|
|
|
Indiana Methodist Hospital (located in Indianapolis) made national and international headlines this week for publicly apologizing to the families of two premature infants killed by a drug overdose (four other infants were given the overdose too, with one infant still in critical condition.)
Hospital leadership has met with the families, apologized, admitted fault, and offered compensation. They have also vowed to fixed their processes so the same error is never repeated.
In short, this is Sorry Works! in action. The four elements of effective apology (remorse, admission of fault, explanation of how the mistake will be prevented in the future, and compensation) are present. Hospital leaders invited Sorry Works! to speak to their leadership last summer (2005), and it appears our message resonated. We applaud the hospital leadership and encourage other hospitals and med-mal insurers to follow their lead.
Below is an article written and published by the Associated Press on the story with quotes from Sorry Works! Please forward to colleagues.
For more information on Sorry Works! speaking engagements and teaching programs, contact 618-559-8168 or e-mail doug@sorryworks.net.
AP Centerpiece: Hospital apology could go a long way
DEANNA MARTIN and JENNY MONTGOMERY
Associated Press
Tue, Sep. 19, 2006
INDIANAPOLIS - Methodist Hospital has changed the way drugs are handled since six premature infants were given overdoses of a blood thinner, causing two girls to die.
Hospital officials also have apologized to the affected families, which advocates say is often one of the most important steps after such medical mistakes are made. Hospital leaders on Tuesday added that they would financially compensate the families for their loss.
Expressions of regret and offers of up-front payments do not always come so quickly after such mistakes, said Doug Wojcieszak, the founder the Sorry Works! Coalition, a group that advocates more openness in reporting medical errors.
Although money might not be what grieving families want now, it could take away some anger later, said Wojcieszak, who said he lost a brother to medical error.
"They've had their hope and their love tied up in their children, and then something like this happens," he said. "Obviously you can never replace a life, but people need healing. They need people to take ownership of those mistakes."
Of the four other infants who were given the overdose, three were in stable condition, while a fourth was in critical and unstable condition, officials said.
Methodist has blamed the overdoses on human and procedural errors. Heparin comes in premeasured vials, which hospital pharmacy technicians place in a computerized drug cabinet.
Early Saturday morning, a technician with more than 25 years experience took the wrong dosage from inventory and stocked it in the drug cabinet in the Newborn Intensive Care Unit, officials. Nurses accustomed to only one dosage of heparin being available administered the wrong amount.
Emmery Miller and D'myia Alexander Nelson, both less than a week old, died.
Methodist was solely responsible for the error, said Sam Odle, president and CEO of Methodist Hospital, which is part of Clarian Health Partners.
"Of course we have offered our apologies and our deepest regrets," Odle said. "Ultimately the blame for our errors falls upon the institution. A weakness in our own system has been exposed and has been corrected."
Medical errors are estimated to kill thousands of people each year - some studies put the number between 44,000 and 98,000. Cases similar to the problem at Methodist have happened before.
In 1990, three premature infants died in Philadelphia after receiving an incorrectly mixed intravenous solution. In 1991, two premature babies died in Dallas after being overdoses of an antibiotic when a hospital technician prepared the wrong mixture.
Jim Conway, a senior fellow at the Institute for Healthcare Improvement said hospitals need to work to find ways to prevent errors.
"Every one of us will make mistakes, and it's the responsibility of health-care organizations to put in place systems that support safe practice," Conway said.
Some hospitals and doctors have resisted in the past admitting mistakes publicly because they fear lawsuits.
But certain reporting systems allow hospitals to report errors without the fear of a lawsuit, said Rick Croteau, with the Joint Commission on Accreditation of Healthcare Organizations.
"We are seeing, in effect, a shift in the culture that allows people to be more open and demonstrate that they're doing the right thing," Croteau said.
The Indiana Department of Health was expected to approve a rule Wednesday that will require hospitals to publicly report various types of mistakes to the state, a change that was expected even before Saturday's deaths. The first round of data was not expected until 2007.
Michael Cohen, president of the Institute for Safe Medication Practices, said Methodist's error could happen at any hospital with similar medication systems.
Clarian was one of thousands of hospitals nationwide that participated in the 100,000 Lives Campaign aimed at reducing lethal mistakes and breakdowns in care to prevent unnecessary patient deaths. Earlier this year, the leaders of the campaign said hospitals had prevented 120,000 deaths in the past 18 months by changing procedures.
Cohen said even with error reporting, it can be difficult for consumers to determine what mistakes mean.
"The public shouldn't see it as a scorecard," Cohen said. "You can't draw conclusions that one hospitals is any less safe than another."
|
|
|
|
