Case Study: Braxton Rel

“Braxton always had a smile and he just, you know, he loved life. He was putting in the time and the dedication… he spent hours at the stairs – ‘Dad, throw some pucks at me, dad’. You know, I think the difference between an athlete and a professional athlete is their heart and their dedication and I think Braxton could’ve been one to take it real far.” Chuck: “Now let’s go back to the beginning. Braxton needed the surgery for sleep apnea, was Braxton worried?” Steve Rel: “He always put on a tough face but yeah, he was concerned. He was very worried.” Chuck: “What did you tell him?” Steve: “That he was gonna be okay. And it wasn’t true.” Steve: “We brought Brax home from the hospital and everything seemed fine. You know, he wasn’t complaining much of pain. He was resting and we watched some TV. We sat with him. Watched some cartoons. At about 4 o’clock he said dad, I’m hurting. So I gave him his pain medicine. And everything seemed all right. He fell asleep which seemed normal to me and he woke up at 7:30 and he said dad my chest hurts. You know, I’ll never forget that I sat and just comforted him and I asked him Braxton are you all right? Are you in pain? Do you need something for pain? Do you need something for pain? And he said, no dad I’m fine. That’s the last time I saw him alive. We went months and months without any word from the medical examiner and all we wanted to know was what happened to our son. “ The Rels went for 4 months without answers and then they were forced to seek legal help. The system failed them. 13 months after Braxton’s death all they had was an autopsy report sent in the mail. Steve Rel: “When I went to get the medical records I was given two or three pages and I was told that they don’t keep anesthesia records and nursing notes. And it just didn’t seem right to me so I talked to some experts and was given some advice on how to get the complete set of medical records. Which I did. You know, it really erodes your trust and it makes you fearful.  You think you would have answers right away when something adverse happens to your loved one. It’s been 13 months and we still don’t have all the answers.” Chuck: “So you don’t have closure?” Steve Rel: “No closure at all.” Dennis Quaid: “A lot of times I think the lawyers get involved, the hospital lawyers get involved and the focus seems to be on risk management after an accident occurs. Not to say that they weren’t doing everything they could to right the situation but as a human being I felt that the last thing I want to do is focus on legal issues. And somebody’s liability.” Steve Rel: “The […]

Case Study: Emily Jerry

Pharmacist Eric Cropp is part of a growing group of caregivers who’ve been criminally indicted for hospital accidents – very predictable system-driven mistakes.  Eric was incarcerated for the death of a little girl, Emily Jerry, who died of a lethal injection of a salt solution during her cancer treatment. “If I had a chance to make amends and talk with Mrs. Jerry, first thing I would tell her is I’m so deeply sorry that what has happened with Emily.  I never intentionally tried to hurt her daughter.  I wish I was in her place because I’ll never forget your daughter.  She’s in my heart and in my dreams,” Eric stated, through his tears during an interview while he was incarcerated in Cleveland, Ohio. “I’m really sorry and I hope you can someday forgive me.  Thanks.” Patient safety expert, Lucian Leape commented, “well, I think the criminalization is, is a terrible thing.  In every case, there were obvious explanations for why the mistake happened.  And those explanations all have to do with the systems they were working in and the institutions that were responsible for those situations.” Emily Jerry’s father, Chris Jerry struggles daily with the adverse event and reminisced on his daughter’s short life. “She could light up a room when she walked in,” he said. “Emily could always put a smile on your face.  Always.  My heart sank because I knew that she had to have just gone through so much pain.  It wasn’t like she was overdosed on, on an opiate where she would just go to sleep. It had to be very, very painful for her.  And I think that was the toughest thing to deal with, Chuck, was knowing how much pain she was in.” Even with this horrific outcome, Chris reached out to the convicted pharmacist and offered his forgiveness, knowing the error was not his fault, but a system error compounded by failing technology and predictable human error. They have traveled the country together working as the Emily Jerry Foundation to ensure that these system errors don’t happen to other patients.

Case Study: Recognizing and Fighting Tactics of Sham Peer Review with Larry Huntoon, M.D.

VIDEO: Lawrence R. Huntoon, M.D., Ph.D. presents at the 72nd Annual AAPS Meeting, St. Louis, Missouri, Oct. 1 – Oct. 3, 2015 (via YouTube) Dr. Lawrence Huntoon is known for bringing attention to the critical issue of “Sham Peer Review” as he outlined in the article “Sham Peer Review” published in Arizona Medical in 2004 as well in his 2007 editorial in The Journal of American Physicians and Surgeons. Dr. Huntoon is a practicing neurologist as well as the editor-in-chief of the Journal of American Physicians and Surgeons. Dr. Huntoon describes Sham Peer Review as follows: Sham peer review is an official corrective action done in bad faith, disguised to look like legitimate peer review. Hospitals use it to rid themselves of physicians who advocate too often or too vociferously for quality patient care and patient safety, and economic competitors frequently use it to eliminate unwanted competition. The alleged “charges” may be totally bogus, fabricated and false, none of which really matters since the hospital controls the entire process. And, if the hospital continues your sham suspension a mere 31 days, you get reported to the National Practitioner Data Bank, and your medical career is effectively over. The video above is a presentation Dr. Huntoon gave to the 72nd Annual Meeting of the Association of American Physicians and Surgeons in 2017 about recognizing and fighting sham peer review in medicine.

Case Study: Dr. Ricardo Quarrie Falsely Accused But Still Maligned

(Story via CNN) Two years ago, Dr. Ricardo Quarrie, a cardiothoracic fellow at Yale New Haven Hospital, was publicly accused of lying to a patient to cover up a surgical mistake. The stories went viral and the ramifications were swift and severe: Quarrie says he became a “pariah” and potential employers have shunned him. Accused of such a heinous act, his promising future in a prestigious field disappeared. Now, the lawyer who accused Quarrie has recanted. CNN exclusively obtained a copy of the July 16 statement from New Haven, Connecticut, attorney Joel Faxon. In his statement, Faxon said Quarrie did not lie to his client, who was a patient at Yale. “The statements attributed to Dr. Quarrie were made by another health care practitioner at the hospital, or his designee,” Faxon wrote. “I hope this letter clarifies any misunderstandings.” Multiple news outlets, including CNN, covered Faxon’s original remarks accusing Quarrie of lying to the patient. Even though it’s been two years, those stories show up prominently on the first page of a Google search of Quarrie’s name. “Employers told me I was very qualified for positions, but patients Google their doctors, and they didn’t feel like they could refer patients to me,” said the cardiothoracic surgeon, who trained at Yale, the Cleveland Clinic and Ohio State. “It’s been a nightmare,” added Quarrie, the father of two young children. “The spread of that information — or misinformation — is so rapid, and people really do believe what they read.” Quarrie, 36, says the statement is a first step toward reclaiming his name. “But that’s two years of my life I can’t have back,” he said. Digital experts say it might be too late to reverse the damage to Quarrie’s career. When patients do a Google search, the old stories that say Quarrie lied might appear higher on the search than any stories that might be written about the July 16 retraction. “That’s the power of the Internet and the digital age: You can cause extensive damage and ruin people’s lives,” said Craig Bullick, chief operating officer of Empathiq, a company that helps doctors manage their online reviews but which Quarrie does not use. The wrong rib removed In 2015, Deborah Craven had surgery at Yale to remove part of her eighth rib. Quarrie assisted in that surgery. At the time, he was on a two-year training fellowship at Yale. The hospital admits that a mistake was made in that surgery. Craven’s lawsuit details how her seventh rib was removed instead of her eighth rib, and she then had a second surgery to remove the correct rib. But her lawsuit goes on to say something that later turned out not to be true: She accused Quarrie by name of lying to her about the reason for the second surgery to cover up the mistake. Multiple media outlets, including CNN, reported on the mistake and alleged coverup. Faxon, the patient’s lawyer, told a Hartford television station that Quarrie had told his client “lies” […]

Case Study: Julie Thao

“I wanted to be a nurse and work with babies since I was a little girl. In 1990, I graduated from nursing school.  I had four little babies. Until about four years ago, when this happened, my life was full of babies.” – Julie Thao On the 4th of July, Julie Thao worked a double shift at a busy hospital where she had been a celebrated nurse for over a decade. “We were busy, and it was almost 1 AM before I was able to kind of wind down and I was too tired to drive home,” Julie recalled. Living a long way from the hospital, she decided that she was too tired to drive home, and since she needed to be back on shift at the hospital in a few hours for her day shift, she laid down in a patient room in a patient bed and tried to sleep. After some rest, Julie started her day shift. “At 9 o’clock I met the patient. She was just a young 16 year old girl and she was so scared,” Julie continued. “The plan was that they were going to break her water and start some Pitocin and she was going to deliver her baby.” Julie followed nursing unit guidelines designed to improve readiness of patients for anesthesiologists to give an epidural injection. She adhered to a checklist of the guidelines and prepared the anesthetic medication at the same time that she had antibiotic medication ready to hang on an IV drip system. A number of systems flaws led to Julie’s absolutely predictable human error. Julie recalled, “I got her IV, her antibiotic, and her epidural bag. Both bags had ends that received IV tubing. I had her antibiotic in my hand; I knew that. But I didn’t have her antibiotic in my hand; I had her epidural medication in my hand. And after it started running, I heard a sound and turned to her bed and she was already arresting.” “People came to her room immediately, many, many, many people. Dozens of people who are familiar with both those medications that we used.  Everyone saw that hanging there. In fact, I said, I just hung this antibiotic and I think she’s reacting to the penicillin.” “And then somebody cleaning the room found the bag and brought it to me and they were crying and put it in my hands. And it didn’t make sense for a while and I kept looking and it just crumbled.” Julie administered the wrong medication. Fatigue, identical medication tubing connectors, similar IV fluid bags, and a sub-optimal bar code process all collided and lead to the death of the young mother. The hospital fired Julie. She was criminally indicted. As a single mother of four and with no resources to defend herself, she had to plead to a misdemeanor to avoid prison. The National Quality Forum Safe Practice called Care of the Caregiver is inspired by her story. “The Julie Thao story […]