Medical groups release new safety recommendations, questionnaires

Effort aimed at reducing hospital errors

May 19, 2000
Web posted at: 3:55 p.m. EDT (1955 GMT)

From Elizabeth Cohen
CNN Medical Correspondent

STUART, Florida (CNN) -- The American Hospital Association and the Institute for Safe Medication Practices have sent new safety guides and questionnaires to hospitals throughout the United States, as part of an ongoing effort to reduce deadly medical errors.

The institute designed the materials to help hospitals identify procedures that might be prone to error -- especially ones that involve medication. The organization said the practices in the survey aren't minimum safety standards, but have been shown to help reduce errors.

Martin Memorial Hospital in Florida was forced to examine some of its practices after 7-year-old Ben Kolb died because of a mistake in the operating room.

"We had a procedure that was flawed," said Doni Haas, head of risk management for Martin Memorial. "That procedure placed Ben in jeopardy, and it placed our practitioners in a situation where an error occurred that they will carry with them for the rest of their lives."

Ben Kolb was hospitalized for ear surgery, an operation that was supposed to be quick and simple. But during the surgery he went into cardiac arrest. He died the next day.

When the staff at Martin Memorial investigated, they found they'd made a terrible mistake. They had injected the boy with a powerful, highly concentrated form of epinephrine that should never be injected. He was supposed to receive a different form of the drug -- a solution a thousand times weaker than what he was given.

When poured into sterile containers used in the operating room, the two drugs looked exactly alike.

The staff made two important changes because of the error. Now, two staff members must be present when medicines are transferred from labelled bottles to the syringe or container the surgeon will use. They have also instituted a better labeling procedure in the operating room.

Martin Memorial settled out of court with Ben Kolb's family. The hospital is now participating in the national campaign to reduce similar errors in other medical facilities.

Dr. John McLaine, Ben Kolb's anesthesiologist, is featured in a video produced by the American Hospital Association in which medical professionals speak frankly about mistakes they have made and how their hospitals responded.

"We were very forthright with the family," he said in the video. "We said, 'Your son was injected with the wrong drug -- what can we do to help?'"

The AHA has distributed the video to American hospitals, hoping to encourage more of them to learn from their mistakes by first owning up to them.

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American Hospital Association
Institute for Safe Medication Practices
National Patient Safety Foundation
AMA - American Medical Association Home Page

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