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Care and accountability

por Sean Ruck, Contributing Editor | March 24, 2020
From the January/February 2020 issue of HealthCare Business News magazine

In a perfect world, hospitals would be places of healing. However, in a realistic world, there are times when medical technology and professional expertise are unable to deliver. It’s something to be expected when treating those whose resilience has been worn down by long-term illness or the ravages of time. But when something goes wrong for younger patients, especially ones where the expectations of recovery are high, it can be heartbreaking for everyone involved — not just friends and family, but also the medical professionals who were providing care.

When the unthinkable happens, some hospitals may “lawyer up” and correspond through a group that doesn’t have the understanding or compassion, or even the goal of providing healing for those who suffered the loss. Some organizations, though, instead understand that the care they should provide goes beyond the patient they treated.

Leilani Schweitzer was asleep in a chair beside the hospital bed of her 20-month-old son Gabriel. She was awoken by a nurse as hospital staff rushed into the room to revive him, but they were unable to.

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The tragedy occurred due to a combination of factors. Gabriel had been attached to a number of sensors feeding into monitors. When he moved, electrodes shifted or loosened and alarms sounded loudly, creating even more stress. In a gesture of compassion, a nurse offered to turn off the alarm in the room, but unknowingly, she deactivated all the alarms, not just in the room, but in the nurses’ station and on pagers. There was no alert when it was needed.

That was the horror Schweitzer experienced and for all the training, protocols and fail safes put into place in today’s hospitals, stories like hers are far too common an occurrence. What’s less common are the steps Stanford Health took following the tragedy. They didn’t hide behind a legal wall. Instead, they researched what went wrong, gathered information, presented what they found to Schweitzer and apologized.

The nurse who tried to offer some respite for her patient and her patient’s mother would eventually leave her job at the hospital. A pediatric neurosurgeon who had treated Gabriel quit practicing medicine. The impact of the incident cut deep. Which was why Schweitzer’s response to Stanford’s question about what else they could do was so surprising and a testament to the heart and strength she has to help others who might have a similar experience.

Today, Schweitzer is approaching her 10-year-anniversary as PEARL (Process for Early Assessment Resolution and Learning) Patient Liaison for Stanford Health Care. She is the person who has the face-to-face interactions with patients and families when something goes unexpectedly wrong, whether from human error, equipment malfunction or some mystery of the human body.

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