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Saturday, Aug 18, 2018
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Editorial: Johns Hopkins All Children’s should be more open about mistakes

A state investigation raises even more concern about medical errors at Johns Hopkins All Childrenís Hospital and the venerable St. Petersburg institutionís lack of candor to the community. Regulators have determined the hospital broke Florida law by failing to report surgical mistakes at its Heart Institute, including leaving a small needle in a newbornís aorta. All Childrenís has acknowledged "challenges," but violations this serious involving the most vulnerable patients require far more openness, particularly given the hospitalís long reputation for outstanding care and its revered standing in the city.

The Tampa Bay Times reported last month about a 2016 surgery on a 3-day-old baby born with a heart condition. Dr. Tom Karl repaired the girlís underdeveloped aorta using donor tissue, but when he finished, a small suture needle was missing. Katelynn Whippleís medical records say Karl looked for the needle but couldnít find it. Katelynnís parents say he didnít disclose it to them and denied it was there when they questioned him. They learned about the needle from another doctor who discovered it in her medical records during a follow-up visit, and they later had it removed at another hospital. Thatís not how high-level care of a medically fragile newborn should proceed or how young parents should be treated.

THE LATEST: All Childrenís never told state about needle left in baby

The response from All Childrenís since details of this case were reported has been confusing and contradictory. The hospitalís CEO, Dr. Jonathan Ellen, said the hospital reports to regulators when anything goes wrong, adhering to a critical system of self-policing that protects patient safety. Yet it didnít tell the state about the needle left in Katelynn or one left in another child since 2016. Ellen also said hospital policy dictates that parents be informed about problems. But Katelynnís parents say they werenít told.

The hospital cited a study about needles left in body cavities and said leaving one smaller than 10†millimeters in a patient is allowed under its policies when it is intentional by the surgeon and "in the best interest of the patient." But for it to be intentional, Karl, the surgeon, presumably would have acknowledged it was there. Ellen also claimed that some organizations donít even count surgical needles to ensure all are accounted for. Pointing out sloppy medical procedures at other hospitals is no way to restore trust in All Childrenís.

Ellen acknowledges the Heart Institute has problems. It has reduced the number of heart surgeries itís performing, and it is referring the most complex cases elsewhere. But Ellen has refused to release last yearís heart surgery mortality rate, leaving the impression that the news isnít good. With the revelation that All Childrenís broke the law by keeping its errors from state regulators, releasing all available data to the public is paramount.

All Childrenís sent the right signal, finally, when it pledged to comply with investigatorsí findings "without hesitation" and said it is already working to make improvements in the Heart Institute. Going forward, the hospital should be forthright and specific about those changes, how they will ensure superior care for young patients and how they will keep their parents fully informed.

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