Routine Hernia Surgery Results in Brain Damage of Young Boy: Similar Errors Prompting Hospitals to Seek Solution from Pilots

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A children’s hospital with a reputation for good care fails to prevent a common communication failure among its surgical team. The resulting life-changing error could have been prevented if the hospital had equipped its staff with the communication skills and safety tools used by commercial airline pilots.

According to a recent study conducted by the Harvard University School of Public Health and the Kaiser Family Foundation, four out of every ten Americans say that they or their family members have been victims of a preventable medical error.

Sue Stratman is one of those victims. Ten years ago, her son, Daniel Stratman visited the local children’s hospital for routine hernia surgery. His hernia was repaired but his brain was severely damaged in the process.

Prior to the hernia procedure, Daniel had undergone three successful open-heart surgeries at the same hospital, “We went back to the hospital because he had received such excellent care there; we wanted him to have the best for this ‘simple routine’ surgery as well,” said Daniel’s mother, Sue Stratman.

Unfortunately, as a result of several communication failures by the medical team, Daniel suffered a serious anoxic brain injury. After incorrectly setting the anesthetic machine, the anesthesiologist left Daniel in the care of a medical student. The device used to monitor Daniel’s blood pressure was also improperly set and failed to warn the doctors of his condition. The series of mistakes resulted in a period of twelve minutes where Daniel’s brain was starved of oxygen.

Upon discovering their mistakes, the medical team was able to revive Daniel, but he has never fully recovered. He has no balance, is nearly blind, and can only walk with assistance. He needs 24-hour care.

In response to a growing number of these types of errors, scores of hospitals are implementing safety systems adopted from commercial aviation.

The country’s largest provider of these safety systems for healthcare is LifeWings Partners LLC. A group of pilots, physicians, and former astronauts, LifeWings has implemented their safety system in over 45 healthcare organizations. The system has virtually eliminated serious surgical errors, like the type that damaged Daniel, wherever it has been adopted.

Upon hearing about LifeWings and its record of success in preventing the type of mistake that changed her son’s life, Ms. Stratman contacted the president of LifeWings and asked him to use her son’s story. She wanted to create greater urgency among hospitals to adopt a better method of providing care.

Steve Harden, LifeWings’ President and Co-Founder, says, “Professionally, I have had many successes in my life…but nothing I have done gives me as much satisfaction as the safety results we have achieved in healthcare organizations, and the hope we give to families of patients like Daniel that these mistakes won’t be repeated again.”

Although patient safety has become a rising priority for hospitals, the fact is the issue is still often neglected. “We do have good doctors and nurses; however, in a broken system, even the best are prone to devastating mistakes,” said Mrs. Stratman. “If only the children’s hospital had implemented the LifeWings system, my son would still be the way he went into the hospital—healthy and whole.”

LifeWings focuses on a long-term, preventative approach to create a permanent systemic change in the culture of healthcare, and eliminate tragedies like the case with Daniel.

Descriptions of LifeWings’ work have appeared in numerous publications, including among others, Journal for the American College of Surgeons, AORN Journal, Fast Company magazine, hfm magazine, and For The Record magazine.

About LifeWings Partners LLC

LifeWings Partners LLC was founded by a former U.S. Navy Top Gun instructor, commercial airline pilot, and two physicians who are former NASA astronauts. The firm specializes in applying aviation-based teamwork training and safety tools to help healthcare facilities save patients’ lives and reduce costs. LifeWings has helped over 45 facilities nationwide provide better care to their patients. Measurable results are found in all LifeWings’ initiatives, including one hospital that experienced a 50% reduction in procedure turnover times in their OR. The firm also conducts Leadership Development workshops for healthcare executive teams.

Contact

Steve Harden, President

LifeWings Partners LLC

800.290.9314

9198 Crestwyn Hills Drive

Memphis, TN 38125

http://www.SaferPatients.com

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Steve Harden, President
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