Medical Director's Statement from Sept. 30 Press Briefing
September 30, 2010
Statement by Dr. David Fisher, Senior Vice President and Medical Director
As many of you are aware, we had a recent error at Seattle Children’s that resulted in the tragic death of one of our patients. Today we are sharing two additional incidents – one involving an infant on transport, and another involving an adult.
Our heartfelt apologies go out to all families involved. While we cannot take away the pain they are feeling, we are doing everything we can to help them in their time of grief.
As you can imagine, this is a difficult time for every member of our community.
Our mission is to provide excellent care for children. We failed in our effort to provide safe care, and we are devastated.
Every day our clinicians and staff do their best to provide the highest level of care and safety. However, despite our vigilance, errors unfortunately still occur.
As has been reported, a patient in the Intensive Care Unit received ten times the intended dose of calcium chloride. We believe this mistake occurred because of a mathematical miscalculation. The patient, an infant who was profoundly fragile, later died from complications of the overdose.
Although this medication was dispensed with the intention of providing the best patient care, the dose was wrong.
Separately, our neonatal ambulance team was dispatched to another hospital to transfer a critically ill newborn to Children’s for critical care. Against policy and scope of practice, a Children’s staff member administered medications without an order from a licensed prescriber. These medications are often administered in this dosage for infants that are difficult to ventilate or those who have unstable airways. However, our policy and procedures require that the staff member assesses the situation, relates this information to the physician, and administers the medication as per orders of the physician. The order step did not happen in this case. This infant died, but as of yet the cause of the death has not been determined. I want to stress that it is quite possible that these medications had nothing to do with the death of this infant. These are critically ill patients and the ability to administer medications in a timely manner is essential. In a transport situation we must provide staff with medications.
In addition, an adult arrived in our emergency department with life threatening respiratory distress requiring immediate attention. The individual felt they could not have made the extra distance to an adult emergency department, and this was supported by the clinical findings. Our initial therapies were effective, however the patient’s condition later worsened. The physician then ordered the proper medication and dose, but incorrectly ordered it to be given via IV rather than intramuscular. The patient was stabilized and transferred to a hospital for adults. This patient has recovered.
These incidents have caused us to reevaluate our entire medication delivery system. As a result, we have reviewed the clinical records and begun a detailed root-cause analysis to determine why our usual safety processes failed. We have highly skilled nurses, physicians and pharmacists who strive every day to provide safe care. Medicine is a critical component to helping very sick children. As medical director, I take full responsibility and am accountable for patient safety. And, we take full responsibility for any weaknesses in our system. Therefore, beyond a thorough internal review, we are taking the following immediate actions:
Only pharmacists and anesthesiologists can prepare doses of calcium chloride in non-emergent situations.
The appropriate state authorities have been notified and we are cooperating fully in the investigations.
This week, well over 1000 clinical staff at Children’s attended mandatory meetings to review our medication safety policies to ensure everyone is re-educated and fully familiar with safe medication behaviors.
We will suspend all non-emergent operations, including outpatient clinics and elective surgeries, for a full day to review patient safety practices, identify areas of weakness and establish immediate corrective actions.
We are identifying and will engage an independent team of patient safety experts to perform a comprehensive review of our medication ordering, dispensing, and administration.
We will commit whatever financial resources it takes to provide the safest environment possible.
We treat children with the most complex medical conditions in the Northwest, and we remain steadfast in our commitment to provide the best possible care to these vulnerable children.
We are here to help children and their families. We will do whatever it takes to overhaul our medication safety systems. And today is just the start.
To protect the privacy of the families involved, we will not be releasing additional details.
About Seattle Children's Hospital
Consistently ranked as one of the best children’s hospitals in the country by U.S. News & World Report, Children’s serves as the pediatric and adolescent academic medical referral center for the largest landmass of any children’s hospital in the country (Washington, Alaska, Montana and Idaho). For more than 100 years, Children’s has been delivering superior patient care and advancing new treatments through pediatric research. Children’s serves as the primary teaching, clinical and research site for the Department of Pediatrics at the University of Washington School of Medicine. The hospital works in partnership with Seattle Children’s Research Institute and Seattle Children’s Hospital Foundation. For more information, visit http://www.seattlechildrens.org.