Medical error was a topic Melissa Clarkson, Ph.D. ’14, explored as a graduate student at UW Medicine. Then, one evening in spring 2012, the subject turned tragically personal. Her father, Glenn Clarkson, died because of a series of medical mistakes at a rural Kansas hospital.
It would take the Clarksons an agonizing three-and-a-half years to learn the truth about what happened to Glenn. It was a hard journey, and also an inspiring one, one that initiated a partnership with UW Medicine’s Collaborative for Accountability and Improvement.
A Catastrophic Medical Blunder
Glenn, a retired educator, was assisting with an annual controlled burn of brush overgrowth when something went terribly wrong. The fire raged out of control, and he became trapped. Glenn’s wife, Nancy Clarkson, drove him to the nearest hospital, where he was admitted with second-degree burns.
“I was in a state of shock, and I just trusted that the emergency room doctor caring for my husband was making the right decision,” says Nancy. The next morning, Glenn was transferred to a certified burn treatment center.
It was there that Nancy learned something disturbing: the rural hospital that first admitted Glenn did not follow the correct protocol. Instead of being kept overnight in the intensive care unit, Glenn should have been transferred to the burn center immediately. It was one mistake — among others — that cost him his life.
A Breach of Trust
When the Clarksons approached the hospital for answers, they were confronted with what Nancy describes as “a wall of silence.” The CEO refused to talk to them about what had happened to Glenn and did not reveal whether the hospital was investigating his death.
“Instead of being able to grieve, we were now faced with trying to get the hospital to take us seriously. They expected us to simply trust that they were looking into what had happened. But that trust was gone,” says Melissa.
After multiple attempts to communicate with hospital leadership proved futile, the Clarksons sued. “I knew it would be stressful, but I had no other recourse. I owed it to my children to find out why my husband had died,” Nancy says.
By piecing together information revealed through hours of testimony, the Clarksons learned about the cascade of errors that led to Glenn’s death. Not only had he not been transferred to the burn center in a timely manner, but the treatments he’d received at the rural hospital were counterproductive for burn patients.
As painful as it was, the Clarksons finally had answers. But they did not have peace of mind. How could they help ensure that no other family would have to go through such a horrific experience?
A Better Way: Accountability
“After what happened to my father, we leaped into patient advocacy around medical error, but we realized there was only so much we could do on our own,” says Melissa. “We needed a partner.”
That partner was the Collaborative for Accountability and Improvement, a network of physicians, organizations and insurers led by UW Medicine.
“What really drew me to them was that our goals coincided — we both cared about openness and accountability,” says Nancy.
The collaborative serves as a national resource for implementing communication and resolution programs (CRPs). Hospitals that use CRPs take a very different course in approaching medical error: they acknowledge their mistakes. They address the needs of patients and families. And, importantly, they analyze the error so that they can train personnel and prevent the mistake from happening again.
This process is good for families, giving them information, validation and closure. It’s also good for hospitals: those that have CRPs see a significant reduction in malpractice claims.
“We’ve had an incredible response over the last few years,” says Thomas H. Gallagher, M.D., a UW professor of medicine and the executive director of the Collaborative for Accountability and Improvement. “One hundred hospitals are implementing the program this year, and we expect an additional 100 next year.”
His goal is to make CRPs even more widespread — to help more families and hospitals. In this effort, he and his colleagues have been aided by the Clarksons, who have made several gifts to support the work. These gifts are allowing the collaborative to enhance their website — increasing their reach nationally — and conduct CRP training workshops for providers in Kansas.
“It worked out really well that I happened to be going to school at a place that takes patient safety and disclosure seriously,” says Melissa. “Working with the collaborative gives me hope that we can have an impact on transparency in healthcare.”