Care and accountability

March 24, 2020
by Sean Ruck, Contributing Editor
In a perfect world, hospitals would be places of healing. However, in a realistic world, there are times when medical technology and professional expertise are unable to deliver. It’s something to be expected when treating those whose resilience has been worn down by long-term illness or the ravages of time. But when something goes wrong for younger patients, especially ones where the expectations of recovery are high, it can be heartbreaking for everyone involved — not just friends and family, but also the medical professionals who were providing care.

When the unthinkable happens, some hospitals may “lawyer up” and correspond through a group that doesn’t have the understanding or compassion, or even the goal of providing healing for those who suffered the loss. Some organizations, though, instead understand that the care they should provide goes beyond the patient they treated.

Leilani Schweitzer was asleep in a chair beside the hospital bed of her 20-month-old son Gabriel. She was awoken by a nurse as hospital staff rushed into the room to revive him, but they were unable to.

The tragedy occurred due to a combination of factors. Gabriel had been attached to a number of sensors feeding into monitors. When he moved, electrodes shifted or loosened and alarms sounded loudly, creating even more stress. In a gesture of compassion, a nurse offered to turn off the alarm in the room, but unknowingly, she deactivated all the alarms, not just in the room, but in the nurses’ station and on pagers. There was no alert when it was needed.

That was the horror Schweitzer experienced and for all the training, protocols and fail safes put into place in today’s hospitals, stories like hers are far too common an occurrence. What’s less common are the steps Stanford Health took following the tragedy. They didn’t hide behind a legal wall. Instead, they researched what went wrong, gathered information, presented what they found to Schweitzer and apologized.

The nurse who tried to offer some respite for her patient and her patient’s mother would eventually leave her job at the hospital. A pediatric neurosurgeon who had treated Gabriel quit practicing medicine. The impact of the incident cut deep. Which was why Schweitzer’s response to Stanford’s question about what else they could do was so surprising and a testament to the heart and strength she has to help others who might have a similar experience.

Today, Schweitzer is approaching her 10-year-anniversary as PEARL (Process for Early Assessment Resolution and Learning) Patient Liaison for Stanford Health Care. She is the person who has the face-to-face interactions with patients and families when something goes unexpectedly wrong, whether from human error, equipment malfunction or some mystery of the human body.

While she didn’t undergo formal training and her background as a graphic designer didn’t align with her new role, the experience she went through and the understanding of what people really require after a medical error has served her well.

“Most people want three things,” she says. “They want an honest, transparent explanation of what happened. They want an apology. They want to see that changes have been made to make sure what happened never happens to someone else.”

Schweitzer works within Stanford Risk Management, between attorneys, patients and patient families. Ideally she’s involved as soon as an event happens, but that’s not always the case. “Sometimes, there are elements we don’t understand, or we don’t find out that there has been an event until significant time has passed,” she says. “Sometimes it takes time for a patient or family to talk to us.”

Leilani Schweitzer
If the results of the review determine something was not preventable, Schweitzer will meet with the family to find out what questions they have, what they experienced, and to explain next steps and set expectations. If the results of the review determine the outcome was preventable, she and a team meet with the family, explain what was learned, what’s being done to ensure it doesn’t happen to anyone again, apologizes and offers compensation.

Schweitzer meets with patients and families along with the healthcare professionals involved. She says she’s never had an experience where a doctor tells her afterward that he or she wishes she didn’t have the meeting. Quite the contrary, she says, there were medical professionals so distraught over an incident that they were considering getting out of medicine, but the chance to meet with patients and families helped renew their commitment to continue providing the best care possible.

For Schweitzer’s own experience, the investigation into the incident revealed that the monitor manufacturer didn’t put in a fail-safe to prevent all the alarms from being turned off. The information was shared with all hospitals using that system. “I will never know if it helped someone else, but it comforts me to know it might have,” she says.