Hospital mistakes and admission of error

Filed in archive Opinion on August 17, 2005

A story where admission a tragic mistake at the BI-Deaconness in Boston led to changes to reduce medical error:

In a remarkable example of public disclosure, Dr. Benjamin Sachs, the hospital's chief of obstetrics and gynecology, describes numerous judgment errors and miscommunications in the case in today's Journal of the American Medical Association, one of the world's most widely read medical journals. His report highlights 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 hired airline pilots to train the staff in teamwork and conflict resolution and limited obstetricians' workloads. 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.

There is an increasing movement for physicians to admit mistakes and apologize. (Kowalczyk, "A baby's death prompts reforms in care", Boston Globe, Aug.17)