State details safety lapses at Beth Israel

Sloppy cleaning, lax training are cited

By Stephen Smith
Globe Staff / April 11, 2009
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During a surprise visit last month, state investigators witnessed a worker in the Beth Israel Deaconess Medical Center nursery sloppily cleaning a board that had been used during a minor surgery, contaminating a nearby counter.

They also discovered during the inspection that nurses treating the tiniest of babies had received no special training in how to transfuse blood into their delicate veins.

And they watched as a doctor used medical instruments to examine the eyes and ears of one infant - and, then, a half-hour later, used the same ones on a second baby without disinfecting them.

These and other safety lapses, made public yesterday, turned up during an investigation prompted by a cluster of hard-to-treat bacterial infections among mothers and their new borns who had been at the Harvard-affiliated hospital since late last year.

The state investigation didn't establish a direct link between the deficiencies and the infections, but its findings open a window into the inner workings of an institution that has undertaken an unusually public campaign to eliminate hospital-acquired infections and other preventable errors. And it reveals that, despite the best of intentions, reducing mistakes is a formidable challenge.

"The hospital has to fix this," said Paul Dreyer, director of the state's Bureau of Health Care Safety and Quality, whose staff conducted the investigation. "There are systemic problems, there are breaks in practice, there is an ongoing cluster of cases that's not been resolved."

At the same time the state provided the Globe its thick report late yesterday afternoon, Beth Israel Deaconess released an even bulkier response, detailing how it intends to better protect patients from harm. In a lengthy interview, a top hospital administrator conceded that the investigators from the state Department of Public Health had revealed significant shortcomings in safety procedures on the obstetrics and newborn wards.

Dr. Kenneth Sands, senior vice president of health care quality at the sprawling Longwood area hospital, said it has moved swiftly to correct problems identified in the inspection and will require all doctors, nurses, and other healthcare workers to complete compulsory lessons on infection control by May 1.

"We've always known that it's extraordinarily difficult to set ourselves on a path to have no preventable harm" to patients, Sands said. The lapses cited by the state, he said, "are unacceptable, and we fully agree that . . . they need to be corrected." He pointed out that the hospital had succeeded in reducing some of the most worrisome hospital infections.

The federal Centers for Medicare & Medicaid Services will evaluate both the state's findings and the hospital's response, said Roseanne Pawelec, spokeswoman for the Boston regional office of the agency. In the worst case, the federal agency could strip Beth Israel Deaconess of its ability to participate in lucrative government health plans, although that is a step rarely taken.

So far, disease trackers have identified 19 infants and 18 mothers who have fallen ill with infections caused by methicillin-resistant Staphylococcus aureus, a germ that thwarts treatment by first-line antibiotics. The source of the cluster of cases remains a mystery, although genetic testing has shown the same strain had infected all of the patients, a strong clue there is a common source.

The state inspectors were unstinting in their critique of what they observed as they toured labor and delivery rooms and the nursery on three days in early March, declaring flatly at one point that "the hospital failed to implement an appropriate and effective infection control program for the prevention, control, and investigation of infections and communicable diseases."

They found, for example, that at 11 a.m. on March 3, 19 people swarmed an operating room where a mother was giving birth to a premature baby, with both mother and child susceptible to infection. The crowding, investigators said, put both of them at risk. In another case, investigators watched as a surgical technician provided a surgeon with an unsterile needle holder.

And, on several occasions, the investigators observed worrisome lapses related to circumcisions, including an instance when a nurse didn't change gloves before tending to the dressings of a baby. Of the 19 infants who have become ill with the drug-resistant staph infection, 15 have been boys, according to Dr. Anita Barry, who is overseeing the investigation of the cases by the Boston Public Health Commission.

"I think the circumcision dressing example was one we found particularly problematic," Dreyer said. "You've got examples of contamination that may be in the context of kids with open wounds from circumcision. The danger is spread of infection."

As a result, Beth Israel Deaconess has put in place a policy designed to guarantee sterile techniques for circumcision.

The state report also faults oversight by top hospital executives and questions the internal systems in place for overseeing infection control; the hospital responded by establishing a committee to improve coordination of germ control across all wards.

Sands said that hospital workers who are not vigilant about the new infection-control policies run the risk of being fired.

"I don't think that people are intentionally trying to cause harm, I don't think they're irresponsible," Sands said. "I think it requires focus and vigilance, and it does require slowing down, which can be hard sometimes in the day to day bustle."

Stephen Smith can be reached at

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