Practice Based Learning - Quality Improvement

Even leading hospitals can make big mistakes

Monday, September 29, 2003 Posted: 10:00 AM EDT (1400 GMT)

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BOSTON, Massachusetts (AP) -- When their children are critically ill, parents from New England and beyond come to Children's Hospital of Boston, a place where cutting-edge medicine and even apparent miracles are a near-daily occurrence.

But Children's, a Harvard-affiliated teaching hospital considered among the finest in its field, is suffering through one of the lowest moments in its history after a state review sharply criticized its handling of four cases in the past 13 months.

Three people died, including a 5-year-old boy having an epileptic seizure. All of the doctors treating him believed someone else was in charge.

The hospital, now facing a license review for Medicare treatment, has apologized, saying in a statement it was "profoundly saddened that we did not provide the high level of care to these patients." It has promised changes to make sure the same problems are never repeated.

Experts say these incidents, along with others recently, point to a problem afflicting even the best institutions: Providing exceptional treatment to a few patients is often easier than guaranteeing adequate routine care for each of the thousands they treat every year.

"Being at a place like Emory or Harvard, we often look at quality and safety in terms of the brilliant things we do," said William Bornstein, chief quality officer at Atlanta's Emory Healthcare, which includes Emory University Hospital. "That's very important, but an equally important part is the routine stuff, the communications, the systems we put in place to ensure safety."

The review of Boston's Children's Hospital came two years after the hospital was faulted for "systems problems" that contributed to the death of a toddler who suffered fatal brain damage while waiting overnight for surgery.

Children's isn't the only prominent hospital to find itself at the center of a harsh scrutiny. The Duke University Medical Center in North Carolina is also under investigation by the federal Medicare agency.

In February, 17-year-old Jesica Santillan died after a transplant operation there in which she was given organs that did not match her blood type.

Just four months later in Duke University Hospital, a flash fire burned a 2-day-old baby. And in August, an infant suffered burns from overheated air in an incubator.

And last year in New York, Mount Sinai Hospital suspended its liver transplant program using living donors when a donor died from an infection due in part to inadequate supervision. The program was allowed to resume this year.

Risks in the system

Those were just cases that grabbed headlines; the Institute of Medicine has estimated up to 98,000 people die each year from preventable medical errors.

Of course, nobody tracks how many lives are saved at top teaching hospitals, and experts point out risks are inevitable with extremely sick patients.

But they also say teaching hospitals can be more vulnerable to breakdowns, given two aggravating factors. First, their expertise attracts particularly complex medical problems requiring specialists in different fields to communicate. Secondly, their teaching mission requires them to involve medical students and young doctors as part of their training.

These latent risks are embedded in the system, and you could fire everybody in the hospital and they'd still be there. -- Dr. Donald Berwick

Both factors may have played a role in the epilepsy death at Children's, where two young doctors -- a resident and a physician on a fellowship -- were at the child's bedside shortly after the seizure began May 9.

According to the state investigation, the child was not given the proper drugs, and the doctors who were present, as well as several specialists consulted by phone, all believed someone else had overall responsibility. Meanwhile, nobody noticed the boy had stopped breathing.

In the other cases, a cerebral palsy patient who got an infection and died may not have been treated quickly enough with antibiotics, and surgeons may have been slow to spot the drop in a toddler's blood pressure during surgery, the state report found.

Also, a child received a catheter in the wrong kidney, though without apparent harm.

Several experts on medical organizations say the problems at Children's are no surprise. They assume them to be present elsewhere because hospital procedures are still too vulnerable to human error.

"You can bet at that hospital and any hospital there are people all day long who are being heroes, protecting people from errors," said Dr. Donald Berwick, president and chief executive of the Institute for Healthcare Improvement and a professor of pediatrics and health care policy at Harvard Medical School. "A test gets lost, but they find it. There's a miscommunication, but they try again and get it. A wrong drug gets sent, but they see it and go back to the pharmacy."

But eventually, too many errors line up, and tragedy happens, he said.

"These latent risks are embedded in the system, and you could fire everybody in the hospital and they'd still be there," said Berwick, who added that most hospitals still haven't seriously addressed these problems.

Children's spokeswoman Michelle Davis agreed the issue was systems, not people.

"We have outstanding staff that are some of the most skilled and experienced people in caring for children, but we need to have systems that support them, and our systems failed," she said.