the etiology and significance of the sawtooth fetal heart rate pattern are unknown, the mother's frequent contractions at that stage could have signaled an abruptio placenta caused by maternal hypertension or pre-eclampsia.

"However, there were no ominous signs requiring emergency cesarean delivery, such as fetal heart rate decelerations that begin after the peak of a uterine contraction (late decelerations), seen in utero placental insufficiency," Dr. Sachs said. "Despite the confusing picture in this case, no further action was taken. In hindsight, a cesarean delivery should have been performed because of the lack of reassuring fetal heart rate."

Thirty minutes after she started to push the fetal heart rate was 115/min, with late decelerations. It quickly dropped to 90/min for 3 minutes, followed by further slowing for about 11 minutes. Following a failed attempt at low-forceps delivery, she was transferred to the operating room for an emergency cesarean delivery.

When the surgeons opened the abdominal cavity, they found that the uterus had ruptured in the lower segment and the placenta was in the abdomen. The baby, a male weighing 10 pounds, was dead, and was probably already so when the operation started.

"In hindsight, the fetal heart rate, noted in the operating room to be in the 130s, was probably the maternal pulse," Dr. Sachs said at the grand rounds. "The fetal heart monitor may display the maternal pulse if the fetus is dead and particularly in the case of maternal tachycardia."

Had the cesarean section occurred at 5:30 am., it probably would have resulted in a live birth without complications, he added.

For Mrs. W. the uterine rupture, which was likely caused by uterine hyperstimulation or the low forceps delivery, resulted in an emergency hysterectomy, complications involving massive transfusions of packed red blood cells, fresh frozen plasma, cryoprecipitate and platelets.

She spent 18 days in the intensive care unit, and had life-threatening problems such as disseminated intravascular coagulopathy, acute respiratory distress syndrome, sepsis, and a wound infection. After three weeks in the hospital, she was transferred to a rehabilitation facility, and had subsequent intensive physical and occupational therapy and supportive care.

She and her husband have since adopted a healthy child.

For the Beth Israel Deaconess Medical Center, the case became "a burning platform, resulting in a major analysis of our department's procedures and the introduction of team training, a major reorganization of the way care is provided," Dr. Sachs said.

The department began by improving its quality assurance and quality improvement programs, broadening the program to include input from all staff and students -- not just clinicians -- and making the process educational rather than punitive.

"When this was all going on, I was approached by the Department of Defense to see whether we would be willing to adapt the principles of crew-resource management or team training for health care," Dr. Sachs said.

Crew Resource Management is an airline industry safety and error reduction program, which many aviation experts credit with reducing plane crashes and improving survival of passengers and crew when accidents do occur.

The department established a system whereby a core team treats patients, while a coordinating team led by the charge nurse and a senior physician on call, supervises the core teams' clinical decisions and monitors their workloads. A third team called the contingency team is activated when there is an emergency on the unit. There are two or more unit team meetings each day to discuss plans for all patients. Regardless of which team a person is on at any given time, all need to be knowledgeable about and aware of all patients.

In addition, the hospital limits obstetricians to management of a maximum of three patients who are in labor simultaneously, and physicians are encouraged but not mandated to do 12-hour rather than 24-hour shifts.

"I think that the techniques for crew resource management work very well in labor and delivery, operating rooms, ICU settings and emergency medicine, where there is a multidisciplinary approach towards health care and constant change in volumes of patient and acuity," Dr. Sachs said in the interview. "To get people to change is not easy. It's much easier to do physician order entry and have a new computer on your desk than to get people to change the way they practice medicine. So you need the political will to make change."

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