State: Seattle Children's procedures not at fault in recent cases

State investigators looking into three cases at Seattle Children's hospital — the death of an 8-month-old girl who was given an overdose; a medication error that caused a heart irregularity in an adult emergency patient; and a surgical procedure that left a 2-year-old boy permanently disabled — have concluded that hospital systems or procedures were not at fault.

Separate investigations into the actions of the medical personnel involved in each case could take months to conclude, said Tim Church, spokesman for the State Department of Health.

Church said the question in the completed investigations was narrow: "Did the facility have processes, procedures and systems in place to protect patient safety?"

In these three cases, Church said, the hospital did, "and therefore, we didn't find deficiencies."

Dr. David Fisher, medical director at Children's, said it was "absolutely critical" that the hospital met the standards for protecting patient safety.

"However, the fact remains that medication errors occurred, which means there is still room to improve our systems to fully support our patients and staff and minimize opportunities for error."

The frail 8-month-old girl died in September after a nurse gave her 10 times the proper dose of a medication, calcium chloride. The King County Medical Examiner confirmed Wednesday that the accidental overdose caused the girl's death, bringing on an acute episode of her congenital heart condition.

Although the investigator concluded the hospital had a "thorough, functioning medication ordering and distribution system," Church said, the hospital, on its own, has since changed its policy for administering that medication.

The adult who came to the emergency room has fully recovered, the Health Department report said.

"We certainly found there was an error committed" in the emergency room, Church said. But the hospital had a system in place to identify the error and quickly took steps to make sure it didn't happen again. "That's what we're looking for."

In the case of the 2-year-old boy who suffered internal bleeding from a ruptured blood vessel during a procedure, the investigator said there was insufficient evidence to substantiate accusations that hospital policies or procedures were at fault.

A fourth case — involving a newborn who died en route to the hospital in an ambulance — is being investigated by both facilities and the Nursing Care Quality Assurance Commission. In that case, a nurse failed to follow proper procedure in giving the baby medicine.

At a news briefing in late September, Fisher said the incidents had caused the hospital to "re-evaluate our entire medication delivery system."

On Oct. 30, the hospital held a "Patient Safety Day" to address concerns surrounding the medication errors and patient deaths.

The hospital said its chief executive officer, Dr. Thomas Hansen, led opening remarks for the 550 doctors, nurses, pharmacists and others who attended sessions on ordering, dispensing and administering high-risk medications, how to handle interruptions and distractions, and how to hand off orders to the next medical provider on shift.

"How we emerge from this situation today and over the coming months will be the real test of us as an organization," Hansen said, cautioning that the work will not be easy, "but we must strive for zero errors — this must be our promise."

Fisher noted Wednesday that the hospital had engaged an "independent team of patient-safety experts" to begin a comprehensive review of medication ordering, dispensing and administration.

Carol M. Ostrom: 206-464-2249 or costrom@seattletimes.com