All Children’s failed to report 13 cases of patient harm in heart surgery unit

An internal review by Johns Hopkins All Children’s Hospital uncovered 13 cases in which heart surgery patients were harmed by medical care from 2015 to 2018 but that went unreported until recently. Florida law requires such incidents to be reported within 15 days, according to the Tampa Bay Times.

The newspaper continued its ongoing coverage of the scandal at the St. Petersburg, Florida, facility, which began when the TBT revealed mortality rates in the pediatric heart surgery unit tripled within a two-year span and became the highest in the state. The fallout from the investigation contributed to several executives resigning and CMS threatening to cut off the institution’s public funding.

Reporters gleaned their most recent update from video of a pair of town hall meetings held by Kevin Sowers, president of Johns Hopkins Health System and interim president at All Children’s since December. In those meetings, Sowers admitted to staff members Johns Hopkins had “let this organization down” and former leaders had failed to properly notify the board of trustees about safety and quality issues in the heart surgery department. Six of the 13 incidents of patient harm due to medical care resulted in death.

“Leadership knew there were quality and safety issues and did not elevate it in appropriate ways to the board,” Sowers said, according to the TBT.

Sowers also said previous CEO Jonathan Ellen, who was one of the executives who resigned, had too much power atop the organization. Ellen also served as president, vice dean, physician in chief and director of graduate medical education, giving him the authority to set and approve agendas for the board’s patient safety committee, according to Sowers.

“Structurally, one person should never have that much power at the top of an organization,” Sowers said, adding the hospital’s new leadership structure will spread those responsibility among more people.

A former board member told the TBT Ellen was “a person of great integrity” and that he believed the board “was reasonably well informed” about safety issues in the heart surgery unit.

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