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Tragic Loss of Child Illustrates Importance of Patient Safety in MHS

USM By U.S. Medicine
March 12, 2012

By Sandra Basu

WASHINGTON — Army Maj. Kendall Mower expected his wife’s fourth birth to go as smoothly as the births of his three other children. His newborn died shortly after birth, however, as a result of poor patient-safety practices at an Army hospital, he said.

“On the same day that we gave birth, we had to withdraw life support,” Mower said of the child, named Scott.

Mower told his emotional story during a session on patient safety during the 2012 MHS annual conference, in hopes of promoting patient safety and preventing situations such as this from happening again.

Each year, more than 98,000 individuals die because of avoidable medical errors in the United States; the MHS is not immune to these medical errors.

“The numbers are not zero,” said Air Force Brig. Gen. Daniel Wyman, MD, who spoke during the same patient-safety session. “They should be close to zero.”

Mower’s Story

Army Maj. Kendall Mower, who spoke on patient safety at the recent Military Health System conference, is shown here at the conference with Brig. Gen. Daniel O. Wyman, MD, Command Surgeon, Air Combat Command, Langley Air Force Base, Va.

Mower, a dentist, said his wife’s three other births had been easy and they had no reason to believe that the birth of their son Scott would be any different.

The birthing team was made up of a nurse midwife and several other nurses. A second-year family practice resident was also out at the nurses’ station on a computer, Mower said. The hospital policy, he said, was that an obstetrician had to be able to respond to a call within 30 minutes, if contacted.

At first, there appeared to be no problems. “The fetal-monitoring strips were normal; everything seemed to be going well,” he said.

As the day progressed, the situation worsened, he said. The team assisting his wife started “falling apart,” he explained, with the team was not adjusting the fetal-monitoring strip, among other issues.

“There were things along the way that needed to be identified that weren’t. There were things along the way that as a team that they needed to be communicating with each other, and that wasn’t happening,” Mower said.

In retrospect, it was found that the fetal-monitoring strip had been indicating problems but that appropriate action was not taken.

“Nobody said we need to get the OB in here. Is this all right? What is going on? Questions were not being asked, and I don’t know why,” he said.

After the baby was born, the team worked 24 minutes to resuscitate him. He died that day at a different hospital where he had been transferred, according to Mower.

In his talk, Mower raised several questions about what happened. Was the team overconfident or just clueless that there was a problem? If team members thought there was a problem, why wasn’t an obstetrician called in?

 “At first they appeared to be a team that worked very well together, but as fatigue, stress and other things started to take effect, people forgot their roles. They forgot what they were supposed to do. There was not a clear leader,” he said.

Some good has resulted from the tragedy that befell him and his family, according to Mower, who said he learned that, in response, new policies and procedures had been implemented at the hospital where his wife gave birth. A similar outcome was averted in another case as a result of those changes.

Improving Patient Safety

Because of issues such as the one described by Mower, MHS has signaled an increased emphasis on patient safety issues. At the 2012 MHS Conference, Assistant Secretary of Defense for Health Affairs Jonathan Woodson, MD, said the MHS would be announcing a new initiative addressing patient safety.

In 2011, DoD also signed a pledge of support for the White House’s Partnership for Patients, a public-private partnership designed to improve quality and safety of healthcare across the United States. One of the goals of the initiative is to decrease hospital-acquired conditions by 40% by the end of 2013, compared with 2010. Another goal is to improve the continuity and effectiveness of care during transitions from one setting to another, with the goal of decreasing hospital readmissions by 20% by the end of 2013.

Wyman said in his presentation there are steps that everyone can take to reduce medical errors. First, he said it is important to understand that all humans make mistakes, which is why it is so important to have a culture where colleagues are comfortable speaking up when someone is about to make an error in the healthcare setting. Fear often prevents action from being taken, however.

“It is not only your duty, it is your obligation,” said Wyman. “I hold equally wrong errors of commission, omission or tolerance. If someone is about to do something that you think is wrong, tell them, ‘Time out.’ Do something.”

Wyman also said that, in order to reduce medical errors, it is important to follow standards of patient care, such as evidence-based processes, protocols, checklists and bundles.

“Do all our airmen, soldiers and Marines, do all of our nurses, all of our doctors, all of our administrators, logistics folks, do they know and follow code protocol?”

Teamwork is another key in preventing errors, he said. Everyone needs to know his or her roles and responsibilities.

 When a mistake happens anyway, it is important to learn lessons from it.

Wyman said that simulating case scenarios is an important way to do that. He said this is something routinely done among Air Force pilots.

“They go out to the entire C-17 community, and they fly that profile, not in an airplane but in a simulator,” he said. “Before you fly again, we want to make sure that, if you get in this situation — like occurred with the Mower family — the outcome is different. You understand what happened, what they didn’t do right.”

There are also tools and resources available to providers to improve patient safety, Wyman explained. One of those programs is TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety), which is used to improve teamwork and communication in order to improve the quality and safety of healthcare. TeamSTEPPS was developed by DoD’s Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality.

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