Patient Safety at Seattle Children's Hospital, Email From David Fisher

On October 5th, this email message was sent by David Fisher, MD, Sr. V.P. and Medical Director at Seattle Children's Hospital to doctors associated with the hospital regarding recent cases of medical malpractice at the facility.  It was forwarded to us by a Children's Hospital staffer who requested we not mention their name. 

From: "Fisher, David J."
Date: October 5, 2010 12:32:26 PM PDT
To: DELETED
Subject: Patient Safety at Seattle Children's

October 5, 2010
 
Dear Physician,
 
By now you are aware of a medication error in our intensive care unit (ICU) and two other serious patient safety incidents. We are taking these incidents very seriously, and we have already taken steps to prevent recurrence. In addition, we are conducting a review of medication practice throughout the hospital.
 
The ICU error involved the administration of ten times the intended dose of calcium chloride and the child later died from complications of the overdose. We believe this error occurred because of a mathematical miscalculation. To prevent this kind of error in the future, only pharmacists and anesthesiologists are now allowed to prepare doses of calcium chloride in non-emergent situations.
 
To assess and improve medication practice throughout the hospital, we are taking the following steps:
 
Over 1,000 staff have already participated in forums where they have provided feedback that we are now applying to improve all aspects of patient safety.

We are bringing in an independent team of patient medication safety experts to perform a comprehensive review of our medication ordering, dispensing, and administration.

We’re holding a mandatory full-day patient safety assessment to review patient safety practices, identify areas of weakness and establish immediate corrective actions.

Everyone at Children’s is deeply concerned about these incidents, which are a sobering reminder of the opportunity for error in medicine. Our clinicians and staff strive to provide the safest possible care to a highly complex patient population, but errors can occur despite our vigilance. 
 
Patient safety requires ongoing effort, and we remain confident that our focus on continuous performance improvement (CPI) will help us reduce opportunities for error. Guided by CPI, we continue to promote open, transparent discussion of patient safety issues with providers and staff at all levels of the organization.
 
Patients and families may be worried and express their concern to you. Please reassure them that we know we have to do better. We value your trust and pledge to do whatever we need to sustain your confidence that Seattle Children's can provide the very best and safest care for your patients.
 
For your reference, below is a link to our recent statement to the media:
Read the Press Statement
 
Sincerely,

David Fisher, MD
Sr. V.P. and Medical Director

Matthew Allen, MD
President, Medical Staff