Mother Who Lost Infant Son to Medical Error to Join Panel at World Patient Safety, Science & Technology Summit
February 22 2018 - 8:00AM
Business Wire
Panel will release latest evidence-based
procedure designed to prevent misplaced feeding and draining
tubes
New mother Deahna Visscher was feeling hopeful. Although her son
Grant had been born with a heart defect, he was doing very well
after surgery. Just 11-days old, doctors felt he could soon leave
the hospital. But that didn’t happen. A nurse incorrectly inserted
a feeding tube piercing the little infant’s trachea and filling his
lungs with fluid. “The nurse asked me to go out into the hall and
ask for help,” recalls Deahna. “I told them my son was turning blue
and I watched as 20 staff members tried to resuscitate him. “ Grant
was pronounced dead at 9:10 p.m.
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Deahna Visscher will share her personal
experience of losing her 11-day old son to a medical error. (Photo:
Business Wire)
Since that tragic night in 2008, Deahna Visscher has become a
fierce patient advocate. The Patient Safety Movement Foundation
(PSMF) is happy to announce her participation in a compelling panel
on Nasogastric Feeding and Draining Tube Placement and Verification
at the 6th Annual World Patient Safety, Science & Technology
Summit on Saturday, February 24, 2018. Feeding and draining
tubes are used routinely in hospitals and a recent study showed
that 59% of nasogastric feeding tubes are misplaced in newborn
children less than four weeks old, causing serious harm and in some
cases death.1
Since Grant’s tragic death, Children’s Hospital Colorado has
crafted procedures to ensure that such errors are not repeated.
Their procedures and those of a multi-disciplinary experts were
utilized in creating a new “Actionable Patient Safety Solutions”
(APSS) developed by the PSMF which will be released publicly during
the summit.
What is Nasogastric Feeding and Draining Tube Placement and
Verification and why is it critical to patient safety?
Nasogastric tubes (NGTs) are a commonly used in clinical practice
for decompression or for administering nutrition, fluids and
medications.
Studies of adult patients report NGT misplacement with serious
harm to patients in 1.3 to 3.2% of tube placements (Gilbertson
2011, Bourgault 2009). A 2009 study of tube placements in neonates
(infants less than four weeks old) showed that 59% of NGTs are
misplaced the majority of these in the esophagus (October
2009).
The 6th Annual World Patient Safety panelists are:
Moderator Frances Healey, PhD, RN, Deputy Director
of Patient Safety, National Health Service Improvement
– Dr. Healey’s role includes leading the National Patient
Safety Alerting System and clinical review teams of all nationally
reported death and severe harm incidents.
Panelists include:
- Beth Lyman, MSN, RN,
CNSC, Senior Program Coordinator, Children’s Mercy
Kansas City - Ms. Lyman is a member of the board of directors
of the American Society of Parenteral and Enteral Nutrition. She
worked with the board to develop the New Opportunities for
Verification of Enteral tube Location (NOVEL) project which is an
inter-organization, inter-disciplinary and international effort to
promote best practice for NG tube placement verification.
- Deahna Visscher, Patient
Advocate – Since the death of her son in
2008, Ms. Visscher has been on a mission to prevent
further deaths from misplaced feeding tubes. She sits on the
Patient Safety and Reliability Committee at Children’s Hospital
Colorado and the New Opportunities for Verification of Enteral tube
Location (NOVEL) project.
- Christine Peyton, RN,
Clinical Nurse Specialist, Children’s Hospital Colorado
– Ms. Peyton promotes, develops and implements evidence-based
best practices for pediatric nursing. She’s a clinical expert on
revision and development of policies and guidelines for pediatric
cardiology and critical care.
- David Kershenobich, MD,
Director General, Instituto Nacional de Ciencias Medicas y
Nutrición Salvador Zubiran – Former member of the Board of
Governors of the National University of Mexico (UNAM) (2005-2012),
Dr. Kershenobich served as Mexico’s Surgeon General from October
2011 to June 2012 and is Past President of the International
Association for the Study of the Liver and the National Academy of
Medicine of Mexico. He is an Honorary Fellow of the Royal College
of Physicians, England.
For more information, please visit the Patient Safety Movement
Foundation website. Members of the media may request a press pass
by visiting http://bit.ly/2mCeyay or by contacting Tanya Lyon –
phone (949) 351-2858 or email
tanya.lyon@patientsafetymovement.org.
1 AM Bourgault, MA Halm. Feeding tube placement in adults: safe
verification method for blindly inserted tubes.. Am J Crit
Care 18, 73-6 (2009).
About Patient Safety Movement Foundation:
More than 200,000 U.S. patients and three million worldwide die
each year from preventable causes. The Patient Safety Movement
Foundation (PSMF) was established through the support of the Masimo
Foundation for Ethics, Innovation, and Competition in Healthcare to
reduce that number of preventable deaths to zero by 2020 (0X2020).
Improving patient safety requires a collaborative effort from all
stakeholders, including patients, healthcare providers, medical
technology companies, government, employers, and private payers.
The PSMF works with all stakeholders to address problems with
actionable solutions. The Foundation also convenes the World
Patient Safety, Science and Technology Summit bringing together
some of the world’s best minds for thought-provoking discussions
and new ideas that challenge the status quo. By presenting
specific, high-impact solutions to meet patient safety challenges,
called Actionable Patient Safety Solutions, encouraging medical
technology companies to share the data their products are purchased
for, and asking hospitals to make commitments to implement
Actionable Patient Safety Solutions, the Patient Safety Movement
Foundation is working toward zero preventable deaths by 2020. Visit
http://patientsafetymovement.org/.
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Patient Safety Movement FoundationTanya Lyon,
949-351-2858tanya.lyon@patientsafetymovement.org