Mark Graban, creates a interesting compilation of experiences as he examines avoiding dangerous or deadly healthcare mistakes in his blog, Looking at Medical Mistakes – Learning and Preventing or Repeating?
In Graban’s first case he discusses a 12-year old boy’s untimely death after he was prematurely sent home from a local ER. This story was covered recently in the NY Times. Says Graban,
“The hospital’s emergency room sent Rory Staunton home in March and then failed to notify his doctor or family of lab results showing he was suffering from a raging infection.
This is arguably a mistake in clinical judgment, if the docs didn’t detect signs of dangerous sepsis. I mean Rory had just cut his arm diving for a basketball in the school’s gym. The E.D. thought he was just dehydrated and had an upset stomach, so they gave him fluids and a pain reliever and sent him home. In retrospect, say some, Rory’s vital signs, should have raised warnings that he was more seriously ill. Lab results came back hours after Rory and his family went home:
Three hours later, when the Stauntons were at home: the hospital’s laboratory reported that Rory was producing vast quantities of cells that combat bacterial infection, a warning that sepsis could be on the horizon.”
Graban reiterates that Rory Staunton died because no one bothered to check those labs and contact the family after they had been discharged. The blog then takes a closer look at what the hospital could have done differently. Suggestions from the NY Times article included instant notification of lab results indicative of something dangerous or important, developing a worksheet to be completed before discharging a patient and if a patient’s labs indicate further investigation a clinician will contact the patient after he is discharged.
The blog continues to discuss whether these measures will actually be implemented, adhered to and create the change necessary to avoid another mistake like Rory Staunton.
Lean Healthcare guru Mark Graban says, “Toyota’s Taiichi Ohno always taught that “standardized work” (in the Lean parlance… checklists are an example) must be developed by the people who do the word. Dr. Atul Gawande teaches the same idea in his book The Checklist Manifesto: How to Get Things Right.”
Graban takes a closer look at whether these hospitals are learning from mistakes such as Staunton and cites the following:
Cedars-Sinai didn’t learn from the series of preventable mistakes that killed three babies in an Indianapolis hospital in 2006, leading to the 2009 overdose of the Quaid twins (which they survived, thankfully).
Taking responsibility for your actions is only part of the process, says Graban. Citing other stories from the news he points out that even firing employees who were responsible for the error at the hospital was not always the correct approach to fixing things either. He ends with an important question, So what ARE we going to do? If I had a biopsy that was suspected cancer, would I be able to trace that specimen through the process with my own eyes? I’d sure want to…
Some other blogs on the topic by Graban:
Being Careful Isn’t Enough, Particularly in Pathology (I warned of this risk in 2006)
This Will Happen Again, Unless… (a mixup that made the news in 2007)
Another Pathology Mishap (in 2008)
Yet Again – A Patient Harmed as Hospital Lab Mixes Up Specimens (a case in 2009)