Update: Boston's Children's Hospital Death---minimal Doctors disciplinary action

[NRSKarenRN, BSN, RN]

3 doctors are warned by board

by anne barnard, globe staff, 1/27/2002

http://www.boston.com/dailyglobe2/027/metro/3_doctors_are_warned_by_board_subhead_+.shtml

the state medical board has issued a warning to the senior surgeon in charge of caring for taylor mccormack, the 13-month-old girl who suffered fatal brain damage at children's hospital while waiting overnight for surgery to relieve pressure on her brain. the board also sent letters of concern to the two resident doctors who decided the procedure could wait until morning.

the letters raised concerns about the doctors' failure to communicate adequately with each other and with the child's family. they focused in particular on the senior surgeon, dr. craig van horne, who failed to answer his beeper that night. he told the board he had switched the beeper to vibrate while grocery shopping, then went home and fell asleep. the letters will become part of the doctors' permanent public files with the board of registration in medicine.

but taylor's father, john mccormack, a state trooper, said he was frustrated that the doctors would not face fines or further discipline.

''they took the doctors' word,'' he said of the board, which is made up mostly of physicians. ''to me, they cover their own.''

taylor's death in october 2000 revealed what public health officials called systemic problems at children's hospital. it prompted several changes ranging from closer monitoring of patients to tighter requirements for reporting alarming laboratory test results.

it also focused local attention on the national debate over how to prevent medical errors and assign responsibility for them. experts on medical errors advocate a system that avoids blaming individuals in order to encourage doctors and hospitals to be honest about mistakes. patient advocates fear that without a measure of blame, there will be no spur for serious change, and families may feel their loss has not been recognized.

the board has the power to fine doctors and suspend or revoke their medical licenses. historically, the board has rarely disciplined doctors for medical mistakes. under a new policy, it is now reviewing all doctors with more than three malpractice payments. since none of the doctors involved in the mccormack case comes close to that threshhold, the letters seemed to indicate that, by its own standards, the board took the case relatively seriously.

the board's harshest criticism was directed at van horne, a member of the neurosurgery service at brigham and women's hospital. he was covering patients at children's hospital on sept. 30, 2000, when taylor's parents brought her in. van horne did not answer his beeper that night, leaving the junior doctors to make the decisions.

''it is your responsibility to be available to fulfill your duties as an attending physician for the patient, the house staff, and the health care facilities in which you work,'' the board's complaint committee wrote thursday in a ''letter of warning'' to van horne, putting the word ''your'' in bold italics.

the resident who handled taylor's case, dr. tien nguyen, and his supervisor, chief resident dr. adel malek, received identical ''letters of concern,'' a less severe designation than a letter of warning. the letters appeared to focus on their failure to contact another attending physician when van horne was unavailable, and their apparent failure to push harder for an operating room for taylor when told there were none available.

''the resident physician has the responsibility to explore every avenue for consultation with an attending physician,'' wrote dr. martin crane, a member of the committee. ''he must be aware of alternative means for contacting an attending physician. the resident also must be aware of how to advocate for his patient regarding the allocation of limited resources to guarantee that the patient receives optimal medical care.''

the board declared the case closed, but reserved the right to reopen it if the doctors violated any of its regulations. the physicians could not be reached yesterday for comment.

the board action ''speaks for itself,'' children's hospital officials said in a statement noting that the hospital cooperated with the board's investigation and a department of public health review that found several areas of deficiency. ''children's has taken several steps to improve the care we provide to all the patients.''

dr. lucian leape of the harvard school of public health, an author of a 1999 institute of medicine report that blamed medical errors for 98,000 deaths a year, said he was reluctant to judge whether the board's response was appropriate. but he noted that promoting a blame-free approach to errors ''doesn't mean that you tolerate substandard care.''

linda debenedictis of the new england patients' rights group said many families are frustrated by board rulings that seem to go easy on physicians. ''after the horror of losing a patient to medical error, it's like another kick.''

taylor was born with hydrocephalus and had a shunt inserted in her skull to drain excess fluid. on sept. 30, 2000, her mother brought her in, fearing the shunt was blocked. nguyen initially slated taylor for immediate surgery to replace it, then told her parents she had been bumped.

taylor was scheduled for surgery the next morning. but around 6:20 a.m., she stopped breathing, went into a coma, and died six days later.

several things went wrong that night, according to the department of public health:

a blood test showing abnormal carbon dioxide levels went unnoted in taylor's record until after she stopped breathing.

nguyen and malek could not reach van horne and did not consult another anesthesiologist or senior surgeon about taylor's priority level.

and she was not put on an oxygen monitor, something the hospital, in response to the dph report, agreed to do with such patients from now on.

anne barnard can be reached [email protected]

this story ran on page b1 of the boston globe on 1/27/2002.

© copyright 2002 globe newspaper company.

seems like double standard exists in massachusetts ----compaired to nurses treatment over patients death at dana faber institute few years ago...they were raked over the coals despite wrong chemo formula and system errors there.

[oramar]

That little quote, "high levels of carbon monoxide went unnoted" could cost some nurse their license. You can rest assured the nursing board won't go lightly.