Friday, July 11, 2008

My Thoughts About the Events at CHRISTUS Spohn Hospital Corpus Christi - South

As I’m sure you have heard, a medication error was discovered this past Sunday night at one of our CHRISTUS hospitals. The nursing staff at CHRISTUS Spohn Hospital Corpus Christi – South discovered that some of the babies in the Neonatal Intensive Care Unit (NICU) there may have received a higher than recommended amount of Heparin, an anti-coagulant used to flush intravenous (IV) lines of patients to prevent blood clots from forming in the lines. The Heparin was prepared in the hospital’s pharmacy for use in the neonatal intensive care unit. The hospital implemented corrective measures and immediately notified appropriate persons about the situation.

Babies who need care in a neonatal intensive care unit are there for specialized treatment due to illness or other life-threatening conditions. However, injury to or the passing of any small child is a tragedy that affects us all.

I can relate to the particular grief of losing a child, and my thoughts and prayers are with all persons affected and the staff caring for them. I realize that this is an extremely difficult time for all the families.

Officials at CHRISTUS Spohn Hospital South confirmed that the event occurred during the mixing process in the hospital pharmacy. While our pharmacies have very specific processes to follow in the preparation of medications, something went wrong in this case, and I am deeply sorry.

The staff at CHRISTUS Spohn Hospital South took immediate actions following the discovery of this error, including a review of policies and procedures with pharmacy staff and the implementation of an additional step to the verification process in the production of these medications.

We are committed to a culture of quality and the ongoing review of our policies and procedures will assist us in building better safeguards and strengthening our processes to ensure a safer environment for our patients.

In all my years as a practicing physician and even now as the president and CEO of an international health care system, I understand the great responsibility we are given by our patients and their families when they choose to place their lives and the lives of their loved ones in our hands.

In fact, I can remember the exact moment when the gravity of this awesome responsibility really became clear to me; I remember the day just like it was yesterday.

When I was a third-year medical resident, I was assigned to care for a 10-year-old child who had come into our emergency room. As I came out of room the child’s room after the examination, my attending physician must have noticed the puzzled (and somewhat shocked) look on my face, because he asked me what was wrong.

“Do you not know the diagnosis?” he said.

I told him that I knew the exact diagnosis, and had just finished telling the child’s mother that her child would require surgery. Her response was, “Alright, then. Do whatever you have to do to make him better.”

And then it hit me that this parent trusted me completely with her child’s life, and I was astounded by the awesome responsibility that accompanies the sacred work we do in health care.

Every day, patients come into our programs and facilities and put their health and lives—or the lives of their loved ones—into our hands. This is why I have always said that for CHRISTUS Health, excellence is a necessity, not a luxury.

CHRISTUS has been on a Journey to Excellence—which I have discussed extensively right here on my blog—since 2000, and we have made great strides in many of the metrics of our four directions to excellence (clinical quality, service delivery, business literacy and community value). This Journey requires the absolute commitment of each and every CHRISTUS Associate, physician and volunteer every single second of every single day. I will not be satisfied until we reach absolute excellence in each of our directions.

I realize that the members of our CHRISTUS family do work tirelessly each day to deliver high-quality, compassionate care to our patients and their families, and I recognize that they are the reason we have made such strides on our Journey. Therefore, I am thankful to each of them for their dedication to excellence.

I also cannot stress enough how thankful I am to all the experienced and dedicated neonatal staff and physicians at CHRISTUS Spohn Hospital South who have gone above and beyond the call of duty in response to this incident and always take extraordinary measures to deliver the best care possible to every baby in our NICU. I would also like to extend special thanks to our pharmacy staff, who worked with the nursing staff in response to the situation.

I, along with the CHRISTUS family of almost 30,000 Associates, am dedicated to our mission of extending the healing ministry of Jesus Christ every day. We understand and take very seriously the awesome responsibility of caring for the health and lives of our friends and neighbors. We pray for all who were affected by the event at CHRISTUS Spohn Hospital South as well as for all of our Associates, physicians and volunteers as we work together to continue our ministry in the U.S. and Mexico.

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