By CYNTHIA McCORMICK
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A state police trooper currently stationed at the South Yarmouth barracks, John McCormack is accustomed to working within a chain of command and respecting authority.
So when his 1-year-old daughter, Taylor, ended up at Children’s Hospital Boston, he let the doctors take charge.
It’s a decision, McCormack says, he lived to regret.
Within hours of her arrival on Sept. 30, 2000, Taylor was in a coma. In less than a week she was dead.
In a case that’s been publicized in the press and now in a book, it turned out that the resident in charge delayed crucial emergency surgery to repair Taylor’s brain shunt because he couldn’t contact the attending surgeon by pager. The surgeon said he had set his pager to vibrate and fallen asleep.
Nobody tried to contact him by home phone or cell phone. The resident told the McCormack family that other surgeries were tying up the operating room — a statement that was later proved untrue.
"They played Russian roulette with my daughter," McCormack says. "They looked us in the face and they lied to us."
Taylor’s story and 10 others are profiled in a new book about deadly hospital errors, "Fatal Care: Survive in the U.S. Health System." The stories range from a healthy teenage boy who died after receiving an overdose of a nonsteroidal anti-inflammatory drug after routine surgery to a man who died of a heart attack after emergency room staff ignored his wife’s frantic calls for help.
"The idea was not to scare anybody," says Sanjaya Kumar, the medical doctor who wrote the book. Kumar is president and chief medical officer for Quantros Inc., a provider of safety and quality-technology products based in Milpitas, Calif.
Kumar says he wrote the book to alert the public to the fact that 98,000 patient deaths occur as a result of medical errors in U.S. hospitals annually, and about half of them are preventable.
"This is the equivalent of losing one commercial jumbo jet airliner full of about 270 passengers each day," he says. "Think of it as Medical Errors Airways. It’s got a lot of jetliners, and one is going down every day."
The deaths don’t get the kind of public attention crashes do, in part because the medical system is shrouded in mystery, Kumar says.
He says many families don’t even know their loved ones were killed or hurt by preventable errors until they start digging. A hospital’s own process of internal review is not open to families, although some hospitals are beginning to include patients in the process.
And until McCormack got "Taylor’s Law" passed, families were not even allowed to testify in disciplinary hearings before the state Board of Registration in Medicine.
The mystery begins even before patients head to the hospital, since there is little public information on the safety records of health care providers and institutions, Kumar says. In the age of the Internet, he says, it should be easy for a patient to find out what a doctor’s practice record is or how many procedures a surgeon has performed – but it’s not.
Once in the hospital, it often is not made clear to patients and their families who does what.
The doctor could be the attending physician with years of experience or an intern just out of medical school. In Taylor McCormack’s case, the family was dealing with a resident who was shy about contacting the attending surgeon or finding a substitute doctor when repeated pages failed.
The family didn’t know that until later, when it filed a lawsuit that was later settled. By filing suit, families get the right to subpoena testimony and records. The McCormacks found out through testimony from the chief operating room nurse that two operating rooms had in fact been available to take patients the night Taylor’s surgery was postponed.
Taylor had been born with a condition caused hydrocephalus, which is a buildup of fluid in the brain. Doctors installed a shunt under her skin to drain the excess fluid into her abdomen, and Taylor lived the life of a normal, healthy, round-cheeked baby, the third child and only girl in the McCormacks’ Pembroke household.
On Sept. 30, 2000, Taylor was lethargic and began vomiting. Her mother, Catherine McCormack, took her to Children’s Hospital, where the neurosurgery resident told her Taylor’s shunt needed to be tapped.
But no fluid emerged, and the neurosurgeon said she needed to be operated on that night to repair the failing shunt.
Throughout the evening, as Taylor grew glassy-eyed, the resident’s story changed. The operating room wasn’t available, he said, but that was OK because Taylor could wait until morning.
"I knew in my heart something could be wrong," McCormack says. "But, on the other hand, I was saying I’m in the best hospital in the world for children — how could anything go wrong?"
Taylor was put in a crib in a hospital room, while Catherine McCormack slept on a chair next to her.
At 2 a.m. Taylor awoke briefly, called out and went back to sleep. "The last word she ever said was ‘Mama,’" John McCormack says.
When Catherine McCormack awoke the next morning, her daughter was blue from lack of oxygen. She had stopped breathing and was put on life support for five days until her family let her go on Oct. 6.
McCormack insisted on carrying Taylor’s body to the morgue himself. "I made a promise to my little girl I was going to protect other little Taylors," he says.
He succeeded in getting Taylor’s Law passed and recently lobbied for a bill to guarantee safe levels of R.N. staffing in all Massachusetts hospitals. The Patient Safety Act passed the state House of Representatives May 22 and is scheduled to go to the Senate.
But more needs to be done, McCormack says. Patients need to be included in hospitals’ internal reviews of situations that have gone wrong, and boards of registration in medicine need to have more civilian members.
Children’s Hospital Boston e-mailed a statement to the Cape Cod Times yesterday that "Providing safe and high quality patient care is the top mission of Children’s Hospital Boston. Each day, the hospital’s clinicians care for children who face the most complicated childhood illnesses with the goal of helping them return home healthy. Delivering care in a safe environment and manner is a responsibility taken seriously by all clinicians at the hospital. Over the past several years, Children’s has undergone a transformation in its approach toward patient safety, including increased oversight by leadership, the recruitment of new leaders in patient quality and safety, and a ongoing program of safety and quality initiatives. The hospital has also invested heavily in its information and other systems to protect safety, including a new $40 million electronic medical record system. These initiatives have had a significant and positive effect on everything from a reduction of hospital-acquired infections, to the elimination of medical transcription errors, to improved communications between attending physicians and their trainees."
Kumar urges people contemplating a hospital stay or procedure to bring a patient advocate with them — be it a family member who is not afraid to ask questions or a friend who is good at advocating for others or who is a health professional.
"If you have an advocate, he says, "you probably have a better chance of coming out erect."
Do your part as a patient or advocate to prevent medical errors:
Find out what safeguards your hospital uses to prevent errors.
- Know what medications are being ordered and administered and why.
- Immediately report any adverse effects in your or the patient’s condition after receiving a medication or treatment.
- If something about a medication or dosage or procedure doesn’t seem right, say so. Never automatically assume the hospital staff is right and you are wrong.
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