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Johns Hopkins wrote the rules on patient safety. But its hospitals don’t always follow them

January 14, 2019

BALTIMORE

Johns Hopkins touts itself as a national leader in patient safety.

Its doctors invented a simple checklist credited with saving thousands of lives. They developed a system to reduce medical mistakes through teamwork and communication. They wrote one rule to follow above all: Listen to the frontline staff.

But the renowned Johns Hopkins Hospital in Baltimore and its five sister hospitals haven’t always followed those principles, the Tampa Bay Times has found.

In at least nine recent cases, the hospitals have been accused of making preventable errors or setting aside basic safety rules. Some serious problems continued long after frontline workers brought them to the attention of high-ranking executives.

In Bethesda, Md., doctors at Suburban Hospital kept performing surgeries even though Johns Hopkins had learned the operating rooms weren’t being properly cleaned, according to federal inspectors.

In the heart of Baltimore, a pediatric burn unit continued treating patients after its leader begged administrators to shut it down, saying the unit had made mistakes that left children disfigured, court records show.

And in St. Petersburg, at least eight employees warned supervisors about issues with a pair of heart surgeons at Johns Hopkins All Children’s Hospital, the Times reported in November.

By late 2017, when the hospital stopped the first of those surgeons from operating, the mortality rate in its Heart Institute had tripled, and at least 11 children had died.

Severe incidents

Every hospital makes mistakes; federal inspection reports show safety problems at many top institutions. And Johns Hopkins continues to be a leader in health care. The flagship Johns Hopkins Hospital spent more than 20 years atop U.S. News and World Reports’ rankings. It is now No. 3.

But some of the incidents at Johns Hopkins hospitals stand out for their severity. Taken together, they illustrate the $6 billion health system’s struggle to consistently follow the principles its experts preach.

Johns Hopkins’ efforts to reduce harm have brought “great fame to the system,” said Sara Singer, a Stanford University professor who studies how hospital culture affects patient safety.

When told about some of the incidents, Singer said, “I see a problem in the culture here. I think there are real lapses.”

Johns Hopkins did not make an executive available for an interview to discuss the cases. In a statement, it described medical errors as a “tragic fact” that occur in all health organizations. But it also said “we can and will do better” and that it would take steps to prioritize safety.

“The Tampa Bay Times has identified occasions where it is apparent that as an organization we failed to act quickly enough, we failed to listen closely enough and, in some instances, we failed to deliver the care our patients and their families deserve. This is unacceptable,” the statement said.

The system said it would remind employees “that they have options for reporting their concerns outside of the direct reporting chain.”

“Anyone who demonstrates that they are unwilling or unable to maintain our rigorous and exacting safety culture will not be a welcome member of our caregiving community,” the statement said.

In the burn unit case, however, the program’s director said he took his concerns higher and higher, ultimately writing an urgent letter to the health system’s chief executive.

The director, Dr. Stephen Milner, said he presented “incontrovertible proof of children that were being mutilated in that department, and they did nothing but cover it up,” court records show.

Asked why under oath, Milner responded bluntly.

“I think that they care more about the reputation of the hospital than they do the care of patients,” he said.

Pledge to change

Johns Hopkins’ reputation for safety was built atop tragedy.

In 2001, a toddler named Josie King was seriously burned in a bathtub. Doctors at the Johns Hopkins Hospital treated her wounds but missed signs of severe dehydration. She died after an infection she caught in the hospital led to septic shock.

Months later, a 24-year-old Johns Hopkins employee participating in an asthma study run by the institution died from inhaling the chemical compound that was being tested.

Johns Hopkins’ top leaders pledged sweeping change.

They created a center for innovation in patient care and safety. Its medical director developed a revolutionary checklist to follow when inserting central venous catheters, a common procedure that often caused deadly infections. Among the simple steps, medical professionals should wash their hands; clean the patient’s skin with antiseptic; and wear sterile masks, hats, gowns and gloves.

When the checklist was deployed in intensive care units across Michigan, the infection rate dropped 66 percent, according to research published in the New England Journal of Medicine. In 16 months, it saved an estimated 1,500 lives.

Johns Hopkins also developed a widely used system known as the Comprehensive Unit-based Safety Program that trains teams of employees to prevent hospital-acquired infections, falls, medication errors and other common problems. It empowers nurses and other frontline workers to speak up if patients are in jeopardy.

The thinking, said patient safety researcher Douglas McCarthy, was that “the people on the front lines are the ones who really know what the problems are and how to solve them.”

The expertise has brought Johns Hopkins millions of dollars.

The Armstrong Institute, as the Johns Hopkins safety unit is now known, consults for hospitals around the world. It charges $3,495 for patient safety certification and $3,500 for three-day workshops to observe safety in practice.

Johns Hopkins also gets paid to develop safety guidelines for the federal government. The Armstrong Institute has received at least $28 million since 2011, records show.

It is due to get at least $4 million more this year.

7 serious problems

Despite Johns Hopkins’ reputation for safety, federal inspectors have cited its network of hospitals for at least seven serious problems since 2011.

At Howard County General Hospital outside Baltimore, inspectors in 2015 noticed some staffers not wearing protective gear during invasive procedures, and others not washing their hands in a unit for critically ill newborns.

At the Johns Hopkins Hospital in 2013, an operating room technician mixed up two patients’ blood types. One received the wrong blood during surgery. His heart failed and he died. The hospital blamed a reaction to medication, but inspectors said his medical records were too contradictory to know for sure.

In January 2012, a nurse manager at Suburban Hospital began raising concerns that a contractor wasn’t properly cleaning operating rooms. A Johns Hopkins senior director was informed that March, and a plan was developed to properly sterilize the unit. But it was found to still be dirty at the end of April. A new plan wasn’t put in place until June. Inspectors cited Suburban for its “failure to recognize and respond to a substantial risk to patient safety.”

Suburban’s chief executive and chief operating officers remained in their jobs, despite being criticized by inspectors for a “lack of awareness” that “directly affected patient outcomes.” The nurse manager who first raised concerns was “terminated” in April 2012, the inspection report said.

Every hospital has safety issues, said Dr. Robert Wachter, who wrote the book Understanding Patient Safety and leads the Department of Medicine at the University of California San Francisco. “The test is what do we do when we find them,” he said.

Johns Hopkins teaches medical professionals to be transparent.

Nonetheless, All Children’s broke Florida law by not reporting two cases in which surgical objects were left inside patients to regulators, the Times reported. In one case, the child’s parents had not been told.

At Johns Hopkins Bayview Medical Center in Baltimore, radiologists didn’t note a fracture on a CT scan of a patient’s spine. The patient was in pain for months before the fracture was found. She wrote the hospital a letter asking what it was doing to prevent similar mistakes. It acknowledged her letter but never answered her question. Federal inspectors later cited the hospital for letting one of the doctors who originally read the scan conduct the hospital’s internal investigation.

A year later, inspectors found that Bayview radiologists missed life-threatening embolisms on a CT scan of another patient’s chest. The hospital said it had been unusually busy that day.

At Suburban, the inspectors who found the dirty operating rooms also learned that two patients were operated on with instruments that hadn’t been sterilized. Neither the patients nor their primary physicians had been told.

Wachter said it is difficult for hospitals to be “100 percent transparent” but that should be every hospital’s goal. The Johns Hopkins cases, he said, are “bothersome.”

Pediatric program

At least one situation reached the highest levels of Johns Hopkins leadership.

One-year-old Elijah Adams was just waking on Nov. 16, 2012, when smoke filled his upstairs bedroom. His mother, Danielle Rayside, scooped him out of his crib and rushed him to safety. He was limp in her arms.

Elijah was treated for third-degree burns at the Johns Hopkins Hospital. Four days into his stay, hospital workers had trouble placing a catheter in Elijah’s left thigh. They injured his leg so badly that it had to be amputated, his parents alleged in a lawsuit.

After seeming to improve, Elijah’s condition suddenly worsened, his mother said in a deposition. He developed infections that led to septic shock. His kidneys and heart started to fail.

Elijah died on Dec. 17, 2012.

In the months that followed, the doctor in charge of the Johns Hopkins Regional Burn Center became concerned about results in the pediatric program that treated Elijah.

The doctor, Stephen Milner, examined the medical records of several recent patients.

A spokeswoman for Milner’s current employer said a settlement agreement meant he was “unable to talk to about anything remotely related to” a lawsuit he would later file.

But a review of memos and medical notes filed in the lawsuit shows he detailed a range of problems.

Children were saddled with unnecessary procedures. Serious burns were treated with Bacitracin, an over-the-counter antibiotic used for minor cuts and scrapes, leading to infections and septic shock.

Milner initially tried to address the problems by meeting with the unit’s nurse manager and one of the surgeons in August 2013, he said. He instituted regular burn training. But staff members ignored his efforts to mentor them, he said.

In November 2013, a surgeon who Milner felt lacked the proper training performed a controversial procedure on a child’s second- and third-degree burns. The boy lost use of his hand, his parents said in a lawsuit.

The following month, Milner presented a memo to the surgery department’s chairwoman describing four children he believed were harmed and expressing “grave concerns about the lack of appropriate patient care.”

He proposed a “radical overhaul.” It didn’t happen.

‘Failure of leadership’

In May 2014, Milner provided a memo to the hospital’s vice chairwoman of quality and patient safety. The hospital convened an internal review of the issues Milner raised. But Milner believed an external review by qualified burn surgeons was necessary.

Milner said the burn unit’s staff began to prevent him from accessing the records of patients who suffered unusual complications or died. Attorneys for the health system said Milner was “fishing” for evidence for a lawsuit and could have seen the records at a meeting he canceled.

In October 2014, Milner wrote to Dr. Paul Rothman, the CEO of Johns Hopkins Medicine, saying he believed children were still being injured.

“There has been a failure of leadership and this failure continues to place Johns Hopkins pediatric patients in serious jeopardy,” he wrote Rothman. “The actions of some doctors have been excused then covered up by others.”

Milner recommended the program be suspended until surgeons with more expertise in burns could be hired. It stayed open.

Rothman met with Milner that month, Milner’s lawsuit said, and health system leaders asked him to serve on a committee overseeing burn care protocols. “Significant institutional resources at the highest levels have been devoted to responding to Dr. Milner’s concerns,” the general counsel for Johns Hopkins Medicine wrote in a letter.

But Milner believed Johns Hopkins wasn’t adequately addressing the safety issues or the personnel who were disregarding his authority. He filed a whistleblower lawsuit against Johns Hopkins in 2015, alleging retaliation from colleagues who made it impossible for him to do his job.

In court filings, lawyers for the health system said that the unit “successfully treats hundreds of children” each year. They pointed out that Milner had not been demoted or fired and said he never had the authority to fire employees or close the burn unit.

In September 2015, a circuit court judge in Baltimore ruled that Milner could not prove retaliation and dismissed his other claims. Judge Jeannie Hong wrote that Milner raised concerns only after another surgeon had been named director of the pediatric burn center, a position that would report to him. The judge expressed doubt as to Milner’s “good faith and reasonableness.”

Milner appealed. The case settled last in 2017.

The families of five children treated in the burn unit filed malpractice lawsuits in 2016. All the families except Elijah’s were represented by Milner’s attorney.

The children’s cases settled in 2017. Rayside and another mother declined to comment. The other families could not be reached.

Milner has since left Johns Hopkins to work for a biotech firm. The pediatric burn unit remains open, with some of the same doctors working there.

‘Blind eye’?

The hospital system’s safety practices have recently come under new scrutiny.

In late November, the Times reported on the problems at All Children’s, which started after Johns Hopkins absorbed the local hospital and made changes to the heart surgery unit.

After the Times report, the health system announced that All Children’s CEO Dr. Jonathan Ellen had resigned, along with the vice president in charge of risk management and one of the surgeons highlighted in the Times’ investigation.

Rothman, the health system’s CEO, was “unaware that employees had raised safety concerns,” a spokeswoman said.

Some nurses at the flagship Johns Hopkins Hospital in Baltimore have also raised patient safety concerns in their attempts to unionize.

A report released in December by the union National Nurses United described chronically understaffed units, shortages of medical supplies and a culture of “fear and futility.”

It said that one cancer unit had bacterial outbreaks because patients were sharing vital-signs machines. In the emergency department, patients had to wait for life-saving medication because there weren’t enough pumps to deliver the drugs.

In an interview, medical intensive care unit nurse Kate Phillips recalled a day when she was caring for two patients. Both needed surgery, one in the hospital room. Phillips had to shuttle between the two patients, creating dangerous gaps in care, she said.

“When you are in an operating room, which my room became, it should be one to one: one nurse to one patient,” she said.

Derek Jannarone, a nurse in the comprehensive transplant unit, said his department saw a spike in the number of falls last summer because there were not enough staff members to monitor confused patients after procedures. Rather than staffing more technicians, the hospital hung signs urging patients to call for help before moving around, he said.

Jannarone said the situation was another example of Johns Hopkins “turning a blind eye to problems.”

“This is the culture at Hopkins,” he said.

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