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Originally published May 5, 2011 at 8:19 PM | Page modified May 6, 2011 at 1:40 PM

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Children's hospital says it's fixing flaw found in survey

The problem involved the Seattle institution's process to assure and improve the quality of its ground-transport program — and could have put its Medicaid program at risk.

Seattle Times health reporter

Medical errors and nurses

"To Err Is Human: Medical Errors and the Consequences for Nurses": Tuesday, May 10, 3 p.m. to 5 p.m.; Hogness Auditorium, UW Health Sciences. Open to the community.
quotes I hope they fix all their flaws and will be all right! Read more
quotes How is a nurse to know the latest law> Government illogical rules change more often... Read more
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A federal survey of Seattle Children's hospital found a serious flaw in its process to assure and improve the quality of its ground-transport program — a finding that could have put its Medicaid program at risk.

The hospital says it has taken steps to fix the problem. "There is always room for improvement," said Dr. Tom Hansen, hospital CEO. "That's why our work to provide error-free care will never end."

The investigation, by the Centers for Medicare & Medicaid Services (CMS), came in the wake of four cases last fall investigated by the state's Department of Health. In two cases, including a baby being taken by ambulance to the hospital, the patients died.

The CMS report, triggered by a state finding of deficiencies in hospital procedures, said transport nurses appeared to be confused about what they were allowed to do and whether they could administer medications without a doctor's order. It said the hospital's review of the cases didn't pick up that documentation was inaccurate and incomplete or that doctors' orders — required by law — were missing.

A CMS Region 10 representative said the finding regarding the quality improvement process was serious, because failing to comply with the condition could lead to the hospital's being terminated from the Medicaid program. Nearly half the children seen at Children's are covered by Medicaid.

CMS has accepted the hospital's plans to correct the deficiencies in the quality improvement process and others noted in that survey, as well as for additional problems cited in a more wide-ranging follow-up survey done in March.

The second survey is automatically triggered when serious deficiencies are found in an initial complaint survey.

The hospital has now been recertified as meeting all CMS conditions, the federal agency confirmed.

Susan Heath, Children's chief nursing officer, said inspectors found the hospital wasn't taking the necessary steps to improve the quality of its transport program — that while the hospital was reviewing cases one by one, it wasn't taking what it learned from each case to improve care over time.

Children's said it has engaged an outside expert, hired a nurse manager for the ground transport program and will seek regular feedback from referring hospitals about its program.

"We use these events, as painful as they are, as an opportunity to say what are we missing," said Cara Bailey, Children's vice president of continuous performance improvement. "This has been a very difficult journey for us, but it's part of an ongoing journey that I think you'll find that every health care organization is on to try to make health care safer."

The care delivered by Children's is "very complex, our kids are very fragile, and our staff are committed to giving the best care that they can," Bailey said. "But it is a journey. As long as we have humans involved in this process, there's always room for error. It's about getting better faster."

The newborn who died last fall was given four medications by a transport-crew nurse who did not have a physician's order. The King County Medical Examiner's Office last year found that the critically ill baby died of natural causes.

The second CMS inspection included such issues as building safety, records content, and infection control.

It found about 15 lower-level deficiencies, including not adequately reassessing patients in a timely way and deficiencies in biohazard trash disposal and infection control.

In one instance noted, a "sharps" container full of used needles was left in a cleaned patient room.

The report also criticized the hospital's system for checking water quality in the therapy pool, and for not testing dialysis machines monthly for bacteria and toxins.

The transport case was the only one of the four last year in which state investigators found that Children's had deficient policies or processes.

The state cleared the doctors involved in the four cases. Its investigation into the actions of a nurse in a case in which a child died after an overdose was closed after the nurse's suicide.

State investigations continue into the nurse in the transport cases, as well as another nurse in a case in which an adult in the ER was mistakenly given medication intravenously instead of intramuscularly.

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

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