In the wake of medical mistakes that led to three patient deaths, the Massachusetts health department announced last week it would conduct a review of the state hospital license for Boston's Children's Hospital.
The announcement followed a highly critical report issued by CMS investigators that cited a pattern of poor communication among clinicians and blurred lines of authority for the care of children with complex problems, which contributed to the deaths.
In a statement, James Mandell, the hospital's president and chief executive officer, said the facility "did not provide the high level of care to these patients that is our standard."
Two of the patients died in August 2002. One was a cerebral palsy patient who died of a heart attack five days after admission; the other died from a perforated ulcer after removal of both the patient's kidneys in advance of a planned transplant.
But some of the same problems with delineating responsibility remained in early May 2003 when a patient with epilepsy died hours after surgery to insert electrodes inside his skull to detect where seizures were taking place.
The boy suffered a rare grand mal seizure while recovering in the intensive-care unit, but residents did not recognize the seriousness of the event and waited too long to call for help, said Michelle Davis, a hospital spokeswoman.
An attending intensive-care physician was in the hospital, but the authority for the case had not been transferred to her from the surgeon, Davis said. Meanwhile, residents and neurosurgery fellows at the bedside eventually contacted the neurosurgeon by phone, but the boy's condition already had deteriorated.
The hospital submitted to the CMS and state health department a corrective action plan that assigns responsibility for the care of children in transition from one department to another. For example, the critical-care attending physician in the ICU, not the surgeon in charge of the procedure, will be in charge of patients admitted to the unit after surgery.
According to the plan of correction, the hospital created a set of expectations in July on the role and responsibilities of attending physicians and their supervision of residents, including insistence that physicians "respond fully and respectfully to any questions or concerns expressed by the care team, including residents and fellows."
The action plan also reported that a new ombudsman position was created to investigate concerns by trainees that physician faculty are either too slow to respond to requests for help or give the impression that such requests are unwelcome.
Davis declined to say whether such an atmosphere of disrespect for residents was a factor in the deaths, but she added, "Here at Children's that's not going to be tolerated in leadership. That's not the kind of leaders we're looking for."