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September 4, 2007 - SPECIAL SORRY WORKS! NEWSLETTER
Doug Wojcieszak, Founder & Spokesperson
Contact phone/e-mail address: 618-559-8168; doug@sorryworks.net
Two weeks ago we issued the first-ever "special" Sorry Works! newsletter to share the great news about the Chicago Tribune'sfront page story on the new disclosure program at the University of Illinois Medical Center in Chicago, IL. This was "special" because it was a true sign of how far the disclosure movement has come...front page news about a successful disclosure program in the litigation hot-bed of Cook County, IL.
Today, we are issuing another special Sorry Works! newsletter, which again shows how we have come.
The Methodist Hospital in Omaha, Nebraska recently produced and released a video about an error they made that led to the death of a 19-year old patient. The video was produced in conjunction with the young man's family. This video includes candid admissions of fault from the leadership of hospital concerning a missed diagnosis. The video was produced as part of the settlement agreement between the patient and family.
Nineteen-year old Tyler Kahle had a family history of aortic dissection. His father had the disease and his unlce died from it a year earlier. When he developed severe chest pains Methodist physicians were sure he was having respiratory problems. The doctors stuck to their diagnosis even though Tyler made three separate trips to the same emergency room in a eight (8) day time period and his parents informed the physicians of the family history. No, the doctors said, his symptoms had nothing to do with the heart, and, besides, Tyler was too young for aortic dissection. Unfortunately, they were wrong and Tyler died.
This video not only provides closure and healing for all sides in this sad story, but it also led to process improvement within theMethodist Hospital and elsewhere. In the video, the Methodist leaders show how they have changed their processes to make sure this mistake doesn't happen again. Furthermore, Methodist staff say in the video since the process improvements have been instituted they have properly diagnosed five cases of aortic dissection - and successfully treated those patients. Tyler died, but thanks to this video and the disclosure process five patients (and five families) live on. Methodist Hospital is sharing the video with other hospitals so others can learn from their mistakes.
That's success. That's also the ultimate benefit of disclosure and apology: process improvements and enhanced patient safety. Nothing increases patient safety and thus reduces liability better than disclosure and apology.
The link for the video is on the front page of the Methodist Hospital website. Please share with colleagues and friends. Here is the link for their website and the video story is at the top of page directly below the banner: bestcare.org
In case you have trouble with the link above, simply visit the Methodist Hospital website: www.bestcare.org.
Also, below is a story about the video and the case in a local Omaha, Nebraska newspaper:
August 29, 2007
Hospital offers rare mea culpa after death
BY MICHAEL O'CONNOR
WORLD-HERALD STAFF WRITER
The death of the 19-year-old Omahan five years ago resulted in a lawsuit against Methodist and an out-of-court settlement that included creation of the video.
Parts of the 20-minute video are a tribute to the young man. It shows him graduating from high school, skateboarding, wave-boarding and doing the high-energy activities he loved.
Aortic dissection is a tear in the lining of the aorta. If diagnosed quickly, it can be treated.
The problem runs in families. Nineteen-year-old Tyler Kahle died from the condition, and so did his uncle. His father and brother survived aortic dissection.Other parts carry messages that legal experts say are surprising and uncommon.
In the video, initiated by Methodist, the hospital's doctors acknowledge the mistakes that Methodist made in diagnosing the medical problem that caused his death. Legal experts say it's rare for doctors and hospitals to publicly acknowledge mistakes after a settlement.
"It's more common that they don't parade around (saying) that we made a mistake," said Craig Dallon, a professor at the Creighton University School of Law.
What's also unusual, he said, is that Methodist has posted the video, made in cooperation with Kahle's family, on its Web site and plans to distribute it as a DVD nationally to educate other hospitals and doctors about the aortic dissection that led to Kahle's death.
"It was a way to memorialize Tyler, and we hope to prevent this from happening again," said Sara Juster, a vice president for Nebraska Methodist Health System, whose duties include overseeing the hospital's legal cases.
During negotiations for the settlement with the man's family, Methodist raised the idea of the video and the family backed it, said Juster and Deb McMillan, Kahle's mother.
Tyler Kahle case
Late September, early October 2002: Tyler Kahle goes twice with chest pains to Methodist Hospital's emergency room and once to his family doctor at Methodist Physicians Clinic. All three times Methodist physicians diagnose and treat him for upper respiratory problems.
Oct. 7, 2002: Kahle dies of an aortic dissection, four days after his last trip to the Methodist emergency room.
June 2003: His family sues Methodist.
November 2005: The family and Methodist reach out-of-court settlement that included Methodist producing a video about the case.
August 2007: Methodist releases the video.McMillan said the video provided the justice she wanted for her son. She wanted Methodist to publicly admit its mistakes. She also wanted the hospital to help educate other health care providers and prevent deaths.
"If I can't have my son back, we (can still do) some good," she said.
During an eight-day span in fall 2002, Kahle went twice with chest pains to the Methodist emergency room and once to his family doctor at Methodist Physicians Clinic.
All three times, Methodist physicians diagnosed and treated Kahle for upper respiratory problems.
McMillan repeatedly told Methodist doctors about her son's family history of aortic dissection, but he was never given a scan for the ailment. He died four days after his last trip to the Methodist emergency room.
Aortic dissection, deadly if not diagnosed quickly,is a tear in the lining of the aorta. It can be spotted with medical imaging equipment and can be treated. The ailment, which killed actor John Ritter, runs in families, including Kahle's.
In the video, Methodist doctors say Methodist did not take into account Kahle's family history of aortic dissection and did not consider the fact that it can occur in young people.
Dr. Anton Piskac, Methodist vice president for quality improvement, said in the video: "We had multiple opportunities to do the right thing and repeatedly neglected to do so."
Dallon, the law professor, said the video may reflect the frustration some doctors and hospitals have with defense attorneys who typically advise not to acknowledge any mistakes. The "I'm sorry" laws in Nebraska and more than 25 other states are another sign, he said.
Nebraska's law, approved in the last session, makes a health care provider's expression of apology, sympathy or compassion inadmissible as evidence of liability in a lawsuit.
Janice Mulligan, a California attorney and chairwoman of an American Bar Association committee on medical liability, added that it's unusual for a hospital to share its mistakes publicly in the hope that other hospitals will learn from it.
However, law schools and medical journals are increasingly discussing the need for the types of steps Methodist took, she said.
Juster said Methodist wanted to share its experience because hospitals across the country have lacked an understanding that young patients with a family history of aortic dissection can suffer from it.
She said Methodist did not offer to produce the video as a way to reduce the financial payment to Kahle's family that was part of the settlement. Both sides declined to reveal the amount.
Omaha attorney Jeffrey Welch, who represented Kahle's family, said money wasn't the family's priority. They wanted to keep the young man's memory alive and prevent other deaths.
The Methodist video, he said, accomplishes both.
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