Memphis sentinel event may provide answers
Unfortunately for Regional Medical Center in Memphis, TN, it may become the guinea pig everyone has been waiting for in regard to the sentinel event policy from the Joint Commission on the Accreditation of Healthcare Organizations in Oakbrook Terrace, IL.
With all the controversy surrounding the sentinel event policy, much of the frustration has come from the many unanswered questions. Exactly what is expected of a health care facility when investigating an incident? How well is that information going to be protected from eager plaintiffs' attorneys and others?
Unsatisfactory answers
In the past months, observers have noted that the JCAHO's answers on those points are unsatisfactory, and the most telling lessons would come from the experience of some hapless facility with a sentinel event. That facility may be Regional Medical Center, which accidentally sent a baby home with the wrong mother.
The incident happened on April 12, when two newborns were placed in the wrong bassinets after their circumcisions, according to public statements by hospital officials. One mother, 23-year-old LaDonna Harris, took home the wrong baby, but the other mother remaining in the hospital noticed the error the next day. She thought the baby had a different skin pigment than what she remembered seeing earlier. Harris reported her suspicions to hospital authorities, who then checked the baby's wristband and discovered it was the wrong one.
The damage is done
The discharged baby was taken back to the hospital, and the mother reporting the error took home her actual child. But Harris refused to take home the baby the hospital said was her own, saying she couldn't be sure the child was hers. At one point, she even said the baby at the hospital was "ugly" and couldn't be her child. The baby stayed at the hospital for almost two weeks before Harris relented and agreed he was hers.
Harris agreed to take the child home only after DNA testing proved conclusively the two mothers had the right babies. But while the baby was waiting in the hospital, Harris and her attorney garnered a lot of media attention with explanations about how traumatic the experience was, accompanied by threats of litigation.
Call in the lawyers
Harris's attorney, Sadler Bailey, JD, says the hospital will be sued for emotional distress and other damages if it does not promptly offer a settlement. The other mother's attorney also has indicated that litigation would be likely, so the hospital is "seeking to negotiate and conclude any claims made by either family," says Deenie Parker, vice president of communications and marketing for the hospital.
The baby mix-up apparently was the first at the hospital, which handles about 4,000 births a year. Hospital leaders admit the mix-up occurred, and they say a preliminary investigation traces the error to a failure to properly check the identification bands on the baby discharged to Harris. The babies apparently were placed in the wrong bassinets after their circumcisions, and then when it came time to discharge Harris's baby, the nurse didn't notice that the baby had the wrong identification bands on both an arm and a leg.
Rhonda Nelson, vice president of patient care services, says, "We have policies in place to assure the proper identification of patients and their mothers, and in this case, the crucial procedure was the comparison of the baby's arm bands at the time of discharge. Our initial conclusion is that this comparison was not performed or was not performed properly."
As a result of that error, the hospital already has changed its policy on the discharge of newborns. Now two nurses must check the baby's identification and document that it's correct. Nelson says other policy changes are possible. She won't say whether hospital staff have been disciplined for the error.
Parker says the hospital is in the midst of conducting a root cause analysis, as suggested by the Joint Commission after a sentinel event.
It's a sentinel event, no doubt about it
The mistake in Memphis definitely is a sentinel event, says Julia Roberts, spokeswoman for the Joint Commission in Oakbrook Terrace, IL. Some of the controversy surrounding the sentinel event policy has involved the definition and scope of the term, but mistakenly discharging a baby to the wrong parent is one of the events that qualifies automatically, Roberts says. There's no need to determine whether it meets the criteria for a sentinel event. The sentinel event machinery already is churning toward Memphis.
"The event in Memphis is being investigated as a sentinel event, and we will take all the appropriate steps to determine what happened," Roberts says. "Any time we believe there is a threat to patient safety, we have to go in and start the analysis process that will help ensure it doesn't happen again."
For Regional Medical Center, that means a lot of work ahead. Stay tuned to see how the hospital fares in the sentinel event process and what might be learned from its experience.
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