SAN DIEGO — Piece by piece, Capt. Ryan Carron’s life was clicking into place. An accomplished naval aviator, he had recently gotten married and moved to a new home. And he and his wife were expecting their first child, a son.
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March 2020Then things took a tragic turn that led him to become a champion of patient safety, an experience he recounted here at the Triological Society Combined Sections Meeting.
At regular check-ups for the pregnancy, their obstetrician-gynecologist told them everything was going “fine,” said Capt. Carron, a Navy Helicopter Wing Commander. The doctor discovered placenta previa, in which the placenta blocks the cervix, but it was early in the pregnancy and they were told later that it had resolved on its own.
The baby was big, estimated at eight pounds several weeks before the due date, but the healthcare team didn’t see this as worrisome. As the due date came and went, there were some light discharges the team also said not to worry about. Finally, two weeks after the due date, a planned induction was scheduled for a Friday. When the birthing center became full, the delivery was pushed to Saturday.
It was a scheduling change that ended up having profound consequences, Capt. Carron said.
They were again told all was normal when their doctor performed artificial rupture of the membrane and labor was induced with oxytocin (Pitocin). Along with bleeding, his wife experienced “stabbing pain.” The doctor, they didn’t realize until later, then went home, 12 miles away.
Eventually, Capt. Carron’s wife found herself in a pool of blood and was allowed to go to the bathroom. When she got back, they couldn’t find the baby’s heartbeat. Another nurse who was called in couldn’t, either. The doctor was called and showed up 20 minutes later in a track suit.
The baby, born with no heartbeat, was revived but couldn’t breathe on his own and was transferred to a hospital with a neonatal intensive care unit. Named Kenneth and called “Kenny,” he died five days later.
Aviation safety systems are being applied right now in some degree to medicine. These human performance enhancers and control mechanisms just need to be accelerated if we want to make a true difference in patient safety. —Capt. Ryan Carron
One Mistake after Another
Capt. Carron recounted the litany of warning signs that were missed and ways the system failed.
For instance, his wife was allowed to get out of bed while in labor on oxytocin. While hospital procedures required the doctor to be “on hand” during labor, there was no clear definition of what that meant. Any amount of blood was supposed to be reported to the obstetrician-gynecologist, but it wasn’t.
The Carrons’ nurse didn’t have documented fetal heart rate monitoring training. In a lapse of situational awareness, a physician was never called in, although the room was right upstairs from the ER.
And when an internal investigation was done, the nurses who were the closest witnesses to the whole episode were never interviewed.
Learning from Aviation
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Capt. Carron decided to became a member of the hospital’s annual safety training after a leadership change there and says the hospital has undergone changes since his family’s tragedy. He draws parallels between aviation and the medical field. In aviation, for instance, there are briefings and checklists; in medicine, there are “timeouts” and checklists. In aviation, there is “crew resource management”’; in medicine, teamwork training. In aviation, there are crashes or investigations into mishaps; in medicine, there are sentinel events and investigations.
“Aviation safety systems are being applied right now in some degree to medicine,” Capt. Carron said. “These human performance enhancers and control mechanisms just need to be accelerated if we want to make a true difference in patient safety. They are low cost with high return. Mistakes will happen, but it is our ability to hardwire lessons learned that makes a high performance organization. Naval aviation has come a long way to achieve our safety record. Flying high-risk missions, with a lot of adaptability and flexibility, and entrusted with the lives of others, has a strong correlation to the operating environment of healthcare.”
The Institute of Medicine estimates 268 deaths due to medical errors a day—the equivalent of a jumbo jet crash every day, Capt. Carron noted, and recent estimates suggest this figure may be much higher. A renewed focus on patient safety is a worthy pursuit for both moral and economic reasons, he said.
In the case of this hospital, a change in leadership prompted by the tragedy has led to a culture change, and the medical staff has thanked his family, he said.
“The hospital has seen tremendous positive change in both safety and efficiency,” he said.
Thomas Collins is a freelance medical writer based in Florida.
Medical Errors Still a Top Killer
In 1999, the Institute of Medicine published a landmark report, “To Err is Human.”
The report’s authors estimated that up to 98,000 people in the U.S. die every year because of medical errors and called for a national patient safety movement. In response, the Clinton administration issued an executive order mandating that government health agencies implement strategies for reducing medical errors, and Congress called for hearings. The report has also been credited with influencing an entire niche of medical research focused on improving patient safety (Qual Saf Health Care. 2006;15(3):174–178).
Two decades later, a more recent study estimates the number of deaths due to preventable errors to be much higher: more than 250,000 a year (BMJ. 2016;353:i2139). That would make medical errors the third leading cause of death in the U.S., the study’s authors note.