Reliability Case Study: Sentinel Event - RCA of Sudden and Unexpected Intraoperative Death

Root Cause Analysis Movie

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Linked Resources:
Justin's HOPE at
The Task Force for Global Health:
Website | Blog

Partnership for Patients
Pediatric Anesthesia | Abstract
Informed Choice | Abstract
Phenylephrine Safety
Respectful Management of Serious Clinical Adverse Events
Root Cause Analysis for Healthcare

Comments:

"Dale, I got a chance to see the video and I have to say what you said was so quietly moving---how could anyone not be affected?. I agree with Dr. Kavanagh about "The power of the patient narrative should not be underestimated"....and yours is among the most powerful!!! It had to be unbelievably hard to read that letter but you did it with great dignity and I defy anyone to fail to stop what they're doing and listen."
~MB, Health Communications Specialist

"I have been planting this root cause analysis (RCA) seed with providers since 2002. When I first learned that medical error played a part in my wife's permanent brain damage, I requested to be actively involved in the organization's RCA investigation. The resistance I encountered became the catalyst for my ongoing patient safety advocacy. The need to involve patients/families in RCA is catching on, albeit way too slowly. Engaging patients/families in the effort helps to break down the walls among/between providers and patients, is good business for providers, and speeds up the healing process for all. It is the right thing to do!"
~ Dan Ford -- patient safety advocate, Vice President, Furst Group

Engaging Patients and Families in Root Cause Analysis
Presented By:
Robert J. Latino, CEO, Reliability Center, Inc.
Tricia Pil, MD, Medical Director for Quality and Safety, Children's Community Pediatrics.
Dale Ann Micalizzi, Founder/Director Justin's HOPE at The Task Force for Global Health. Download RCA Report | Download Article: The Patient Protection & Affordable Care Act

Summary:
On January 15th, 2001, Justin Micalizzi, a healthy 11-year old boy, was taken into surgery to incise and drain a swollen ankle. He was dead by 7:55 a.m. the next morning, leaving behind two grieving and bewildered parents who desperately wanted to know why their son had died. But medical care was to fail them twice – first their son died and then no one would explain to them why. --excerpted from "A Family's Search for Truth," Patient Safety and Quality Healthcare, Nov/Dec 2006

This true patient story and others like it are the inspiration for this video, Engaging Patients and Families in Root Cause Analyses of Sentinel Health Care Events: Sudden and Unexpected Intraoperative Death.

Resources:
About Dale Ann Micalizzi: Dale is an advocate for pediatric patient safety and transparency in medicine. Her 11-year old son, Justin, died following a "simple" incision and drainage of an infected ankle in 2001. She has worked tirelessly in search of answers about her son's death, giving rise to a quest to improve pediatric patient safety and transparency in health care. She is the founder/director of Justin's HOPE Project at The Task Force For Global Health.
Website | Email | |

About Tricia Pil, MD: Tricia is Medical Director for Quality and Safety at Children's Community Pediatrics in Pittsburgh, Pennsylvania. She Tricia Phil, md earned her undergraduate degree in biochemistry from Harvard University and her medical degree from the University of Pennsylvania School of Medicine. Ever since a series of medical errors nearly killed her and her newborn son at his birth in 2005, she has dedicated her career to improving quality and safety in health care. Tricia is a passionate advocate for engaging patients, families, and frontline health care providers in QI efforts and RCA investigations.
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About Robert [Bob] J. Latino: Bob is an author and co-contributor to several books and articles. Robert has co-written an article entitled MRI Robert J. Latino safety 10 years later: What can we learn form the accident that killed Michael Colombini? Gilk, T. & Latino, R. J. (2011) Patient Safety & Quality Healthcare Magazine. Bob also co-written an article entitled The Benefits of Enterprise Risk Management: An Automated Approach to Organizational Reliability can Boost Clinical and Financial Outcomes, Latino, Robert J. and Jenkins, David S. (2010). H&HN Online Magazine. Bob also wrote an article entitled In Healthcare: Is the Human Being an Asset or a Liability?, ASHRM Journal, 2010, Volume 29, Issue 3, pages 34 – 38. He has been published in numerous industry trade magazines on the topic of Reliability, FMEA, Opportunity Analysis and RCA as well as a frequent speaker on the topic at domestic and international industry trade conferences.
These and other published articles for our Healthcare Channel can be found at the Editorial Board section. | Email | |

This video was a collaborative effort among Bob Latino, Dale Micalizzi and Tricia Pil.
All services provided by all participants were provided pro bono, with no commercial ties to Reliability Inc., Justin's HOPE, or Children's Community Pediatrics, in an effort to further the cause of patient safety and advocacy.

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