In 2007 we settled a wrongful death suit that we had brought against the hospital and the doctors. It was a painful process for us, but we felt that we needed an independent assessment of what happened and the legal system provides for this. At every turn in this protracted process, we encountered nothing but respect and compassion from all parties. (Download below for full comments.)
We also sponsor annual lectures on patient safety--especially the risk of diagnostic error--at the University of Minnesota Medical School. (A list of presenters is available below.)
(This article was published anonymously due to a confidentiality agreement with the doctors and hospital. Describing the circumstance of Julia's death and the errors that were acknowledged as contributing factors, the article was written in the hope that its publication will contribute to the safety of other children and patients who depend on the wisdom as well as the skill of the doctors who serve them. Welcome's name appears as Debra.)
For what it’s worth, as a layman and as a father who has replayed countless times the six days before his daughter’s death, here’s what I find to be the common denominator: Everyone involved in Julia’s care gave someone else the benefit of the doubt. The gastroenterologist ceded to the surgeon; our pediatrician to the specialists; the surgeon to the anesthesiologist; the PACU nurse to the 6th floor. We, Julia’s parents, to the whole system.
But, isn’t trust the fundamental building block of collaborative care? How can the system function without an interdependent web of expertise? Don’t you strive for and ultimately depend upon a team of qualified experts? Doctors, technicians, nurses and families who know their children best?
The team attending Julia was experienced and well-qualified. But in this case, with its confusing indicators there was, perhaps, too much trust. Where was the empowered skeptic, or the culture that rewards those who question, question and question again?
There is so much knowledge, so much capacity, so much data. And yet with all of these assets the chances for confusion, miscommunication, and conflicting analysis remain. Maybe they’re enhanced. In a field like no other in its capacity to intervene between life and death, maybe it’s time to reexamine the value of doubt in the diagnostic equation.
(To read the entire article, please download the link below...)