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A Mother’s Prescription for a Health Care System that is Meant to Comfort and Heal. Dale Ann Micalizzi Advocate for Pediatric Patient Safety & Transparency in Medicine Medical Resident & Staff Training Presentation 2006 Questions/comments welcome email@example.com
Dale Ann Micalizzi
Advocate for Pediatric Patient Safety &
Transparency in Medicine
Medical Resident & Staff Training Presentation 2006
Questions/comments welcome firstname.lastname@example.org
The Task Force for Child Survival and Development
“On January 15th, 2001, Justin, a healthy 11-year old boy, was taken into surgery to incise and drain a swollen ankle. He was dead by 7:55 a.m. the next morning, leaving behind two grieving and bewildered parents who desperately wanted to know why their son had died. But medical care was to fail them twice – first their son died and then no one would explain to them why. I was one of the consultants, from another Children’s Hospital, contacted by Justin’s parents to review his records and figure out what went wrong.”
I know the chaos, the nursing shortages, overtime, the financial obligations, the insurance company guidelines and the arrogance that interferes with the quality of care. I have worked in healthcare and education for over 20 years. I also know, when it came time for my son’s surgery, you remove the chaos. You develop a team effort to review all information and establish a plan. You openly communicate between specialists, remove arrogance and intimidation and have a common goal to heal.
It is your obligation to complete checklists, check and double check medications and dosages, assign a nursing team and treat every case as a possible emergency with the patient as your ONLY focus. Look at the child, listen to the parents and use common sense and professional judgment when making all decisions. Slow down! You are holding my child’s life in your hands. Justin WAS important and should have been important to his healthcare providers also.
I trusted you.
The hospital failed us, the nurses who were his
advocates failed us, and the resident who
failed to draw pre-op labs failed us. Most
importantly, the surgeon who gave the case to
the resident and was NOT even in the OR at the
time of surgery failed us. The health department
failed us by accepting the medical personnel's
information as truthful. The hospital CEO failed
us by not providing us with any information or
support. Error upon accepted error killed my
son and my faith in a medical system that was
meant to comfort and heal. We will not let
this happen to another family as the pain
“ All day, each and every day, we are making decisions affecting people’s lives. We do not and cannot stop to cross every T and dot every I. If you live in that mind set, day after day, it is hard not to become casual about the people we deal with. Sometimes the outer shell is necessary to continue to do what we do, to see what we see, and still keep doing it. Caring parents are then regarded with suspicion, labeled as over-protective. A culture of us Vs them develops. Then when disaster we cannot fix tears us out of our complacent, protective shell, we have no effective coping mechanisms. At that moment we doctors are at our most vulnerable, easily persuaded by hospital spin doctors and risk adjusters…told to say nothing. Perhaps it is the hospital administrators you need to convince that the “truth will out” in the end.”
~by an Anesthesiologist abroad.
"We are truly social animals who need to know that someone cares. That is not a weakness; but, a basic need like eating and breathing.”
~ by Colonel John H. Chiles, M.D.
The family needs to sit down with all of those involved and discuss the adverse event with honesty and civility. This is OUR CHILD and it is your obligation to release every detail. Don’t protect us. Don’t lie to us. Don’t diminish our need to know. You owe us this much. Disclosure is part of healing those who are left behind. It is your responsibility to make sure that disclosure happens for your patient and yourself.
"I'd doubt that an ethics course would have made a difference in the docs attitude toward you. That kind of attitudinal change must occur on a much deeper level than cogitating about the right and the good (which is what ethics courses usually emphasize). Rather, one has to feel utterly disgusted over deceiving or stonewalling. I'm convinced of that. You have to be so revolted by dishonesty that you simply won't do it. And because physicians become inured to cutting the corners on honesty all the time, they often do poorly on disclosing mistakes, etc."
~by John Banja PH.D. Author of Medical Errors and Medical Narcissism and Bioethics Professor Emory University
who are the future.
Some of the most despicable human behavior has been conducted in the name of “I’m only following the law” or “I’m just doing my job.”
"Despite the difficulty in changing actual behavior, there may be symbolic importance and moral worth for medical schools to demonstrate their normative commitments, encourage apologies as the virtuous thing to do, and to put increasing moral pressure against the silence that surrounds mistakes."
~by Marlynn Wei (MD/JD Yale candidate)
Special thanks to all of the physicians from across the US and abroad who cared enough to help a grieving stranger understand. I had to search for them but I found them in abundance. They were my teachers, my confidants, my friends. They listened to my heart and shared theirs. They are the reason why I know compassion, integrity and safety really do exist in medicine and we can do better. I will be forever grateful. They know who they are~
(All rights reserved 2006)
It is most certainly a time in history for an era of compassion, integrity and safety. Let’s begin with medicine and blaze the trail. The others will follow when they see our success.
Please remember me….