Interesting read about Hopkins and medical errors

[Lux Aeterna]

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Was googling for the Hopkins admissions office phone # when this story came up on the top of the Google page.

It's an interesting read, although every hospital has stories or cases like this one. Of course, as future doctors we'll have to react and deal with the line between really &#*#*ing up and an honest mistake in the complex system--which other people may not see it as.

At least the family in this story has reached some point of peace with the circumstances surrounding their loss.

part 1: http://www.sunspot.net/news/health/bal-te.sorrel14dec14,0,5578677.story?coll=bal-health-utility


part 2: http://www.sunspot.net/news/health/bal-te.sorrel15dec15,0,6037431.story?coll=bal-home-headlines

 

[darkcity998]

If you want further reading on reducing medical errors,

I'm enjoying Demanding Medical Excellence: Doctors and Accountability in the Information Age, by Michael Millenson.

Definitely something worthwhile for would-be doctors.

 

[Califlower]

I remember when I used to volunteer at Women's and Children's at LA County, there was a code in the pediatric wards. All I remember is loud sounds and everyone running to one side of the wards. Later I learned that a 5 yr old boy, who was admitted with a mild infection (he was recovering and was supposed to go home in a few days) had died.

I know the shock of the parents and family are far greater, but I saw the attending, residents, and nurses who were somber for a very long time. Each felt that they could have done something or said something. I guess these kinds of things happen quite a bit, which scares me. The thought that I may be part of something like that would haunt me for life. I wonder how the care-givers are feeling now. Very sad indeed.

 

[priscy921]

i just read the link that was originally posted, that was the saddest story ever and i cried despite all of the hospital/clinical experiences that i've had. the very last sentence about them attending the funeral just makes me so sad because I hope so much that I'll never make a mother feel that way about me as a physician but it's impossible to never ever make mistakes, we'll all make mistakes at work just like everyone else does, but our mistakes can have such devastating consequences.... 🙁

 

[Brickhouse]

While agree that the loss of a child is tragic - I think that if Sorrell had not let her baby wander away for long enough to turn on the bath water, let it run long enough to get scalding while submerged in it, then the whole thing would have been avoided. In a way, mother is too blame as much as the doctors.
I too hope that I catch everything that goes wrong before there are consequences, but I think that people need to remember that the alternative to seeking health care would more likely produce tragic outcomes than seeking health care and having it go awry.
This is one story that is getting a lot of attention and it is absolutely devastating. But these doctors cared so much for this child, they were doing what they thought was best, and there must have reason for them to miss the dehydration diagnosis. Of course it's obvious to us, in hindsight, but these are the top phsycians in the country - something must have been missing.
I am scared more than anything to harm someone through my oversight. I think that's why I'm more sympathetic towards the doctors. And I hate kids. Just kidding.

 

[Lux Aeterna]

Here is another article I read today referencing a new medical error case at Hopkins Children's. This one involves excessive potassium levels in an IV-feed.

http://abcnews.go.com/wire/Living/ap20031219_1725.html

I think at the end of the article they do reference Sorrel's story and the launch of the patient safety initiative.

 

[CalBeE]

THere's a saying that for certain illnesses, you have more chances of surviving if you stay at home and rest than to stay in a hospital 😀

Lux Aeterna, what happened to the liquid icon? WHo's that girl in the new avatar?

 

[greggth]

Originally posted by Brickhouse
While agree that the loss of a child is tragic - I think that if Sorrell had not let her baby wander away for long enough to turn on the bath water, let it run long enough to get scalding while submerged in it, then the whole thing would have been avoided. In a way, mother is too blame as much as the doctors.

I thought it was the case that liittle children wander around and play with things like faucets all the time. Do you think it's reasonable to say this mother was to blame for letting her child wander away?

How can a child get 2nd-degree burns so quickly, with only brief exposure to hot water?

What surprised me most was the disagreement about the cause of death. According to the article, the hospital said it was dehydration, the autopsy report said it was "complications" from the burns (what does that mean, exactly?), and someone else said the methadone contributed. But someone else said the methadone couldn't have been "absorbed" that quickly (which doesn't sound right to me, if it was given intravenously).

How do they know the methadone was not a contributing cause?

 

[bullhorn]

As a mother, I partly agree with Brickhouse. I know that my lil one likes to wonder, as do my nephews but we keep a very close/tight grip on their whereabouts. So, of course hearing that this lil 18month girl was gone long enough to turn the water on, get into the tub, AND time for the water to get scalding hot...SMELLS of neglect...but probably was just an honest parenting mistake.

Keeping that in mind, as a future doctor, I feel it is obvious they made an honest mistake as well...and no one is infallible. It is a great thing that they are devoting time AND money to improving patient outcomes/error-rates. I also think this is a good example about how health care professionals need to pay MORE attention to the patients AND in the case of children, their parents. Because tests and exams don't always tell the whole story...and health care professionals in my opinion, currently do a rather poor job incorporating patients(or parents) into the care they are given. Instinct/intuition is a wonderful thing, and it should not be ignored.

The whole story was very tragic, but I will admit it bothered me that Sorrel(the mom) did seem to place alot of blame on the hospital..and while there is enough blame to go around there, she AND her husband, have to realize their role in this entire tragedy. In effect, they started the ball rolling towards this outcome.

Very depressing indeed...

 

[musiclink213]

medical mistakes happen all the time. at every hospital. when my grandmother was in the hospital, they gave her twice the amount of insulin she needed (and she wasn't even in the hospital on diabetic complications). she turned out fine, but we were all mad. it said on the medication chart that she takes X cc's of insulin twice a day. a while ago, when my grandfather was in hte hospital and had surgery, they left some sort of tool in his stomach, had to go back for more surgery to remove it, but for some reason, there was a lot of damage, and they had to put in this metal grate type thing into his stomach wall. over the summer, i was in the hospital, and the nurse forgot to give me the medication that she was supposed to give me. they wanted to test me out on this medication and wanted to give it to me at night cause it is known to drastically lower blood pressure, and the nurse forgot to give it to me. i even reminded her that i my doc said i was supposed to get this medication. i ended up falling asleep, and the next morning, the nurse was yelling at the night nurse and i ended up getting it in the morning and leaving in the evening after i didn't pass out from a low BP (it;s naturally lower anyway, so i think they were more worried or at least that's what the nurse told me).

basically what i'm saying is that mistakes happen all the time, and it's tragic, and if the world were perfect, doctors wouldn't need to practice their trade on people, but they do. even though the examples i gave are minor compared to the ones posted, it just goes to show how easily a person can fall through the cracks.

 

[CalBeE]

Well supposedly medical staff (doctors, nurses, technicians) are encouraged to explain treatment plans to the patients as much as possible.

When you explain things to someone else, you may notice some inconsistencies in what you have said or the patients may notice some mistakes.