[Medical/Surgical Team Meeting]
Danielle Poston (Risk Manager): Team, thank you
for joining me here today.
We've thoroughly reviewed the case of Jason Hollis.
This included interviews with all of you.
Jason, as you know, was born with congenital heart disease
that required placement of an artificial conduit at birth.
At 18, on our recommendation, he agreed to have
the conduit replaced.
It seems clear to us that although the surgery was
performed correctly, the sutures used for the
anastomosis unfortunately pulled through the vascular
tissue shortly after he arrived in the PACU.
And despite the team's heroic efforts, he died.
Again, after careful review, we've concluded that in this
case, although the results were tragic, there is nothing that
would warrant financial compensation.
Still, the family needs closure.
Dr. Michael Stiver (Surgeon): [Interjects] Nothing?
You've got to do something for this family!
I performed both surgeries on Jason.
His family sends me a birthday card every year.
The kid was months away from starting college.
Really, nothing?
Mike, we've been through this.
No one can identify a single thing that we could have done
better in this case.
But... you have no idea how hard this has been on me.
Mike, I know this has had a dramatic impact on you.
And if you want to talk further about your personal
feelings about this case, we're here for you and can
support you.
But let's do it after this meeting.
Right now, we're here to talk about the family.
OK.
[pause] I hear you.
Alright.
Over the past several weeks, we've communicated with the
family multiple times, during which we shared portions of
our extensive investigation.
They've got some idea of the direction but now it's
important for them and for us that we draw this to a close
and share our full findings.
I'd like everyone in this room to participate in a meeting
with the family.
Dr. Wes Myers (Anesthesiologist): No disrespect,
Danielle, but... Are you serious?
Their minds are already made up.
A lawsuit is their next likely step.
I don't think it's a wise decision for us to give them
more information to use in their lawsuit.
There's no guarantee that talking with Jason's family
will lead to a different outcome, but I've been down
this road before.
And I've witnessed many more positive outcomes than not.
I do know one thing for sure: the likelihood of us getting
sued goes way up if we don't try.
This represents the best chance for giving the family
the closure they're looking for so they're not forced to
look to lawyers for answers.
We'll definitely fail if we don't try.
I'm for trying, but all of the signs are pointing to us
getting sued.
Mr. Hollis is really angry.
Even if the family sues us or complains to the state medical
board, they deserve closure.
And like it or not, that's what we're about here...
that's the culture of this organization.
We can't control how they're going to respond, but we can
control whether we do the right thing.
Michele Thornton (Nurse): Danielle, you have no idea how
important it is to all of us to do the right thing.
Wes, if it's all the same to you, I want to have this
conversation.
We need to have this conversation.
I never thought of it like that.
I guess I've been reluctant because I've never been in a
situation like this before.
But if I were in the family's shoes, I would want some
answers, too.
OK, I'll give it a chance.
Thank you, Wes.
We're all in agreement then?
What's next?
Alright, here's how we'll proceed: I'll structure a
conversation with the family.
On the day of the meeting, our team will assemble in the room
30 minutes ahead of time to make sure everybody's ready.
I'll assign seats to each of you at the table.
Then, I'll bring the family in and introduce everyone.
It's important that you behave in a respectful manner.
For example, please don't bring food in with you.
It sends the wrong message.
Not even a cup of coffee?
No.
It sends a message of nonchalance.
Also, please schedule an hour for this meeting on your
calendars.
It is important that we avoid any distractions so that we
can give our full attention to the family.
Also, be aware that in these situations, a family may bring
a lawyer unannounced or they might tape record the meeting,
without telling us in advance.
I just want to prepare you for that.
Thanks for the heads up.
OK.
So right now, I'd like to review with all of you the
issues that the family has raised, and we've raised
ourselves.
As you all know, we've investigated this extensively.
We've had external reviews, internal reviews, and reports
about the conduit from the manufacturer.
You've all seen the draft investigation report.
Alright, let's go through the issues chronologically.
On the question of whether or not the surgery should have
been performed in the first place, Mike, you've explained
to me thoughtfully about why Jason needed the new conduit
sooner rather than later.
Yes.
That's true.
But Mr. Hollis is beating himself up about not talking
his son out of the surgery.
I think that's very much a part of this issue.
Often people in pain lash out with accusations as their way
of dealing with their own guilt feelings.
Even though we wish we could turn back the clock, our
investigation has found there's no reason, even in
retrospect, that anyone, his father included, should have
talked him out of that surgery.
Agreed
Mike, can I look to you in particular for a clear,
unambiguous statement on that?
It would really go a long way to helping this grieving
father.
Yes, I can do that.
Ok, great.
Now let's continue to review the other issues and talk
about how best to handle them.
OK.
Now that we've gone over these specific areas of concern,
let's be clear about who will address each.
In talking with each of you, I'm aware that you're all
hurting too.
We're in unison with the family on this.
And though it's not about us right now, you should all be
honest about your emotions.
It's not wrong for them to see how this has impacted you.
You can be sensitive to their grief without spending time
blaming yourselves.
Mike, you know that Mr. Hollis has been angry that you didn't
attend the funeral.
I'd like to meet this head-on, and I'd like for you to
explain why you weren't there.
You've had a close bond with this family, and as painful as
this might be, addressing this openly will begin to
reestablish that 18-year bond.
You've explained to me how important it was for Jason to
have this surgery.
So drive home the point that the older Jason got, the more
complicated the procedure was going to be for him.
OK.
Finally, I need you to dispel specific concerns expressed by
the family.
Were the sutures improperly placed?
Did you have any reason to think that the cardiac tissue
was going to pull through once this patient was reperfused?
Got it.
Should I talk about my post-surgery conversations
with the manufacturer about the graft we used?
Yes.
And you can talk about the many cases you've done...
the care with which you placed the sutures.
Just be clear.
Be honest.
Be compassionate.
Always show empathy.
That goes for all of us.
Oh, and be aware that Mr. Hollis may ask additional
questions.
He has asked a lot of questions since his son's
death.
What if he asks a question we can't answer?
Don't answer it if you're unsure.
We can always tell him we'll get an answer to him later.
OK.
So how do you see my role in this meeting?
You'll address what happened once Jason was moved to the
post-op recovery unit.
You'll establish that he was hemodynamically stable,
although not fully reperfused.
That's correct.
The nursing team was completely sure that the
patient was fine.
Dr. Megan Shaffer (Cardio Thoracic Fellow): I was the
one that moved him from the OR to post-op and his vitals were
good and strong.
And then all of a sudden that changed.
Megan, I'd like you to add to Michele's comments related to
the patient's initial stability.
Your role is unique.
They see your actions as heroic, opening Jason's chest
right there in recovery to stop the bleeding.
The family empathizes with you and the position you were put
in on that day.
I know, but I'm in complete support with the decisions
made by Mike.
Good.
Feel free to express that support during the meeting.
At some point I want to turn the discussion to any lessons
we might learn from this tragedy.
The question of whether the chest could have been left
open until the patient was completely reperfused may be
brought up.
Wes, that may be a good time for you to talk about the
challenges with managing blood pressure and the practical
problems of managing post op with a wide open chest.
I can do that.
But I have to ask again.
What if we go into this room and the father becomes
agitated and the discussion becomes heated?
My role is to control this meeting.
If at any time - and I do mean any time - you feel
uncomfortable, all you have to do is signal it by looking
directly at me and nodding your head, and I will end it.
And by the same token, when I say we're done, we're done.
Please don't question it.
Don't argue.
Just get up and leave.
Well I'm glad we met today and discussed this.
I have a much better understanding of what we plan
to do, and how this really is in the best interest of all
concerned.
I'm glad you feel that way, Wes.
Any other questions or concerns?
No
Once again, I know Jason's death affects each of you and
this can't be easy.
I'll update you with a meeting location, date, and time.
If before then you have any questions please don't
hesitate to call.
Otherwise, I'll see you at the meeting.