As a parent and grandmother, I know the feeling of when your child is ill and needs to go into the hospital for surgery. We all assume that everything will go well and we will take a tired child home. Unfortunately, that did not happen for the parents of Justin Micalizzi, a healthy 11-year old boy.  Please watch the youtube video to learn more....

When a sentinel event occurs, and that is what occurred in this case, the hospital and staff must conduct an in depth review of the case to find the root cause(s) so the event does not happen again. Colleagues of mine had done this in the attached story. An interesting and helpful presentation of this case and lessons learned.

On January 15th, 2001, Justin Micalizzi, a healthy 11-year old boy, was taken into surgery to incise and drain a swollen ankle. He was dead by 7:55 a.m. the next morning, leaving behind two grieving and bewildered parents who desperately wanted to know why their son had died. But medical care was to fail them twice – first their son died and then no one would explain to them why. --excerpted from "A Family's Search for Truth," Patient Safety and Quality Healthcare, Nov/Dec 2006

This true patient story and others like it are the inspiration for this video, Engaging Patients and Families in Root Cause Analyses of Sentinel Health Care Events: Sudden and Unexpected Intraoperative Death.

http://www.youtube.com/watch?v=y63eICMOXSw&feature=youtu.be

Resources:
About Dale Ann Micalizzi: Dale is an advocate for pediatric patient safety and transparency in medicine. Her 11-year old son, Justin, died following a "simple" incision and drainage of an infected ankle in 2001. She has worked tirelessly in search of answers about her son's death, giving rise to a quest to improve pediatric patient safety and transparency in health care. She is the founder/director of Justin's HOPE Project at The Task Force For Global Health.

About Tricia Pil, MD: Tricia is Medical Director for Quality and Safety at Children's Community Pediatrics in Pittsburgh, Pennsylvania. She earned her undergraduate degree in biochemistry from Harvard University and her medical degree from the University of Pennsylvania School of Medicine. Ever since a series of medical errors nearly killed her and her newborn son at his birth in 2005, she has dedicated her career to improving quality and safety in health care. Tricia is a passionate advocate for engaging patients, families, and frontline health care providers in QI efforts and RCA investigations.

About Robert [Bob] J. Latino: Bob is an author and co-contributor to several books and articles. Robert has co-written an article entitled MRI safety 10 years later: What can we learn form the accident that killed Michael Colombini? Gilk, T. & Latino, R. J. (2011) Patient Safety & Quality Healthcare Magazine. Bob also co-written an article entitled The Benefits of Enterprise Risk Management: An Automated Approach to Organizational Reliability can Boost Clinical and Financial Outcomes, Latino, Robert J. and Jenkins, David S. (2010). H&HN Online Magazine. Bob also wrote an article entitled In Healthcare: Is the Human Being an Asset or a Liability?, ASHRM Journal, 2010, Volume 29, Issue 3, pages 34 – 38. He has been published in numerous industry trade magazines on the topic of Reliability, FMEA, Opportunity Analysis and RCA as well as a frequent speaker on the topic at domestic and international industry trade conferences.

http://www.reliability.com/justin/#
http://www.reliability.com/images/justin-over.jpg