Death of a healthy 11 year old boy in surgery

Justin Micalizzi

This blog post is reproduced with permission from Beth Boynton of Confident Voices. Beth and Dr. Alan Rosenstein provided an insightful interview for Avoid medical Errors about Bullying in Health Care.

On January 15th, 2001, Justin Micalizzi, 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

– second, no one would explain to them why.

(excerpted from “A Family’s Search for Truth,” Patient Safety and Quality Healthcare, Nov/Dec 2006)

Earlier this month, Bob Latino, CEO of Reliability, Inc. Tricia Pil, MD released a video of a Root Cause Analysis, (RCA) that included the compelling and heartbreaking perspective of Justin’s Mom, Dale Ann Micalizzi. It is called, “Sudden And Unexpected Intraoperative Death”.

As a mother, it is almost too painful to even think of this family’s tragic loss. And then on top of it the betrayal of trust in the silence from the hospital that permeated the aftermath.

Yet, as a nurse, I know all too well how sentinel aka adverse events can happen. Much easier, perhaps than we can defend or explain with staggering and persistent statistics from the Joint Commission. AND YET, how can we prevent them if we don’t dig deep into sentinel events with the intention of seeking to understand rather than covering up?

And doesn’t the family deserve to be part of the process? Certainly this helps healthcare professionals to stay connected with the emotional consequences of our ‘failures’ and consumers to learn more about our world. They become more empowered and stronger, more credible advocates.

Healthcare consumers bring their injuries and illnesses to us in good faith. That we will do our best to provide safe and quality care for themselves and loved ones. They are vulnerable and trusting. Sometimes I think we trivialize this part of the relationship. We maintain silos of ‘us’ vs ‘them’. Rather than being resources and team leaders, at times we take on a role of managing their lives. Then something goes wrong and we abandon them. It seems we nurture the dependence and when threatened and sever all ties.

When asking CEO, Bob Latino about the Patient-Engaged RCA process he stated, “It demonstrates a sincere interest in finding the truth, promotes transparency and is the beginning of the healing process for the victims. As the video demonstrates, ‘silence’ produces the opposite effect and polarizes the two parties instead of bringing them together for a common purpose.”

I believe Patient-Engaged RCA is a landmark effort in bridging the gap between healthcare professionals/organizations and patient advocates. Please reserve 20 minutes of your time to watch, offer feedback and share this video. “Sudden And Unexpected Intraoperative Death”. It may be scarey and complicated from a liability standpoint, but we will be so much more powerful in providing safest care if we are aligned with full and truthful disclosure.

Hat’s off to Bob, Tricia and Dale, for this progressive effort in patient safety.

My heart felt condolences to Justin’s family.

Learn more about the work Justin’s Mom is doing at Justin’s Hope-The Task Force for Global Health

Read about a family that participated in a root cause analysis when their child died. Sorrel King lost her 18 month old child in a hospital to a medication error.

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