Communication failure blamed for sentinel events

Sentinel events at Children’s Hospital Boston have been traced to poor communication between residents and attending physicians, prompting a federal investigation and a plan by the hospital to overhaul how the two groups interact. The hospital is responding to the tragedies with a plan designed to make sure that attending physicians don’t leave the younger physicians with too much responsibility by poorly communicating, says hospital spokeswoman Michelle Davis. The plan makes clear some issues that previously were uncertain at the hospital, she says, such as when a resident is expected to contact the attending physician about a change in the patient’s status.

A review by the Massachusetts Department of Public Health criticized the hospital’s management of four cases in the last 13 months. The state inquiry followed concerns expressed by an official at the Boston branch of the Centers for Medicare & Medicaid Services (CMS). Two years earlier, state officials found systemic problems at the hospital contributed to the death of a toddler who suffered fatal brain damage while she waited for surgery. The most recent state review identified cases in which four patients received inadequate care, and three of the patients died as a result.

In one case, the state report concluded that a 5-year-old boy died because all of the doctors treating him believed someone else was taking responsibility for his care. All of the physicians caring for the child thought someone else was taking responsibility for him, the state concluded, and no one noticed the boy had stopped breathing until it was too late.

Attendings ordered to be receptive to residents

CMS delegated the review to the state department. The hospital announced that the state has accepted its plan for addressing the problems and CMS is likely to follow suit. Among the changes implemented, Davis says the hospital created a uniform, institutionwide set of expectations regarding the role and responsibility of attending physicians and supervision of residents. These standards mandate that attendings respond "fully and respectfully to any questions or concerns expressed by the care team, including residents and fellows."

The attending physician also is required to communicate clearly to each trainee involved in the care of the patient when the attending expects to be contacted by the trainee. At a minimum, the trainees must be told to notify the attending of significant changes in the patient’s condition, regardless of the time of day or day of week. The hospital outlined eight situations that automatically qualify as "significant changes" in the patient’s condition and require that the resident notify the attending.

In addition, Davis says the hospital created the role of "ombudsperson" to provide trainees and other clinical staff easy access to a senior physician in the institution who will investigate any concerns by trainees or clinical staff that members of the faculty are either slow to respond to requests for help or create the impression that requests for help or advice are unwelcome. The hospital appointed a physician in the hospital’s psychiatry department as the new ombudsperson.