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Editor's Page
Slow Down for Safety's Sake
Dan O'Connor
Publish Date: October 10, 2007

Dan O We've reported in the last year on the deaths of three kids, each of whom had minor outpatient surgery and died from what the medical examiners would term accidental morphine toxicity.

Dan O My (over)reaction: Rage, sadness, disbelief and no way, no how should Hannah and Nicholas and Steven be gone.

  • Hannah Yutzy, 3, died March 13, 2003, after she had a tonsillectomy with adenoidectomy and bilateral myringotomy at an ASC.
  • Nicholas Marlow, 6, died Oct. 3, 2003, after surgery on his toenails at a hospital.
  • Steven Tyler Verdin, 3, died Oct. 11, 2003, after he had a tonsillectomy with adenoidectomy and bilateral myringotomy at the same hospital.

Too much pain medication. Why? And how? Just as the father of one of the three children asks in this issue (see "My Turn" on page 96), we wanted to know why and how does something like that happen in this day and age.

We pored over autopsy reports and department of health investigations. We interviewed surgeons, anesthesiologists, nurses and relatives. We wrote our stories, thinking we were the writers of wrongs when in fact, as we were reminded, people die in surgery. It's part of your landscape, an outcome that's almost always a possibility with every case you do. We print a correction when we make a mistake. Mothers and fathers sometimes bury their children when you make one.

To steal a line from the signs you see on the shoulder of the highway: slow down, save a life.

Take gastric bypass. While the operations can produce dramatic benefits for very obese people, some hospitals and surgeons may be rushing too quickly to satisfy the surging demand, offering the lucrative procedures without adequate training, experience and support, experts says.

The trend in outpatient surgery is to push the envelope, to turn more inpatient cases into outpatient ones (see "23-Hour Gastric Bypass the Shape of Things to Come?" on page 8), to let RNs administer anesthesia (see "Gastro Docs Closing Their Eyes to Dangers of NAPS" on page 16) and to let RNs perform endoscopy (see "Nurses Doing Flexible Sigmoidoscopy and Colonoscopy" on page 28). We're all for economy and efficiency and evolution, but if patient safety is compromised or squeezed out of the equation, then the medical examiners and the funeral directors get pulled into it.

And we're left asking why. And how.