Entire System Failure is not Simply a Mistake

St. Mary’s Hospital in West Palm Beach issued a statement relating to the wrong medication errors during the treatment of Tesome Sampson and her unborn child:

“On Sept. 4, 2008, a patient came to St. Mary’s in extremely premature labor. Due to a medication error, the patient was given medication to speed up her labor instead of medication that attempts to stop premature labor. Ultimately, the baby was born and suffered brain damage,” the statement said. “This was an unfortunate error that occurred despite the safeguards we have in place. . . . We apologized to the family for this deeply regrettable error.”

From all indications, this is the first time that St. Mary’s and its parent, Tenet Corporation, has acknowledges this error. Still, they characterize the error as almost normal negligence. They claim that their safeguards were in place and, presumably, they were appropriate. If that is the case, then they have a system in place, which permits colossal errors to occur without a system “catch” to cause someone to question, to investigate, and to stop a very serious error like this. In this case, a drug (Prostin) was administered to a pregnant woman. This is a drug that would never, never be given to a pregnant woman unless you wanted to force an abortion. This is not an oops sort of mistake, this is providing care you would almost never provide to this particular patient.

Hopefully, St. Mary’s risk management is approaching their system check with a more serious tone than their public explanation.