Hospital launches assault on errors

The first specialist on her call list, the doctors supposedly available for consultation, said he shouldn't have been on the list. The second said he would have helped out earlier, but he was no longer on call. Not until the nurse reached a third specialist did she find someone willing to look at the child.

Normally, such mixups might be lost in the hubbub of running a 325-bed hospital. But, since the death of a 5-year-old at Children's last May from an epileptic seizure that wasn't treated aggressively enough, the hospital has launched an assault on mistakes of all sizes. According to Dr. James Lock, chief cardiologist at Children's, the reluctant specialists were chided at a staff meeting by their department head, who said, "The first thing out of your mouth should be, `Do you think somebody needs to see this child now?'

"What we're trying to do is learn from our small mistakes, so we don't have the big ones," he said.

State and federal regulators say the hospital is off to a good start in addressing problems revealed by the deaths of 5-year-old Matthew Siravo and two other patients over the past year. After a sweeping review of the hospital's activities, the officials recently removed Children's from a kind of probation under which it could have lost the right to treat patients covered by Medicare and Medicaid. However, the regulators found continuing, though less serious, problems last month, such as the lack of a centralized tracking system for patient complaints.

The hospital's president, Dr. James Mandell, said Children's will spend several million dollars to improve accountability and communication, ensuring that senior doctors are available in the intensive care units around the clock and requiring specialists to share responsibility for children with difficult health problems.

"There's a radical change in the way we handle children with complex needs," he said.

But the hospital's overarching goal is less tangible: to change a culture common in academic medical institutions, in which specialists often operate autonomously and in which medical trainees sometimes feel discouraged from asking superiors for help. Skeptics worry that Children's and other teaching hospitals have promised such changes before, without lasting results.

The renowned hospital was shaken in September when a report by state and federal regulators found serious communication and accountability problems in the care of four children, three of whom died.

They focused in particular on 5-year-old Siravo, who died May 11 after suffering an epileptic seizure while his brain was being monitored after surgery at Children's.

Medical trainees from three different specialties -- intensive-care medicine, neurology, and neurosurgery -- responded, but they were confused about who was in charge and did not order the aggressive treatment he needed. A senior physician did not come to the boy's bedside until an hour into the seizure.

Children's had vowed to improve communication more than a year earlier, after public officials partly blamed communication problems for the death of 13-month-old Taylor McCormack, who suffered fatal brain damage in 2000 while waiting overnight for surgery to drain excess fluid from her skull.

Dr. Anthony Whittemore -- chief medical officer of Brigham and Women's Hospital, which jointly runs a neurosurgery training program with Children's -- said that following the Siravo case, the hospital has made "a clear commitment to cultural change."

"That's a little bit different than the last time they were in the press," he said, alluding to the McCormack case.

Cardiologist Lock said that residents at Children's are now more likely to ask for help and that supervisors are quicker to fault them if they don't.

For example, a resident working one recent night in intensive care dismissed a dark spot on a scan of a teenager's abdomen, even though it could have been a sign of cancer. Senior doctors later determined that the shadow was not significant, but told the resident at a staff meeting that he didn't have the background to make that judgment.

"The trainee didn't recognize his own limitations," Lock said.

Children's officials are paying particular attention to patients who have a chronic disease such as kidney failure or epilepsy and come into the hospital for treatment of an unrelated condition. A review at Children's this summer found that such complex cases account for 37.5 percent of serious adverse outcomes.

Under the new approach, 10,000 patients with chronic conditions are on a list requiring that their specialist be notified before they undergo surgery for another condition, Lock said. Just as important, their care is shared by two senior, or attending, doctors; for instance, an epileptic coming in for an appendectomy would have an attending neurologist and an attending surgeon. When the patient is admitted, the two must communicate directly, not through their junior trainees.

"The problems [at Children's] do reflect the problems in all academic medical centers," said the Brigham's Whittemore. "We've gone from the days of a single admitting physician calling the shots and taking care of all the patient's problems to one person admitting and calling in a host of specialists to consult. That just breeds confusion as to who's got the prime authority, and that's what we're wrestling with."

Parents of children frequently treated at Children's say that they see improvements, but that the hospital still has a long way to go.

One woman, who asked not to be named for fear of alienating her child's doctors, said her child was treated much more quickly and monitored more aggressively on hospital visits after the death of Taylor McCormack, who had a similar condition. But she said that as recently as this summer, she still frequently witnessed turf battles between different specialists, even once when her child was in the middle of a seizure.

"I said, treat the seizure now and worry about your turf battle later," she said. On a visit this fall, she said, specialists coordinated with each other better, but only after she insisted.

Another parent, Risa Sherman, said she was angry when she learned of the Siravo case and the McCormack case, because in 1999, multiple residents failed to realize that her son was struggling to breathe; he was given a breathing tube after her father-in-law, a doctor, flew up from New Jersey to insist. David Weiner, then the hospital's president, promised changes, she said.

"It's the same mistakes being made over and over again," she said. "It's poor supervision of residents. It's bad communication. It's no one person in charge."

Cardiology chief Lock acknowleges that it will take time to create a more vigilant medical culture, but he said he is encouraged by the broad support of the medical staff. "I can't just write a memo," he said. "It has to be a bottom-up event and it has to permeate the institution."

Scott Allen can be reached at allen@globe.com.