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What to do about hospital mistakes?

November 2, 2011

Today we learned that Lifespan’s computer software accidentally sent incorrect prescription information to as many as 2,000 people. The hospital system sent out a statement before the Department of Health alerted me to the news and its Chief Quality Officer Mary Cooper spoke to me on the phone for about 15 minutes, explaining what happened.

It’s not the first time a hospital has made a mistake. It won’t be the last.  Coincidentally, an executive from another Rhode Island hospital was talking about how to handle mistakes at an event last night- Kent’s president and CEO Sandra Coletta.

Coletta was speaking at the 10th annual dinner for Medically Induced Trauma Support Services (MITSS), an organization devoted to supporting patients and medical professionals after a medical error happens.

Coletta talked about an old incident- the 2006 death of Michael Woods, the brother of actor James Woods. Michael Woods died of a heart attack at Kent three hours after entering the hospital’s emergency room.

After a court battle, Kent settled with the Woods family and promised to make dramatic quality improvements at the hospital. We’ve seen one iteration of that in its new approach to emergency care.

The CommonHealth blog over at WBUR has a great recap of Coletta’s appearance last night along with some information about the Woods case. The authors say they were struck by her candor.

The news is nearly two years old, that Kent Hospital in Warwick, R.I. settled a suit by actor James Woods over his 49-year-old brother’s Emergency Room death.

But it is still quite something to hear the hospital chief involved, Sandra Coletta, say out loud before an audience of hundreds that she apologized for what happened and that “Quite honestly, I did nothing other than what my mother taught me.”

You can also watch the complete video of her speech here, taken from the CommonHealth blog-

Here’s the part that struck me, when Coletta described her meeting with James Woods-

In health care, we evaluate and we’re counseled and we read books upon books. But sometimes you just have to go back to your core values… When I met that man I did not meet James Woods, I met a family member who had lost a brother because an order that was written by our emergency room physician was not carried out by the staff.

It’s hard to admit that you’ve made a mistake, especially in the world of health care when patients already feel so vulnerable. But maybe Rhode Island’s hospitals are starting to figure it out.

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