Report Identifies "Inadequate Procedures" at Seattle Children's Hospital

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The Washington State Department of Health released a report Tuesday.  It says inadequate procedures at the hospital, “may potentially have contributed to the death” of the newborn. 

They say a newborn was being transported to Seattle Children's from another hospital when a member of the hospital's transport team gave the baby medication.  Karen Jensen, Assistant Secretary for Health Systems Quality Assurance Division, said they sent the hospital a "Statement of Deficiencies".

"The child in the process of the transport was administered medication without a doctors order behind that administration," Jensen said.   

After the death, the state looked at eleven other cases and realized something was wrong.  "We're concerned because in all 12 cases we found exactly the same problem," Jensen said.  "We couldn't find documentation in the record that a physician actually ordered medicine that was given."

The four-month investigation concluded the hospital didn’t meet a legal requirement that only authorized practitioners may issue orders “for all drugs, intravenous solutions, blood, medical treatments, and nutrition.

The latest DOH finding states that, “hospital leadership failed to establish hospital-wide patient care services appropriate for the patients served.”

Officials with Seattle Children's Hospital disagrees with the findings claiming the newborn had died because of natural causes.

In the hospital statement, it says, "Children’s takes this matter very seriously. However, we disagree with the DOH’s statement that the lack of clear written guidelines describing our transport team’s processes and responsibilities may have contributed to the patient’s death. The King County Medical Examiner has determined that this patient died of natural causes. We are confident that our transport guidelines, procedures, and supervisory structure did not contribute to the death of this patient."

The DOH had previously reviewed Seattle Children's for three other instances that happened in November.  The report found no deficiencies in procedures relating to those cases.

The DOH says they will work with Children's to review existing policies and procedures and develop a "plan of correction."  

The state's investigation is frustrating news for families that have lost loved one's because of medical mistakes.  Attorney Chris Davis represented Tammy Blankenship when her son Michael died after being given the wrong medication.  "She does not like to re-live what happened to her son when he lost his life in 2009," Davis explained.

Davis said he and his client hoped something good would come from her loss, but so far it's been more bad news.  "She wants these things to change she wants these types of errors to stop," Davis said.


Copyright © 2014, Los Angeles Times
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