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THIS WEEK'S EDITION:
- Parents looking for answers in death of infant
- Healing Words 2nd Edition hits the street!
- On the road again
- Perfect stocking stuffer/CME & CEU credits
- Question & Answer
- Year in Review
Parents looking for answers in death of infant
It seems like the hospital below does not have a Sorry Works!/disclosure program in place. Sorry Works! brings patients and families - customers - closer and works to solve their problems after adverse events....whereas the family featured below seems to be out of the hospital's sphere of influence, they're angry, and searching for answers in a way that is very damaging to the hospital. As you read this article try to imagine how much this bad PR is costing the hospital in question.
http://www.kvbc.com/Global/story.asp?S=5779640&nav=15MV
KVBC News 3 Las Vegas
Dec 6, 2006 07:40 PM EST
Parents asking hospital for answers in death of infant. A baby dies in the hands of those who were supposed to care for her. That's how it appears to the parents who lost their little girl. Kathlene and Richard Shinn say their daughter was given a lethal dose of zinc sulphate at Summerlin Hospital last month.
On Wednesday, the parents spoke out about what they call a medical mistake.
The Shinns say the hospital hasn't given them many answers. Alyssa Shinn was just three weeks old and healthy before she was given a deadly dose. Born at a pound and four ounces, Summerlin hospital staff kept a close watch over Alyssa in the neonatal intensive care unit.
But something went fatally wrong a month ago when a prescribed nutritional fluid had too much zinc sulphate. Zinc normally helps in the metabolism of a growing baby but in this case too much of it led to her death. Alssya's mother said they didn't find out until it was too late.
They knew three hours before that. I talked to them on the phone, (the staff) didn't indicate there was a medication error. Didn't tell me to come in as soon as possible and spend last three hours of her life with her. Didn't give me opportunity, husband the opportunity.
The hospital responded by saying it's saddened by the situation and are further investigating what happened.
Alyssa's mother says so far, it's been a game of point the finger. There were up to seven people who came across the prescription, but no one saw anything wrong until there was nothing anyone could do.
Alyssa's parents and nurses administered an anecdote hours after the zinc was given. According to a coroner's report, the baby died of cardiac arrest because of the overdose
Healing Words 2nd Edition hits the street!
The second edition of Dr. Mike Wood's book "Healing Words, the power of apology in medicine" has hit the streets. The book is revised and updated and being distributed by Joint Commission Resources. The first edition of Healing Words sold thousands of copies and was popular throughout the United States and around the world. Mike is a Sorry Works! board member and we wish him and his new colleagues at Joint Commission Resources all the best. Get your copy today!
On the road again
Sorry Works! spokesperson Doug Wojcieszak will be hitting the road for the last time this year. This Tuesday Wojcieszak will be in Teaneck, New Jersey to speak to the staff at Holy Name Hospital. The following Tuesday Wojcieszak will be in El Paso, TX to present a grand rounds ethics seminar co-sponsored by the Thomason Hospital (El Paso County Hospital District) Ethics Committee and the Texas Tech University Health Sciences Center.
It's been a busy year of travel with 33 presentations in the United States and Australia. However, 2007 looks to be even busier with several speaking engagements already booked. If you are interested in a Sorry Works! speaker please call 618-559-8168 or e- mail to doug@sorryworks.net. Furthermore, if you know people or institutions who need speakers on disclosure, please forward this e- newsletter to them. Thanks!
Perfect stocking stuffer/CME & CEU credits
Malls too crowded? The box of stale chocolates or cheap wine bought over the Internet won't make for a cool Yule? Don't despair...Santa is here with the Sorry Works! audio conference CD to spread holiday cheer. Get yours today by contacting our friendly elf Melanie Gober at mgober@rmpsi.com or call 517-886-8226.
Better yet, ol' St. Nick informs us that the Sorry Works! audio conference can count for CME and CEU credits for two (2) full- years after the conference date (November 14, 2006). So, gather the staff around, pour some egg nog, pass the Christmas cookies, and earn 1.5 AMA PRA Category I CreditsTM and/or 1.8 nursing contact hours by listening to the Sorry Works! CD.
Don't be a Scrooge - order your CD today and make all the folks on your list happy. Ho, ho, ho!
Question & Answer
Welcome to this week's Q&A with Dr. Geri Amori, RM&PSI Senior Director (www.rmpsi.com) and experienced risk manager, educator, and counselor and Doug Wojcieszak, Founder and Spokesperson of The Sorry Works! Coalition (www.sorryworks.net). This week's question comes from the recently completed Sorry Works! audio conference. Over the next few weeks will be sharing some of the questions we received from the audio conference.
Question: "I got the impression that counsel for the hospital is involved in the process. Our in-house counsel is generally not involved in malpractice litigation other that for program oversight. Would it be wise to retain counsel to assist us in this process?"
Geri: You are asking an important question. When we talk about involving your counsel, it's not for the purpose of "protecting" yourself, so much as to help ensure that you understand all the ramifications of your actions in light of your own specific state laws. Often in-house counsel is more of a corporate counsel and not involved in malpractice litigation. Most of the time they are not the ones to be involved because they may not have the knowledge base that you are looking for. Medical malpractice defense attorneys tell us that they like to be involved so they can serve as an outside voice to help ensure you have identified and preserved evidence in case the early compensation offer isn't accepted. In addition, since we believe it is important to allow patients/families to engage an attorney during this process so they feel safe, you might want your attorney involved so they can talk "lawyer jargon" peer to peer, and so you feel safe as well.
Part of who should be involved and how they are involved is determined by the type of risk financing program you have. Here's the bottom line: Involve those parties who will have to cooperate with you and might have to help you achieve the goal of legitimate compensation for any injury that you may caused through error. What you don't want is for you or the physician to apologize and make an offer THEN for the insurer to say you were out of line making the offer, or your attorney to say that you based it on hearsay...or some other thing. You'll have a mess on your side and the patient/family only sees that you are behaving strangely, backing off your original position, or are beginning to sound "wiggly." All the potential good you have done to re-establish trust can be destroyed by appearing like you are changing your tune.
We suggest working out the bugs in your system before you have an actual situation to handle. Do you have commercial insurance or are you self insured? Who handles your claims? Are they on your team philosophically? Do you agree on what constitutes a preventable error? Just because an error happens everywhere, doesn't mean it is less of an error if it has caused a compensable injury. (That would be like saying, if a certain car has a poorly designed fuel system - remember the Pinto? - and lots of people get injured because of it, we don't need to compensate them. Sorry folks, I don't accept that as fair to those who are injured.) On the other hand, our claims litigation system has historically been based upon a methodology that says that if you can find an expert that says it's a "normal" outcome, then there is no liability. SO, involve your claims people to ensure you are in philosophical agreement.
Through your insurer, or directly through your risk management department, involve your malpractice attorney to ensure that she/he is philosophically aligned with you. You want them to support and guide you through the early compensation process, not be a deterrent.
Back to your question of whether you need to hire someone for this function. My guess is that you have someone, you might need to identify them and ensure you are philosophically aligned.
Doug: Geri gave an excellent answer. It's important for both sides (patient/family & doctor(s)/hospital/insurer) to have the opportunity to use compentant legal counsel, if they wish. Discussing and negoitating medical errors is something most people are unfamilar with....not something we do every day (thankfully). That's why experienced attorneys can help in the process. But, Geri is right...it's important to get everyone on board (including your attorney) before an adverse event. It's important to make sure your counsel is philosophically aligned with your disclosure program. If not, tell them they need to change or make a change - hire a new attorney! For disclosure programs to be successful, all the key players (medical leadership, administration, insurer, and counsel) have to be on board.
Year in Review
This will be the last newsletter for 2006. We will be taking the next two weeks off to enjoy the Holidays and get ready for next year. So, we want to take a moment to thank you, our loyal readers, for another fantastic year. The website had nearly 800,000 hits this year, and our membership has swelled to over 2,000 healthcare, insurance, and legal professionals. We gave 33 presentations all around the United States and Australia and many more talks all already booked next year. We have seen interest in disclosure and transparency continue to grow at a remarkable pace, especially among insurers, and we anticipate more growth in 2007. We launched a new partnership with the Risk Management & Patient Safety Institute (RM&PSI). The Sorry Works!/RM&PSI team produced a successful audio conference that had participants from 34 states, the District of Columbia, and two provinces in Canada. Three more audio conferences are planned next year - stay tuned. The RM&PSI/Sorry Works! team also held the first of many train-the-trainer seminars with our first client being the West Virginia Hospital Association. Look for Sorry Works! and RM&PSI to develop and market more training and teaching opportunities for healthcare, insurance, and legal professionals in 2007. Disclosure is a hot topic, and we will continue to lead the charge!
We wish all of you a safe and happy holiday season, and we'll see you right back here in the New Year. Cheers!
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