Consumer Engagement: Residents Hire Staff at Nursing Home

Over the years, I have railed about lack of true consumer engagement within healthcare organizations. I have pushed people to go beyond the “window dressing” of one or two family members on a committee. I have advocated for healthcare organizations and insurers to interview patients and families post-event to add credibility to the review process and subsequent disclosure conversations. And I have shared stories of patients/families getting involved with healthcare organizations in a meaningful way after adverse events with Grand Rounds presentations, being involved in the safety fixes, and even consulting.

Then, there was this story that was recently circulated on Facebook by Martine Ehrenclou. One Illinois nursing home is actually letting residents have the final say on applicants for staff positions. The home’s leadership conducts the initial vetting of applications and does the first round interviews, but the residents give the final thumbs up or thumbs down….and apparently the residents have given the kibosh to several would-be staff members. Wow! Talk about empowerment, and talk about a great way to strengthen relationships and trust. That’s the kind of relationship that can withstand adverse events so long as effective disclosure is part of the picture.

How could acute care organizations follow this example?

Hey, remember, tomorrow — Feb 26th – the Risk Authority-Stanford is holding their FREE webinar with three big-time disclosure rock stars: Michelle Mello, Dr. Tom Gallagher, and Leilani Schweitzer. You will learn a lot from Michelle, Tom, and Leilani. Here is the link to register for this free webinar.

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The Risk Authority-Stanford Holding Free Disclosure Webinar with Three Rock Stars

Last week I was contacted by the good folks at the Risk Authority-Stanford to help promote their upcoming FREE February 26th webinar with three big-time rock stars: Michelle Mello, Dr. Tom Gallagher, and Leilani Schweitzer. You will learn a lot from Michelle, Tom, and Leilani. Here is the link to register for this free webinar, and below is the text from Stanford’s marketing materials.


- Doug

Doug Wojcieszak, Founder, Sorry Works, 618-559-8168


Title: Communication and Resolution Programs: Voices of Experience

Date: Thursday, February 26, 2015

Time: 11:00 AM Pacific Standard Time

Duration: 1 hour

Format: Live panel discussion delivered by video webcast with Michelle Mello, Dr. Tom Gallagher, and Leilani Schweitzer



Communication and Resolution Programs:

Voices of Experience.



Communication and Resolution Programs (CRPs) promise to reduce liability costs, promote a culture of safety and provide a vehicle for disclosure and healing between providers and patients after a medical error. Over the past decade, several CRPs have been pioneered and studied at leading medical centers.

In this live webcast event, we bring together three leading voices in the field – a health law scholar, a physician and a patient, to discuss:

  • Have CRPs delievered on their promise? What do the data show?
  • What best practices have emerged?
  • What challenges need to be overcome?
  • What resources are available to institutions interested in exploring or strengthening CRPs?

The Risk Authority – Stanford, in partnership with Aon Risk Solutions, Lockton Health Risk Solutions and The Medical Protective Company invite you to participate in this important event and gain insights and solutions into the critical aspects of communication and resolution programs.

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Hospital Demands Signed Confidentiality Agreement Before Talking

I heard from a physician friend recently who lost his mother in an East Coast hospital. My doctor friend believes there were several medical errors committed during the care of his mom. He wrote a detailed letter listing his concerns and asking for specific responses. The doctor also asked to be involved in the investigation, and to meet with senior leadership of the hospital. After three months of phone calls, voicemails, and e-mails, the hospital finally agreed to meet….but only if the physician friend signed a confidentiality agreement! My doctor friend wrote back to the hospital saying he would not sign the confidentiality agreement simply to receive information he was legally and ethically entitled to. The hospital has never responded.

The friend has now filed complaints with the regulatory authorities, and is in the process of pursing litigation. My doctor friend believes in disclosure now more than ever….he told me if the hospital had only been transparent, open, and accountable he wouldn’t be pursuing litigation and filing complaints.

First, why would anyone wait three months to meet with this family? We want to stay connected or quickly get re-connected with families post-event. If you are not meeting with your families, who is? A lawyer? A regulator? A member of the media? Or all of the above?

Second, when communicating with patients and families post-event, don’t play games and or put pre-conditions on anything. Surefire way to destroy trust. We’ve told our readers time and time again to welcome plaintiff’s attorneys, tape recorders, and note pads. In fact, we’ve told you to just assume the smart phone in the woman’s purse is recording every word, and the “brother” at the end of the table is actually a lawyer. You should be happy for everyone to see and record your ethics in action.

Making a family sign a confidentiality agreement will destroy the trust you are trying to re-build. Don’t do it. If your doctors, nurses, or lawyers are nervous about disclosure meetings, then YOU need to help them feel comfortable. Explain how disclosure works, provide training, role plays, etc, and in the end if a particular team member is still not comfortable he/she probably shouldn’t go to the meeting. Send someone else. But it’s not the job of the patient or family to get your side comfortable by signing a confidentiality agreement. That’s just wrong.

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Sorry Works! Celebrates 10 Years

It was 10 years ago, February, 2005, that Sorry Works! was officially launched with a press conference via conference call. Myself and a few friends spoke to a handful of reporters over the phone and we were off the ground…but I never could have imagined or expected the growth, impact, or staying power of Sorry Works!  It’s been an amazing journey.


I initially started Sorry Works! to be an advocacy organization — to encourage healthcare organizations to consider disclosure. I also wanted Sorry Works! to be a resource center for healthcare, insurance, and legal professionals who wanted to learn more about disclosure and get some encouragement.  Sorry Works! was started as a pro bono project within my PR consulting firm…and I never thought it would grow beyond that.  At first, Sorry Works! took a few hours of my time…then 10 hours per week…which quickly grew (within the first year) to 20 and 30 hours per week. We had a hit a nerve with people…..many folks said disclosure was long overdue, while others wished we would go away and wanted to fight us. During that first year, we spent a lot of time debating folks about should disclosure be done…aren’t we just inviting more lawsuits and why should doctors say “sorry?” were just some of the battles we fought during that first year. Soon, however, these battles turned into requests for help implementing disclosure: “Doug, we agree with disclosure principles, but how do we actually teach our doctors and nurses to say ‘sorry,’ and how do we coordinate this with our legal counsel and insurer?”A training and consulting business was born.


Sorry Works! has developed books, booklets, CME-accredited presentations, webinars, Train the Trainer seminars, and other content. The original Sorry Works! Book has sold over 25,000 copies, and the Little Book of Empathyhas sold thousands more copies, and several organizations have customized the Little Book of Empathy for their staff. The weekly Sorry Works e-newsletters have touched thousands of people by keeping a laser focus on all things disclosure, while the Sorry Works! website receives over 500 unique visitors per day. Sorry Works! has become the face, voice, and brand of the disclosure movement. We like to say Sorry Works! has trained over 30,000 healthcare, insurance, and legal professionals, but the number is probably much, much higher.


None of this would have been possible without YOU. Sorry Works! does not have a big marketing budget.  In fact, we don’t have any marketing budget besides our website and e-newsletter distribution service.  Everything we’ve accomplished has been through word-of-mouth and grass roots efforts. People like YOU sharing our message with others, buying our content, and inviting us to speak at hospitals, nursing homes, and major conferences.  So, “Thank you!” for 10 great years, please keep spreading our message with your colleagues and friends, and here’s to the next 10 years and however long it takes to make a disclosure a reality in every healthcare organization.


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Leadership Says They Do Disclosure Really Great…..Really?

When I speak at a hospital or insurer it’s not uncommon for me to hear the following from leadership, including risk, legal, and claims personnel:

“Hey, we already do disclosure great…we do everything you’re talking about…we’ve spoken with other disclosure hospitals like Michigan, Stanford, and others…we’re all over this!”

One part of me feels good, as 10 years ago when Sorry Works! started these same leadership types would be arguing with me about whether or not they should do disclosure. Now, they all claim to be experts in disclosure….but are they?

Usually, these same folks who swear they are fluent in disclosure begin asking me questions….

“We do great at the clear cut cases, but struggle with the ‘gray cases’ where we’re not sure if there was a mistake or not. Unfortunately, these ‘gray cases’ make up the bulk of our adverse events. How do we handle ‘gray cases’ with disclosure?”

“What if the family disagrees with our assessment of the case?”

“Should we stay in touch with the family during the review process?”

“How do we determine the value of a case?”

And so, and so on, and so on….

Then I start asking questions, such as:

“How much do your front-line docs & nurses understand about disclosure? Do they know how to empathize and stay connected with families post-event without prematurely admitting fault?”

“Do you have a disclosure policy? When was it last updated? Have any doctors or nurses read the policy…do they even know the policy exists?”

I usually get lots of blank stares and silence when I ask these questions.

Look, talk is one thing – “We do disclosure great” – while having a real, working disclosure program is something entirely different. A true disclosure program has an updated and vibrant disclosure policy, has staff who are trained in empathy, and leadership who knows how to handle all cases, including gray cases. You really need a disclosure program before you can claim to be “great at disclosure.”

At Sorry Works! we can help you develop a vibrant disclosure program, with consulting, presentations, train the trainer seminars, and great content for your staff. Our recently released “Pocket Notes” is great for front-line staff, and the “Little Book of Empathy” is geared towards managers and directors. Start your disclosure journey with Pocket Notes and Little Book of Empathy — click here to order.

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Hospital Throws Away Kidney, Apologizes, Denies Negligence — and Settles for $650K

In Fall 2013 we told you the story of an Ohio woman, Sarah, who desperately needed a kidney transplant, her brother was a perfect match and agreed to donate, but the hospital — University of Toledo Medical Center — accidentally threw away the brother’s kidney during the transplant procedure. The hospital apologized and worked hard to find a new kidney and covered all expenses, and a new kidney was eventually found, but, apparently, not as good a match as the brother’s kidney. The family wanted more — apparently money — and the hospital balked, so the family sued and the hospital moved to have the lawsuit dismissed saying they didn’t breach the standard of care. Original e-newsletter is below.

Well, update for you…the hospital settled last year for $650K, which are the limits in Ohio for such cases.

This is a story about hitting the finish line with apology and disclosure.  You have to be ready to hit the finish line with these cases, which means you need to have your leadership, claims team, and counsel (in-house or outside counsel) philosophically aligned and ready to be pro-active especially with fair, upfront compensation for cases of true medical error. It’s not enough to say you are “sorry.” You have to show it and mean it, which often means identifying the mistake, discussing how the mistake will be fixed and possibly including the patient/family in that fix, and then fulfilling the emotional and economic needs of the patient/family. Some risk managers are now asking patients/families what they need and then letting the family talk. Often the demands range from reasonable to too modest, in which case the hospital/insurer has to suggest things so the final settlements will be considered fair and reasonable by outsiders.

I wrote this below in Fall 2013: How different would this case be portrayed had the University of Toledo Medical Center said sorry, found a new kidney, offered the family $500K, and provided the opportunity for the family to be involved in quality improvement at the hospital? If the family had still sued, the family — not the hospital — would have appeared to be greedy and unreasonable. But that was not the case, apparently no such monetary offer was made, the family sued, and untold legal bills were racked up while the hospital’s reputation was crushed in the national and international media. How completely stupid.

Let’s this be a lesson for everyone. There are still people in healthcare and insurance who think saying “sorry” absolves them of their financial responsibilities. That’s not how that game is played. Here is how the game is played: Being accountable and taking care of your financial responsibilities in an ethical and expedited fashion will reduce litigation and other forms of revenge while improving patient safety which will lead to significant savings for your organization.

Disclosure starts with your front-line staff. To help your staff understand their role in the disclosure process, we’ve introduced “Pocket Notes.”  With Pocket Notes, your front-line staff will learn how to empathize and stay connected post-event without prematurely admitting fault. To order your copies of Pocket Notes, visit this link.

To see the story about the $650K settlement with University of Toledo Medical Center, visit this link.


- Doug

Doug Wojcieszak, Founder, Sorry Works!


Original Fall 2013 e-newsletter

Last year (2012) Sarah Fudacz, age 24, desperately needed a kidney transplant, and her younger brother, Paul, age 20, turned out to be a perfect match. One hitch: The hospital threw away Paul’s kidney before they could transplant it into Sarah.

The hospital apologized and worked hard to find Sarah a new kidney a few months later. Sarah and her brother are now physically doing fine, although, according to the family and their attorney, the donated kidney wasn’t as good a match her brother’s kidney. Moreover, the family is absolutely furious. And they are suing.

Another wrinkle to the story is one nurse involved in the operation resigned, and another was fired…and the nurse that was dismissed is suing the hospital.

According to an article published by the Toledo Blade, the hospital’s Dr. Jeffrey Gold, UTMC chancellor and executive vice president for health affairs, released a statement Friday.

“The university continues to express the sorrow that we feel that this unfortunate incident occurred. We apologize sincerely. We have done our best to provide many remedies to help those affected move forward,” it said. “All of us at UTMC are sympathetic and sorry that this has happened….While the legal realities of this situation are complex and ongoing, we have worked hard to learn from this incident and have spread these lessons widely to try to make hospitals and transplant programs safer across the country.”

According to the Blade article and a story by Good Morning America, the hospital was initially very open with the family and accommodating, including the assistance finding another kidney. But, things broke down when the Ohio Attorney General’s Office, which is representing this university hospital, thought the family’s additional requests for assistance were unreasonable. Now the AG’s office is trying to dismiss a suit by the family by claiming the hospital was not negligent and seeking to recover costs.

Lots of lessons here for the disclosure movement:

1) When designing a disclosure program, make sure to have all the folks on your side (medical staff, leadership, outside insurers, defense counsel, etc) on the same page. We’ve told folks time and time again to feel out your defense counsel and insurers long before an event happens, and make changes, if necessary. In this case, perhaps the hospital should have discussed their disclosure program with the AG’s office long before the situation with the Fudacz family.

2) This story also hammers home the importance of the compensation piece in disclosure. When trying to resolve a case, all options need to be on the table, and you need to have the ability to proactively address financial as well as emotional needs of all stakeholders. For many people, money is how they keep count…and your disclosure program needs to reflect this reality. However, when you diminish the anger and need for revenge, monetary figures usually decrease. Moreover, there will be times money won’t be an issue (for whatever reason), but you need to be able to handle the compensation piece or your disclosure program can be made to look hollow and meaningless. I would be curious to know what the family’s additional demands were that the AG’s office deemed unreasonable. At Sorry Works!, we have taught folks that disclosure does not turn you into an ATM machine, but this case feels funny. Instead of arguing the case on damages, the AG’s office is apparently trying to deny negligence and also wants to recover costs. It appears there is a disconnect on the compensation piece. Moreover, the family did not want to litigate, according to their attorney. You have to have the compensation piece in place or your disclosure program will look like a white-wash job. How different would this story be if it read, “Hospital throws away kidney, apologizes, finds new kidney, offers $500K or a $1M, but family still sues?”

3) Think of the PR implications. Here’s one story where Ms. Fudacz says the hospital “threw away her life.” Ouch! This story has been splattered across the country and around the world, and denying negligence makes this hospital look even worse. Again, this is why it is so important in a disclosure environment to be on the same page with defense counsel, and the time to get on the same page is long before an event happens. Think how much business this is costing the hospital. The next time your CFO says we can’t afford to implement disclosure, or the CEO says “we’re too busy right now,” drop this story on their desk.

4) Let’s not forget about the second victims…one nurse resigned, and another was fired and is now suing the hospital. Good disclosure programs take care of staff.

Finally, Ms Fudacz and her brother are actually interested in medical careers, and this situation has only heightened their desire to be clinicians. Let’s hope they become healthcare professionals because they are both in a unique situation to do a lot of good. Talk about a powerful story!

Here are the links for the Blade article and the Good Morning America story.


Doug Wojcieszak, Founder, Sorry Works!

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“Pocket Notes” Teaches Disclosure to Front-Line Docs & Nurses

Happy New Year!

To help your organization truly embrace disclosure this year, you need to train your front-line staff how to empathize and stay connected post-event without prematurely admitting fault.   Our newly released “Pocket Notes” can do the trick. 

Over the last four years Sorry Works! has sold thousands of copies of The Little Book of Empathy…..this short booklet is a great tool for disclosure team leaders, physician leaders, and nurse managers. Now we have developed “Pocket Notes” for front-line staff which summarizes the most critical details from the Little Book of Empathy.

In a few minutes, Pocket Notes will teach your docs and nurses the basics of empathizing and staying connected post-event without prematurely admitting fault. Small and economical, Pocket Notes is a must have for all of your front-line staff. Pocket Notes will raise disclosure awareness among your clinicians, and help them through difficult post-event discussions.

To order copies of Pocket Notes and also the Little Book of Empathy, visit this link.   Bulk pricing is available by calling 618-559-8168 or e-mailing   Lastly, Pocket Notes and the Little Book of Empathy make great gifts for the upcoming Doctors’ Day and Nurses’ Day. 

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Holiday Message Worth Reading (Seriously!)

This is a holiday message actually worth reading because it contains a deep, personal confession and a link that is pee in your pants funny.

First, the deep, personal confession: I don’t have a smart phone. Nope, no iPhone or other web-connected mobile device in my pocket.  Just a good ol’ fashioned flip phone for me. When I speak at hospitals and insurers and whip out my trusty flip phone the reactions range from shock to laughter. Some express disbelief that flip phones still exist! And of course, people ask why…why?!?…I don’t have a smart phone. Don’t I understand all the fun I’m missing?? I’m taken my fair share of good natured ribbing, and now it’s my turn to return the favor with this link.

This link is really my Hanukkah and Christmas present to all my smartphone addicted friends out there. This 3 minute 30 second YouTube video is entitled “Get Off The Phone” produced by the creative duo of Rhett and Link. “Get Off The Phone” has been viewed over 4.6 million times. The video link is truly hysterical, but it’s also why this is a holiday message actually worth reading (and sharing). No, not another hollow, throw-away greeting wishing you good cheer with some goofy family picture, but something that will actually help you enjoy and remember the season: Get off your phone! Live in the moment! Be present!

Again, here is the link for the “Get Off The Phone” YouTube Video. Go on…click on it!

I want to personally wish all my readers a very Happy Hanukkah, Merry Christmas, Happy New Year, and God’s rich blessings to you and your family. And if you need that last minute holiday gift, be sure to check out the Sorry Works! Store…we’ll get anything you want faster than ol’ St. Nick.

See you in 2015!

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Not All VA Hospitals Disclosing Errors…Surprised?

An article was recently published in the Tampa Bay Times saying – in short – that despite a national reputation as being a leader in disclosure of medical errors, not all VA Hospitals are following the VA’s national policy of disclosing medical errors.  In fact, the Times article implied very few patients/families are receiving disclosure and apology from VA facilities.

My response: I am not surprised, and, within the disclosure world, I’m not sure this is earth shattering news.

Look, to be absolutely candid, you could write almost the same article about any hospital in the United States, because around 2001 JCAHO told hospitals they needed disclosure policies, and most complied.  Again, so what?  Sometimes when I speak at a hospital I will hold up a copy of the JCAHO-inspired disclosure policy and ask how many doctors & nurses know the policy even exists?  Usually only a few hands go up.   I will then ask those with their hands up to continue to keep their hands up if they have actually read their hospital’s disclosure policy.  Almost always all the hands go down.   When I read these disclosure policies, they appear to be written by lawyers for the benefit of lawyers.  Absolutely worthless.  No wonder we have so many doctors and nurses not knowing what to say post-event, no idea who to call for help, etc, etc. 

Dr. Steve Kraman and Ginny Hamm, JD did an awesome job at the VA Hospital in Lexington, KY several years ago.  They had a good disclosure program, and their work became the template/model for disclosure programs at many other hospitals and insurers.  Kraman and Hamm received much well-deserved praise as did the VA System for giving them the ability to do this work.  I believe Kraman and Hamm’s work also was the reason for the disclosure policies within the VA and by JCAHO….but there is a world of difference between a policy and a program.   Not enough private hospitals and VA hospitals have disclosure programs.  We have a lot of work to do.

You need to have a program…a program that raises awareness within the institution from c-suite to front-line staff, provides the necessary training for all staff, and the institutional follow-through when adverse events happen.  If all you have is a policy the Tampa Bay Times could write the very same article about your hospital (or insurer).   You need a program, and the best part is the cost of developing a program will be recouped by stopping just one lawsuit.

To help train your front-line staff, be sure to get some copies of the newly released “Pocket Notes.”  Adapted from the successful Little Book of Empathy, Pocket Notes will in a few minutes teach the basics of empathizing and staying post-event without prematurely admitting fault.  To order,click on this link.

Finally, here is the link for the Tampa Times story.

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Oregon Hospital Apologizes for Fatal Medication Error, Shares Details

An Oregon Hospital recently apologized in person with the family and in writing for a fatal medication error that took the life of 65-year old Loretta Macpherson. The hospital apparently gave the Mrs. Macpherson the wrong drug. Here is text from a letter released by the hospital:

“On Monday afternoon, a tragic medication error occurred at St. Charles Bend that ultimately caused the death Wednesday of a 65-year-old patient. The St. Charles family is devastated by this situation and our thoughts and prayers go out to the patient’s family along with the caregivers who were directly involved in this case during this incredibly difficult time.

“As soon as the error was recognized, we met with the patient’s family to explain what had happened and apologized for the grave mistake. We are in the process of investigating the cause of the error and are working closely with our internal team to ensure that it will not happen again. We will be reporting the event to The Joint Commission and the Oregon Patient Safety Commission in the coming days. St. Charles has never experienced a medication error of this kind in its history.

“The caregivers directly involved in this patient’s situation are on paid administrative leave while the investigation continues. They are long-term caregivers who have provided compassionate and skillful care throughout their careers.

“All of us have chosen health care as a career because we have a heart for serving people. When a patient is harmed on our watch it affects us deeply.

“We are committed to handling this tragedy in a transparent and responsible manner that takes into account the needs of the patient’s family, our family of caregivers and our community.

Dr. Michel Boileau
Chief Clinical Officer
St. Charles Health System”



THEN, this more detailed analysis of the situation, what went wrong, and how errors would be fixed was shared with the public and the media:


Results of Medical Error Investigation

Press Conference Statement – Dec. 8, 2014

As you are well aware, a tragic medication error occurred here last week that resulted in the death of Loretta Macpherson. All of us at St. Charles are devastated by this event. Our thoughts and prayers are with Ms. Macpherson’s family and friends during this incredibly difficult time.

After completing our root cause analysis – or internal investigation – we have a more detailed understanding of what led to the medication error.

I would like to first say that while human mistakes were made in this case, we as a health system are responsible for ensuring the safety of our patients. It is the executive leadership team’s responsibility to ensure that processes are in place and those processes are followed. No single caregiver is responsible for Loretta Macpherson’s death. All of us in the St. Charles family feel a sense of responsibility and deep remorse.

  1. On Monday, Dec. 1, Loretta Macpherson came to the St. Charles Bend Emergency Department for treatment following a brain surgery at Swedish Medical Center in Seattle. The physician who cared for Ms. Macpherson here ordered fosphenytoin, an anti-seizure medication, to be administered intravenously.
  2. The drug was correctly entered into the electronic medical records system and the correct order was received by the inpatient pharmacy.
  3. The order was read in the inpatient pharmacy, but an IV bag was inadvertently filled with rocuronium – a paralyzing agent often used in the operating room.
  4. The label that printed from the electronic medical records system and was placed on the IV bag was for the drug that was ordered – fosphenytoin – although what was actually in the bag was rocuronium.
  5. The vials of rocuronium and the IV bag that was labeled “fosphenytoin” were reviewed without the error being noticed.
  6. The IV bag was scanned in the Emergency Department, but because the label on the bag was for the drug that had been ordered, the system did not know to sound an alarm.
  7. The bedside caregiving staff had no way of knowing the medication within the bag was not what had been ordered.
  8. Shortly after the IV was administered to Ms. Macpherson, a fire alarm, known as a “code red,” sounded due to an issue in the Heart and Lung Center.
  9. A staff member closed the sliding door to Ms. Macpherson’s Emergency Department room due to the code red to protect her from potential fire hazards.
  10. The paralyzing agent caused Ms. Macpherson to stop breathing and to go into cardiopulmonary arrest. She experienced an anoxic brain injury. She was taken off of life support on Wednesday morning and died shortly thereafter.

Next Steps:

Since Ms. Macpherson’s death, we have taken several immediate steps to ensure that an error of this kind will not happen again in our facilities.

Issue 1: Incorrect drug chosen and placed into IV

Our Response: We are enforcing a “safety zone” where pharmacists and techs are working that is intended to eliminate distractions. Verification of medication can only be completed in these areas.

Issue 2: Verification of drug dispensed

Our Response: A detailed checking process has been standardized and implemented to bring heightened awareness to the pharmacy team. New alert stickers have been added to paralytic medications and we are training nursing staff to watch for these stickers.

Issue 3: Monitoring of patient after IV started

Our Response: Nursing leaders are currently evaluating patient care processes to ensure we are following best practices. On every unit, our nurses are being hyper-vigilant about how we administer any intravenous medications. We are conducting frequent check-ins with our patients and we are consulting with patient safety experts across the country to ensure we are adhering to best practices.

Additional steps are forthcoming including bringing in an external pharmacy expert to review our internal processes and provide recommendations for improvement.



From a disclosure prospective, this looks and feels like the hospital is doing everything right. I’m impressed. There are no weasel words, no hedging in either letter. They appear completely transparent, apologetic, and ready to fix problems — which what most grieving families want. I hope going forward that the hospital and their attorneys work quickly to address the financial and emotional needs of the family and thus avoid litigation. I also hope they provide adequate support for their staff, including the opportunity for staff directly involved in the mistake to meet with the family and personally apologize. Lastly, I hope when the financial and legal aspects of the case are concluded, that the hospital and family will share their disclosure story with the world.

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