Organizational failures and patient safety at Boston Children's Hospital

Med Challenges

Challenges in Medical Delivery: Recommendations for Solving Problems at Boston Children's

There is a clear ethical imperative for medical organizations and personnel to provide the best possible care to their patients, with the goal to extend life taking precedent over other objectives in all but the most extreme cases. The "first, do no harm" motto that physicians have recited for millennia (with some interruption, no doubt) is still the highest principle in medicine today, with the effort to preserve health and life the paramount concern of medical personnel and the medical industry. When doctors, nurses, administrators, and organizations fail to maintain this principle, or tale actions that are not in the furtherance of this objective, they will lose the trust of the public and the communities they serve. This is something that will be of disservice to all parties involved.

In addition to the intrinsic ethical duty to provide the best possible care and the ethical malfeasance of letting other objectives enter into the decision-making process, there are very real practical considerations that must be taken into account in maintaining appropriate objectives and care levels. The malpractice climate in which modern medicine takes place means that medical errors or negative outcomes can have a direct impact on financial resources available to the organization, and this necessarily has an impact on the level of care that can be provided (Bosk, 2003; Gawande, 2008). Maintaining proper objectives and proper controls over processes and practices is thus essential for any healthcare organization.

The administrator at Boston Children's ultimately bears the responsibility for ensuring that clear objectives exist, clear practices outlined, and clear controls put in place to ensure that the objectives and practices are adhered to. Though of course doctors and nurses are undoubtedly responsible for their own practice and making sure that they comply with ethical as well as organizational and professional guidelines, when there is a breakdown in the hierarchy of responsibility and decision-making amongst the direct providers of medical care it must be the administrator who steps in to solve the problem (Groopman, 2008; Timmermans & Berg, 2005). Matty's case at Boston Children's Hospital is a definite case of this breakdown in the chain of responsibility, as the following pages shall demonstrate, and though the outcome was irreversible and enormously tragic, it can be used as an effective means of avoiding such problems in the future, and educating other hospitals in the provision of more effective and responsive care, as well. The recommendations made following a brief case analysis will help to prevent any similar reoccurrence.

Numerous problems contributed to the problems in Matty

's care and his eventual unnecessary death. Personal decisions made by certain staff members as well as organizational issues that allowed these decisions to be made -- and prevented some decisions -- are influential factors. The broad issues are identified below, and recommendations follow.

Understanding the deeper organizational problem represented in this case requires an understanding of the specific decisions that were improperly made. First, the lack of knowledge in the unit to which Matty was transferred made the use of evidence-based medicine by unit nurses a complete impossibility, against the basic fundamentals of practice (Groopman, 2008; Timmermans & Berg, 2005). Second, the Epilepsy Fellow who was directing Matty's care -- whether or not she knew it -- from her cell phone appears to have made decisions to treat Matty's seizures in a manner that was counter to standard medical practice and the inclinations of other medical personnel, treating far more conservatively than warranted in an attempt to ensure success in the surgery itself. This exposed Matty to danger and the hospital to liability, and was both ethically and pragmatically inappropriate (Gawande, 2008). Other decisions also contributed to the case outcome, but these are the areas of primary concern.

What these underlying problems point to is a lack or clear hierarchy and a lack of effective patient-doctor relationships. There is no mention of communication with Matty's parents at any time during this ordeal, such that patient responsibility was entirely removed. The decision appears to have been made that the information needs were worth a heightened risk, and this is a decision that patients or their informed custodians should have made (Groopman, 2008). When it comes to the chain of responsibility, the finger pointing that occurred after the incident and the fact that no one expressed concerns during the incident that they say they experienced at the time means there is a lack of trust or clear reporting procedures, or both.

Recommendations

These problems must be addressed in a very direct and comprehensive manner, which does not preclude speaking with the individuals involved but must also include broader organizational changes and more widespread statements of policy and guidelines. It must be made clear that every person is responsible for the health and well-being if every patient they encounter, and if they feel that decisions are being made in error that they are to report this immediately to an uninvolved authority. In this case, several physicians reportedly did not want to counter the person they felt was in charge of directing care, and both nurses felt this way about the physicians, as well. If any one of these individuals had spoken up, the consensus regarding appropriate care would have quickly been discovered and changes made, and reporting an outside authority would have allowed this decision to be made objectively and without fear of personal reprisal or issues arising out of perceptions of peer judgment (assuming such reporting would be kept confidential, which it certainly should be).

General reporting techniques and procedures for events and actions being taken, especially with pediatric patients, should also be made more stringent and more clear. The fact that Matty's parents do not appear to have been involved in making his care decisions in the slightest is definitely problematic; though they certainly are not as medially qualified as Matty's doctors, when it comes to the weighing of objectives and risks it is their right and responsibility to make such choices. A chain of communication needs to be established for future cases.

More concrete recommendations for the organization include a clear system for assigning and determining a physician-in-charge for every admitted patient at all times, such that there is never a situation where emergency care is being directed through a cell phone, where there is not a clear hierarchy during medical response, and where there is clear accountability after the fact. Even simply signing at the top of a chart or on a room board can become an assignation of responsibility, and a simply rule that a physician must remain in the building until their patients have been signed over to someone else would ensure that care decisions are being made with immediacy and accountability in the future. More extensive training programs and requirements regarding proficiency testing should also be put into place for special types of cases before units are given actual patients, and switching out some unit staff might have been an appropriate and effective way increasing the transfer of knowledge while also increasing the level of care that Matty received -- and that future patients could receive.

Conclusion

The recommendations made above will make a case like Matty's all but unrepeatable in the future. There will always be issues and mistakes, however, and these recommendations will also enable a more clear and consistent diagnosis of organizational errors and breakdowns in responsibility and communications. By identifying and maintaining a clear hierarchy and guidelines for practice and behavior, the orgnization and its patients will be much better served.