When Children's Hospital got word yesterday that the state Department of Health had finished an investigation into the recent death of one baby and the brain damage to another, the hospital issued what seems an "all clear" to the public: "Today," it said in a press release, "we received reports from the Washington State Department of Health (DOH) on three open investigations recently covered in the news media. After thorough investigations, the DOH reports that they found no hospital 'deficiencies'. This means that the policies, systems and procedures at Seattle Children's meet their requirements for protecting patient safety." Which is not to say every patient is safe.
DOH probers, in their announcement yesterday, concluded Children's "has effective, adequate systems to prevent patient harm in place. No 'deficiencies' in those systems were found."
But it wasn't referring to all three of the above cases that had been the recent focus of news coverage cited by Children's. The death of the newborn was not part of the facilities review, and is still being investigated by the state.
As well, the state Medical Quality Assurance Commission and Nursing Care Quality Assurance Commission are investigating other aspects of the recent news-making cases, including an incident in which a toddler having a heart procedure suffered brain damage. Conduct of the health professionals involved in those cases remains under examination.
In the case of the 8-month-old who died Sept. 19, says DOH spokesperson Tim Church, "investigators determined the child did receive an incorrect dose of calcium chloride five days before the child died. It's unknown whether that overdose contributed to the baby's death." The facilities review thus cleared the hospital's systems and procedures in that case, but the state nursing commission is conducting a second investigation.
As well, the death of the newborn two days earlier, Church adds, "is still under investigation by the nursing commission and facilities investigators. In that case, it's alleged a nurse gave medication without an order while the baby was being prepared for transfer to Children's."
The widely respected hospital and research facility has been working hard to correct problems and did, in the very last paragraph of its release yesterday, note that the state continues to investigate the actions of its clinicians. But it didn't make clear that, while some issues have been resolved by the state, whether or not Children's fully protected its patients isn't one of them.