Report Reveals Issues At All Children’s Prestigious Heart Institute
Johns Hopkins All Children’s Hospital has a reputation as being one of the best children’s hospitals in Florida.
But a recent report in the Tampa Bay Times revealed problems with the hospital's Heart Institute. Health News Florida's Julio Ochoa sat down with investigative reporter Kathleen McGrory to talk about her stories.
The following is a partial transcript of that interview.
When did you become aware of problems with the hospital’s Heart Institute?
Earlier in the year, we connected with a family (Amara Le and Joshua Whipple) that had had an issue at the Heart Institute. Their daughter Katelynn had gone to the Heart Institute for heart surgery a couple days after she was born and the surgery had gone well to the best of their knowledge. But after the surgery at a follow-up appointment they found out that the surgeon had left a small surgical needle in her heart.
Your report says the hospital staff knew the needle was left in Katelynn’s chest?
If you look at Katelynn's medical records, you will see that the folks at the hospital were very aware that there was a needle in her heart. After they had done the surgery, they counted the number of needles they had used -- and this is something that they often do. They count the number before and after and try to make sure that they match. And there was a miscount. So they were one off and they searched around for it and that's all reflected in the medical records. And then, ultimately, they did an X-ray and on that scan they were able to spot something that looked like a needle.
How did Katelynn’s parents learn about the needle?
After Katelynn was discharged, they went to a follow-up visit with a doctor and that doctor was reviewing Katelynn’s medical records and said to them, 'You guys are aware that there is that needle in her chest, right?' And the parents say that they had no idea up until that point.
They say they went right back to All Children's Hospital and demanded to speak with the surgeon. They wanted that needle removed. They say that they were able to get the surgeon on the phone and when they connected with him he said, ‘There's no needle. I'm sure of that.’
I should note that we did ask the hospital for official comment on this. They say they can't talk about individual cases and we weren't able to connect with the surgeon himself.
They went to a doctor for a subsequent follow-up visit and that doctor recommended that she be admitted to a hospital immediately. Her feet were turning blue. The parents elected to go to a different hospital. The team there said she's going to need emergency surgery. This was very much unrelated to the needle but when they opened up her chest they found that needle. It was stuck in her aorta.
How big of a needle are we talking about?
We're actually talking about a very small surgical needle. It's about a quarter of an inch long. That said, it is extraordinarily sharp. And if you think of it in relation to the size of an infant's heart, it could be substantial. I mean, this is a quarter-of-an-inch needle and a newborn's heart is about the size of a walnut with the shell on it.
So you reached out to All Children’s about this. What did you find out when you talk to them?
All Children’s said they weren't in a position to talk about an individual case because of health privacy laws but they did speak a little bit to their protocol for something like this and they say that if a surgical instrument is left behind in a patient, or really if there's any mistake during a surgery, it is their policy to inform the parent as soon as possible.
And you talk to others in the field. What did they say about leaving a needle inside a patient?
Leaving a surgical instrument in a patient, leaving anything in a patient, is considered a “never event.” So it's something that is so serious and so preventable that it should never happen. So it is very serious and it is very dangerous. It's something that hospitals are pretty diligent about.
Your reporting found that the hospitals Heart Institute is experiencing other problems as well. What are those?
They said that there has been an uptick in the mortality rate. So that will mean that the share of pediatric heart surgery patients who died has gone up. They said that they had brought in another hospital to evaluate their program and that the other hospital had observed some challenges. They wouldn't get into the specifics of that. And they said that one surgeon was no longer operating at the hospital and that that had happened after a series of hard conversations with that surgeon.
What is the hospital doing in response?
The hospital says that they are taking steps to improve the quality of patient care and to improve patient safety. And that's included dramatically cutting down the number of heart surgeries that they're doing right now and also referring complex cases elsewhere. They are not taking those cases right now.
I understand the hospital is now under investigation because of your report?
Yeah, after the report came out the Agency for Health Care Administration sent a team to the hospital. They spent two days investigating -- that was how they characterized the work that they were doing -- and they should be releasing a report any day now.