Hospitals Own Up to Errors

When 18-month-old Kaelyn Sosa suffered a bump on the head in a fall at home, her mother took her to the emergency room to make sure it wasn't serious. While Kaelyn was under sedation in an MRI machine, her breathing tube was dislodged, cutting off her oxygen and causing a crippling brain injury.

Kaelyn Sosa, 6, was crippled as a toddler by a medical error. Her mother, Sandy, now helps the hospital protect other patients from such accidents. BARBARA P. FERNANDEZ FOR THE WALL STREET JOURNAL

As often happens after medical accidents, the facility, Baptist Children's Hospital in Miami, settled with the Sosa family for an undisclosed sum. But the hospital went further. Administrators analyzed the chain of events that led to the tragedy. They put in place new measures aimed at preventing the mistakes that injured Kaelyn from recurring and to better respond when something does go wrong. The hospital then engaged the child's parents in educational efforts to underline to medical staff the critical importance of patient safety.

Now Sandy Sosa, Kaelyn's mother, serves as a community liaison on the hospital's quality-and-patient-safety committee. "We wanted something good to come out of what happened to our daughter," she says.

Medical errors kill as many as 98,000 Americans each year, according to the Institute of Medicine, a government advisory group. In an effort to improve this record, some hospitals like Baptist Children's are taking steps to admit grievous mistakes and to learn from them in order to overhaul flawed procedures. That represents a sharp departure from hospitals' traditional response when something goes terribly wrong-retreating behind a wall of silence to guard against potential lawsuits.

Now, some hospitals are hoping to stem the tide of lawsuits by being more open with aggrieved patients and their families. While some experts warn that disclosure will lead to an increase in litigation and costs, there are some indications that patients are less likely to sue if they receive full disclosure and an apology, along with an offer of compensation. But longer term, some administrators say the solution is to improve hospital safety records.


Pitching Patient Safety and Hospital Transparency on YouTube

"Sorry alone doesn't work unless we learn from our mistakes," says Timothy McDonald, a pediatric anesthesiologist and chief safety officer at the University of Illinois Medical Center in Chicago. "We have to also make promises that this won't happen again and get patients and families engaged in the effort to improve our performance."

The University of Illinois center set up a specialized service in 2004 to help staff communicate with patients and families after harm occurs. Since 2006, the center has had a policy of fully disclosing medical errors, apologizing when they occur, and swiftly offering a financial settlement. And patient-family members sit alongside staff on a board charged with overseeing plans to prevent errors.

Dr. McDonald says that over the past four years, the number of lawsuits against the center is down 40% compared to the period between 1999 and 2004, even though the number of procedures increased 23%. While it can't say for certain that the disclosure program was responsible for the decreases, "we can certainly say that it has not caused an increase in lawsuits or payouts," he says.

Among safety measures adopted: After a surgical patient developed a blood clot and died, the University of Illinois center began requiring doctors to assess the risk of a clot before writing any orders for patients who had been in the hospital for more than eight hours.

And after a sponge was left in a surgical patient, despite the fact that a manual count showed that all the sponges had been accounted for, the hospital began requiring an X-ray of patients at risk of retained objects, such as emergency abdominal or chest surgery, or morbidly obese patients. In the past three years, the X-rays have found eight objects left in patients after surgery, even though the manual count had shown that everything was accounted for, Dr. McDonald says.

Despite such efforts, the federal Agency for Healthcare Research and Quality reported in May that the rate of adverse events-a key measure of patient safety defined as unintended harm during medical care-has risen by about 1% in each of the past six years, in part because of a rise in hospital infections. The old and the young are especially vulnerable: One in seven hospitalized Medicare patients experience one or more adverse events, and one in 15 hospitalized children are harmed by medication errors, other studies show.

ENLARGEA hospital crash cart is color coded to prevent errors. BARBARA P. FERNANDEZ FOR THE WALL STREET JOURNAL

A number of patient-advocacy groups are calling for the creation of a federal patient-safety agency as part of the current effort to reshape the nation's health-care system. Among the proposals is to grant such a body the powers to use publicly available data to identify serious recurring errors, recommend preventive actions, and create regulations such as requiring that look-alike medications be kept separately and that medical staff follow checklists to prevent certain infections.

After Kaelyn's injury in 2004, her mother says Baptist Children's candor helped her to move past the initial shock. The hospital's parent, Baptist Health South Florida, with six hospitals and a number of outpatient facilities, had earlier adopted a "full-disclosure" policy on errors, and explained to the Sosa family what had happened as soon as the details emerged.

When Kaelyn first arrived in the emergency department, she appeared to have had a seizure. Medical staff sedated the child and inserted into her trachea a flexible tube connected to a ventilator. A CT scan turned up an abnormal finding, and an emergency MRI was ordered.

As Kaelyn was being moved from the MRI room, an ER nurse noticed that her chest wasn't moving. The breathing tube had become dislodged, cutting off oxygen to the brain, and no one had noticed it until it was too late. At first, it looked as if Kaelyn might not survive. But once she was stabilized, it became clear that Kaelyn would have serious mental and physical disabilities.

"This wasn't just an error caused by one person," says Thinh Tran, chief quality officer at Baptist Health. "We identified additional gaps in care that weren't related to this specific incident."

For starters, the hospital had had only a nurse present to directly monitor pediatric patients on breathing machines during emergency scans; it now requires a nurse anesthetist or anesthesiologist to be present in the MRI room when a patient has a breathing tube inserted. ER nurses also now carry an emergency kit filled with tools needed to maintain the flow of air whenever they move a young patient to another area of the hospital. And although there was a nearby pediatric crash cart, which contains child-size equipment needed for resuscitation and other emergencies, no one on the staff was familiar with it or knew where it was. The cart is now prominently accessible in the MRI area.

The Sosas say that when they later brought Kaelyn in for another MRI, they immediately noticed these and other improvements. "It was a whole new procedure," Ms. Sosa says.

The Sosas didn't sue Baptist Children's. But as part of the mediated settlement, the hospital agreed to provide free medical care for life for Kaelyn, who is now 6 years old. In addition to physical therapy provided through Baptist, her mother works with the girl on skills such as reading, and says she is "cognitively smart as a whip." But Kaelyn can't yet speak or walk independently and has difficulty with motor skills.

The Sosas agreed to recount their story for "Forever Changed," a 15-minute video that is being used internally to educate Baptist Children's staff about the events that led to Kaelyn's injury.

The video includes interviews with both parents about the pain and despair they felt and with the nurse who discovered that the breathing tube had become disconnected and still thinks of it years later.

Ozzie Sosa, Kaelyn's father, says the hospital's dedication to fixing the problems that led to his daughter's injury helped the family form a bond with staff and forgive the unintentional harm.

"No one woke up that morning and said we are going to mess up your little girl," Mr. Sosa says. "We decided we have to keep our emotions in check, get beyond this and help make sure that this doesn't happen to anyone else."

Write to Laura Landro at [email protected]