RESPONDING TO PATIENTS AND FAMILIES ABOUT THE DEATH OF BRIANNA COHEN
Q: How did Brianna Cohen die?
A: At the time of her death, Brianna was a child with cancer followed by the staff at the Johns Hopkins Childrens Center. She was being treated at home with Total Parenteral Nutrition (TPN) through intravenous infusion services provided by Pediatrics at Home, a subsidiary of The Johns Hopkins Home Care Group, when her parents found her unresponsive and took her immediately to the nearest community hospital, where she was pronounced dead.
Tests conducted immediately thereafter showed that the TPN solution bag in use at the time of death contained excessively high levels of potassium. Although our analysis is incomplete, and we are as yet unable to recreate the precise series of events that occurred, the most likely explanation for this tragic event is that human error occurred in the manual formulation of the solutions at the Home Care pharmacy and led to excess levels of potassium in the TPN bag. At the family's request no autopsy was performed.
An additional contributing factor may have been miscommunications between those responsible at Hopkins for ordering the discontinuation of the TPN, and those at the infusion pharmacy at Johns Hopkins Home Care.
Johns Hopkins accepts full responsibility for Brianna's untimely death and is committed to doing whatever it takes to prevent a similar occurrence.
Q: My child uses TPN. Should I be worried about my child's safety?
A: No. We immediately put in place substantive measures to assure that all current and future TPN preparations given to patients are safe. All TPN solutions are being prepared by the inpatient pharmacy at Johns Hopkins using fully automated rather than manual mixing procedures. No further TPN solutions are being prepared at Pediatrics at Home pharmacies.
Q: What is Hopkins doing to reduce medical errors and protect my child?
A: Medical errors are a fixable problem. Through our Patient Safety Initiative, we are re-organizing the way we do our daily work to make sure that we provide the best, safest care possible to patients. One key component of the new initiative is that all Hopkins employees, from medical residents, to nurses to the CEO of the hospital, are responsible for protecting patient safety by identifying potential problems before they occur, and fixing them. Safety teams comprised of doctors, nurses, pharmacists, respiratory therapists, infection control specialists, and other staff have been assigned to make patient safety rounds and to evaluate and identify vulnerable processes, develop a proactive error prevention strategy specific to each patient group, measure improvement, and report findings widely so that all those involved in caring for children might benefit from their experience.
Q: What can I do as a parent to prevent medical errors?
A: The most important thing a parent can do is speak up. Parents should never hesitate to ask a question, voice a concern or request further explanation about a procedure or any other matter. Health professionals rely on information provided by patients and their families or surrogates regarding the patient's health, symptoms, medical history, medications, treatments, allergies and social circumstances in order to make diagnostic treatment decisions in the patient's best interest. At the Children's Center, we understand that no one knows a child better than his or her own parent, and we encourage parents to be actively involved in their child's care. Involving patients and their families in their medical decisions whenever possible, including discussion of risks, benefits, and alternatives is a priority.
