Nick Smith | Wlliston Herald Judy Hartl, Director of Quality, and Interim CEO Kerry Monson of Mercy Medical Center, answer questions Tuesday at a press conference held to address how they dealt with the September incident in which the wrong baby went home with a mother from their obstetric (OB) unit.
These details, as well as both those of the investigation into the cause of the mistake and what corrective measures have been taken to improve hospital policy, were addressed at a press conference Tuesday afternoon.
Kerry Monson, Interim CEO of Mercy Medical Center, said they had narrowed down a basic outline of what had occurred, but would not reveal the names of the families whose babies were involved.
"At some point after 7 a.m. on Sept. 5, a baby was placed in the wrong bassinet...it was human error," said Monson.
The mistake was discovered shortly before 1:30 p.m. that day. Monson said by that time, one of the sets of parents had left the hospital and the baby was at home with them. She said meanwhile at the hospital when they and the other parents noticed the mistake "we called the family at their home immediately." Judy Hartl, Director of Quality at Mercy, said an investigation "started right away."
Hartl said what is known as a Root Cause Analysis (RCA) was begun to investigate the incident.
"We had physicians, OB staff, administrative personnel and others participating. We went through every one of our processes to identify potential breakdowns that could occur in the OB," said Hartl.
Karen Bercier, OB Manager, outlined four policy changes they enacted as a result of the incident.
The first policy was reinforcement of current policies. Second, the hospital moved to simplify nursery policies.
The third and fourth changes were ones considered important to make absolutely sure misplacement doesn't occur again. The third change was to develop a tracking log attached to each bassinet and the fourth change is to refine the discharge process for the mothers and their babies.
"If there's a problem, the infant will be kept with that staff person until any issue is worked out," said Bercier.
Monson said there is always the potential for human error and these types of things could happen. She said its unfortunate that such simple actions done by staff on a daily basis could be mishandled and lead to an event like the incident that occurred.
"It doesn't justify what happened. Our goal is to provide quality, safe care. We want to make sure this never happens again," said Monson.
It was explained that under current hospital procedure, four bracelets are given out for each birth. The first three are for mother and child, one for the mother and two for the child. The final bracelet goes to the significant other or person who is the only other individual allowed to discharge the baby.
Hartl said these changes are meant to improve and expand policies already in place to reduce the odds of such mistakes.
"The changes were put in place as safety nets," said Hartl.
Monson said the incident made for the possibility of the public having its trust in Mercy shaken. Monson she said she is confident that what happened in the OR was an isolated incident and she believes transparency will help repair damage done.
"We have a commitment to the community and by taking responsibility, and not errors, hopefully will help in the community regaining its trust in us again."
Comments
D.J. wrote on Nov 18, 2009 10:02 AM:
hj wrote on Nov 17, 2009 3:48 PM:
James wrote on Nov 16, 2009 10:54 PM:
Bill wrote on Nov 16, 2009 9:20 AM:
new dad wrote on Nov 14, 2009 3:15 AM:
i do believe that this is an isolated incident and again, i could not give enough praise to the way the staff treated me and my loved ones. but that still does not change what happened... "
former coyote wrote on Nov 13, 2009 2:31 PM:
shangord wrote on Nov 13, 2009 6:30 AM:
mother wrote on Nov 12, 2009 10:10 PM:
and others this could happen with other
situations where a human life is
involved,these people stepped up to the
plate that is what is called
accountability thank you. "
Mom wrote on Nov 11, 2009 2:45 PM:
Frank wrote on Nov 11, 2009 2:12 PM:
me wrote on Nov 11, 2009 12:19 PM:
Jk wrote on Nov 11, 2009 11:57 AM: