BEN KOLB

BEN KOLB, A CASE OF DEATH BY MEDICATION ERROR

In Florida, Ben Kolb, 7 was scheduled to go to the operating room for elective ear surgery. Ben had a history of ear problems and he had undergone two successful ear surgeries, one when he was 2 years old and one when he was 5. This surgery was expected to be another routine procedure.

It was two weeks before Christmas. Tammy and Tim, Ben’s parents, were looking forward to the Holidays. Tim was very proud of his son and enjoyed coaching his son’s soccer team. Ben, a natural born leader was the captain of his soccer team.

Ben was taken to surgery.

The surgeon administered Lidocaine, to numb the surgical area around Ben’s ear. Within seconds of the injection, Ben’s heart rate soared and he went into cardiac arrest. Even though the operating room team worked for two hours to revive Ben, he slipped into a coma and died within 24 hours of the fatal injection.⁵

Ben Kolb

When the doctors approached Tammy Kolb to tell her about the tragic error she could not comprehend what had had just happened. “Well, well, when can I give him his Christmas present? I bought him one, I want to give him the present today.”

Martin Memorial Hospital took steps to remedy systems and they disclosed details regarding Ben’s death. Hospital leaders made a full analysis, including a detailed investigation of all the steps and systems that lead up to the Ben’s medical error. They immediately stopped all practices related to this type of error, analyzed the syringes and their contents, evaluated the hand-offs and made significant changes to prevent future errors.

After the investigation surrounding the error and realizing that their systems failed and that they were responsible, the hospital leaders selected to meet with the Kolb family and admit full responsibility for the error that led to Ben’s death.

George Mclain, the anesthesiologist who was called to help revive Ben after the error was made stated, “The damage was already done, the child was dead, OK?” says Mclain. ‘So you have two choices. You can lie. You can cover up. You can spin it. Or you can be honest. And the nice thing about the truth-basically, only have to tell it once.”

Dr. Mclain said, “You know, you look in a parent's eyes that you know their child is dead because of a mistake. And that, you know, it's, How could you take my baby away? Because you know, this was a very beautiful healthy child that should not have died.”

Tim Kolb says, “I was in shock. I was in utter shock that such a simple mistake, number one, could occur in an operating room. And number two, that it could so easily take a life.”

As painful as it was to hear the facts about Ben's death, this is what the Kolb’s needed to know, even more than a multi-million dollar settlement.

“Revenge wasn't there for me," says Tim.

So on the list of things he wanted from them, Tim says it wasn't money at the top. It wasn't people being fired at the top. "No, no," says Tim.

It was just an answer? "Oh, yes," says Tim. "We wanted to know what happened. We wanted the truth."⁷⁴

Hospital Versus PHYSICIAN DISCLOSURE

Currently, many medical errors are not handled with such open disclosure. Although disclosure of this nature could not reverse what happened to Ben, it did provide answers for this family. Both hospital leaders and physicians need to develop a process for meeting with family members and discussing the details of a medical error.

Conflict arises when a hospital and physician become entangled in who should take the “blame” for a medical error. The hospital might decide that they can accept the responsibility for a medical mistake, such as what occurred to Mrs. Hoffmann; however, the physician may not want to admit his part in the error.

On the other hand, a physician may select to admit to an error, but hospital leaders do not want the liability or the financial responsibility of disclosure. These dilemmas do occur. Nonetheless, these predicament focus on the “blame factor” and not on the misaligned health care systems and working toward resolution for the patients.

The most critical factor is a dual approach, much like what was used at Martin Memorial Hospital. Yes, the surgeon injected the wrong drug, but the failed systems, wrought with latent conditions, set the situation up. The surgeon could have blamed the hospital for faulty procedures and poor quality control and hospital leaders could have blamed the surgeon for not rechecking the medications prior to the injection. No one would have benefited, least of all, the Kolb’s. The family needed an explanation about the mistake. They needed answers and not concealment of the facts. Perhaps Debbie Malone would have reacted differently if information about her father’s death were disclosed.

When disclosing events to the patient, it is vital for the hospital leaders and the physician's) to meet together and sort out the details and accountabilities of the error, prior to the patient meeting. This patient meeting should only occur after a full investigation is completed with the identification of system failures and an action plan to correct and prevent comparable errors. Once the root cause analysis is completed, then responsibility can be sorted out more accurately. The last thing that needs to happen is a shouting match between the doctor and hospital administrators in front of the patient. They may all end up in court.

There are missing links for patients when they are not told the details around an adverse event. Anger may be dispelled if the patient and family are informed and involved in action steps surrounding the medical error. Certainly, this type of involvement would enlighten the patient to the facts about the situation. Additionally, disclosure may clarify misinformation that can lead to anger and uncertainty and ultimately litigations. Disclosure may benefit all parties involved.

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