A Tough Two Weeks for Children's

The past two weeks brought bad news for Children's Hospital's patients, staff, and attorneys. On Sept. 16, the hospital's lawyers were in court battling a lawsuit brought by the family of Michael Blankenship, 15, who died last year from a wrongly administered painkiller. On Sept. 17, a newborn baby died after being medicated en route to Children's in a hospital neonatal ambulance. On Sept. 19, Kaia Zautner, 8 months, died after she was given 10 times the proper dose of a medication. On Sept. 22, attorneys for Blankenship notified the court the lawsuit had been settled, with Children's paying damages in an amount undisclosed. On Sept. 26, an adult emergency patient was wrongly injected with medication in a vein rather than a muscle. He was moved to another hospital and recovered. The much-admired hospital and staff "do their best to provide the highest level of care," said safety medical director David Fisher in a statement published in The Seattle Times. "However, despite our vigilance, errors unfortunately still occur." That's the reality in most any hospital. But the recent series of incidents at Children's demand a thorough review of hospital practices. Fisher indicated that would happen, saying "These incidents have caused us to re-evaluate our entire medication delivery system. As a result, we have reviewed the clinical records and began a detailed root-cause analysis to determine why our usual safety processes failed." That's encouraging, but it sounds a lot like the review and changes the hospital promised after Blankenship died last year from an overdose of the painkiller Fentanyl. According to court documents, Blankenship's family claimed that Children's doctors missed four of the five contra-indication factors that should have prevented them from approving use of the pain patch for the teen after dental surgery. Doctors did not review formulary information, nor consult a reliable reference source, nor check with Blankenship's pediatric anesthesiologist before ordering the prescription. Even if the hospital formulary info was accessed, the family said, it was inadequate and unreliable to properly guide doctors. Additionally, Fentanyl is an opioid, and Blankenship was opioid-intolerant. In an amended civil complaint filed in June, the family reported that Dr. Fisher had told them that "Michael's death should never have occurred had the hospital maintained and/or followed appropriate safeguards for the proper and accurate prescription of pain medication, including the Fentanyl patch." Last week, Dr. Fisher was saying much the same thing about additional medication-related deaths. Everyone is hoping the review of the new deaths will produce safer practices than the earlier one did.

 
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