Medical Director's Statement on Nov. 2010 DOH Findings

Statement by Dr. David Fisher, Senior Vice President and Medical Director

Today we received reports from the Washington State Department of Health (DOH) on three open investigations recently covered in the news media. After thorough investigations, the DOH reports that they found no hospital “deficiencies”. This means that the policies, systems and procedures at Seattle Children’s meet their requirements for protecting patient safety.

Statement from Dr. David Fisher, Medical Director at Seattle Children’s:

For Children’s, it is absolutely critical to meet DOH policy and systems requirements for protecting patient safety. However, the fact remains that medication errors occurred, which means that there is still room to improve our systems to fully support our patients and staff and minimize opportunities for error.

As we promised, we have been fully cooperating with state investigations of these incidents and we have taken the following actions:

  • Changed our policy for calcium chloride administration: only pharmacists and anesthesiologists can prepare doses of calcium chloride in non-emergent situations
  • Initiated a reevaluation of our entire medication delivery system
  • Launched a detailed root-cause analysis to determine why our usual safety processes failed in each of the medication error cases
  • Held forums with more than 2,500 staff members to review medication safety policies to ensure all staff are re-educated and fully familiar with safe medication behaviors
  • Engaged an independent team of patient safety experts from The Institute for Safe Medication Practices to begin a comprehensive review of medication ordering, dispensing, and administration
  • Held a day-long patient safety day to bring over 550 doctors, nurses, pharmacists and other staff members together to participate in more than 28 patient safety sessions.

Our commitment to patient safety goes beyond meeting regulatory requirements. Our staff are dedicated to providing the safest care to the patients and families who place their trust in us. It is our promise that we will continue to improve patient safety.

While the DOH has concluded investigations of Children’s regarding these incidents, they are still conducting investigations of some of the clinicians involved. Just as we honor the privacy of our patients, we also honor the privacy of our faculty and staff.

About Seattle Children’s

Consistently ranked as one of the best children’s hospitals in the country by U.S. News & World Report, Seattle 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, Seattle Children’s has been delivering superior patient care while advancing new treatments through pediatric research. Seattle 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 or follow us on Twitter or Facebook.