Lisa Zenzen Baker, 1961-2003


Friday, November 11, 2005

The other victims of medical errors

The Emotional Toll of Medical Mistakes

When medical errors occur, the person who died or was injured is only one of the victims, as this story that appeared last week in the Well section of the New York Times points out.

The physical consequences of medical errors are obvious. One well-known study estimated that as many as 98,000 hospital deaths a year stem from mistakes by health care workers. But what about the less visible emotional costs of these missteps?

The New England Journal of Medicine tackled the issue yesterday in a moving commentary called “Guilty, Afraid and Alone: Struggling with Medical Error.’’ The writers, Dr. Tom Delbanco and Dr. Sigall K. Bell of the Harvard Medical School, note that while the medical community has focused largely on reducing error rates, hospitals also need to address the “human dimensions” of treatment blunders and to assist in the emotional recovery of patients and families.

The doctors, who are making a documentary film on the subject, talked to numerous patients and families affected by medical errors. The authors found that family members often feel guilty for not having protected loved ones from the caregivers’ mistakes and that many feared retribution if they did complain. And Dr. Delbanco and Dr. Bell note that physicians who err often shut out patients and their families, “isolating them just when they are most in need.’’

When mistakes happen, relatives often berate themselves for not keeping close watch on their loved ones. In one case cited in the commentary, the family of a man with sickle cell anemia repeatedly warned health care workers not to administer morphine. But somehow it happened anyway, sending the man into kidney failure and a coma.

“The feeling was impotence, because you can’t stay with a patient 24 hours a day,’’ said his sister. “That’s why you rely on hospitals — you rely on nurses. You feel like you failed your family in terms of ‘I should have been there.’ That’s a guilt that everyone shares.”

But these tragedies don't have to be followed by the wall of silence and years of hostile litigation that many hospitals and their insurers use, even in cases where they know a mistake was made. The story below shows that something positive can result, from even the worst event. In this case, the patient died less than three weeks ago, but the healing process already has begun.

Toddler's death leads to
stricter medical safeguards

A tragic mistake that led to the death of a 3-year-old boy
prompted the University of Florida's medical center to
pledge it will improve its procedures.

Posted on Sat, Oct. 27, 2007


At age 3, Sebastian Ferrero was an active, healthy, intelligent boy who already spoke English, Italian and Spanish and was attending preschool, his parents say.

On Oct. 10, he died at a Shands HealthCare facility at the University of Florida. Doctors say it was because he was given a dose 10 times too high of a substance used for testing growth hormone deficiency -- even though the boy's mother was present and questioning the dose as it was being administered.

In his death, Sebastian's grieving parents are praising at least the facility's candor in taking responsibility and vowing to work with Shands on a foundation to build a ''state-of-the-art children's hospital'' with safeguards to prevent such mistakes.

At a Thursday press conference in Gainesville, Dr. Donald Novak, professor of pediatrics and vice chairman of clinical affairs for the UF College of Medicine's Department of Pediatrics, said: ``We take full responsibility for Sebastian's death and are very, very sorry.''

Dr. Richard Bucciarelli, interim chairman of the UF College of Medicine's Department of Pediatrics, said: ``We will be most delighted to work with the family on these issues.''

Bucciarelli said the hospital is working out a settlement with the family, but that he couldn't reveal how much.

In the press conference and a subsequent news release, Novak gave this account of the boy's death:

• On Oct. 8, Sebastian, healthy but small for his age, went to the University of Florida Physicians Pediatric Outpatient Clinic for a growth hormone stimulation test. He was given an amino acid called arginine to test for growth hormone deficiency. It was dispensed by the Shands Medical Plaza Outpatient Pharmacy.

• The dose prescribed by the boy's doctor was 5.75 grams. Sebastian received 60 grams, even though the boy's mother questioned the procedure as it was going on and Sebastian was showing signs of distress and a headache.

• The clinic had two bottles for Sebastian's test. And while the prescribed dose of 5.75 grams was printed on each bottle, each bottle contained 30 grams of arginine. The bottles were marked ''1 of 2'' and ''2 of 2,'' which may have led the clinic's staff to think both bottles had to be given to Sebastian.

• That night, Sebastian was taken to the emergency room vomiting, and doctors determined he had cerebral edema, a swelling of the brain. On Thursday, he was removed from life support.

Novak acknowledged a series of errors in how the arginine was processed by the pharmacy and administered in the clinic, and outlined countermeasures:

• The hospital placed a nurse and pharmacist involved on administrative leave during an investigation.

• It put a moratorium on such procedures at all outpatient clinics. It is setting up mandatory retraining for all personnel. It will create a double-sign-off system to cut drug errors.

''We mean to have experts look at all areas of our practice and review all of our policies,'' Bucciarelli said.

''Unfortunately,'' Novak said, ``these steps cannot undo the tragedy that occurred. Words cannot describe our profound regret for these events.''

In Miami, attorney Tania Cruz, of Squire, Sanders & Dempsey, representing the family, said Sebastian's parents, Horst and Luisa Ferrero, ``are handling it the best they can.''

``They appreciate that Shands has taken the high road in admitting liability. They want to use this tragedy to create a legacy in their son's name, working with Shands to create a children's hospital.''