Does UF Health Support Disclosure & Apology, Or Not?
In the early days of the disclosure movement, one of the most powerful stories of disclosure and apology came out of the University of Florida Health System (UF Health) It is a story I shared with audiences around the country, and still do from time to time today.
Sebastian Ferrero was a small but happy and healthy boy supported by a loving family. In October 2007, Sebastian's parents took him to Shands Memorial Hospital, part of the University of Florida Health System, for growth hormone treatment to help him catch up size-wise with his peers. Tragically, someone got the decimal point in the wrong place and Sebastian received a crushing overdose which led to severe brain damage and he died shortly thereafter.
UF Health owned the situation quickly, apologizing to the family and publicly disclosing details of this tragic never event -- including a press conference. They did not hide behind "patient privacy." The case was settled quickly, and then a beautiful thing happened: The Ferrero family formed a partnership with UF Health to build a children's only hospital in their part of Florida (there was no free-standing children'' only hospital at the time of Sebastian's death). Moreover, the Ferrero family worked with UF Health on various patient safety initiatives, including with their medical students and residents. Look here and here and here to learn more about this amazingly powerful story. Sebastian Ferrero is Exhibit A in the power of disclosure and apology.
Sebastian would be finishing high school now, but he did not die in vain and his death led to tremendous improvements at UF Health...but have all those improvements stuck?
Last week we shared the story of Judy Karpinski who was misdiagnosed with cancer by UF Health in December 2021 (remember, Sebastian died in October 2007). Thankfully, Judy is OK (she does not have cancer after all), but she and her husband are out $20K in direct bills and also due financial consideration for pain and suffering. Just importantly, the errors that led to Judy's misdiagnosis need to be disclosed -- as was done with Sebastian Ferrero -- and learned from. Yet, UF Health has not owned the situation. They have stonewalled the media, repeatedly citing "privacy" as an excuse not to talk even though Judy has authorized UF Health to speak about her case. UF Health, according to Judy, has offered pre-suit mediation but with strings attached: Judy would have to sign a gag order and agree not to pursue litigation should mediation fail. Judy balked, but cannot find attorney to take a case that, at best, is worth $50K to $100K, and now her story and UF Health are splattered all over the media.
How could this happen at UF Health, the institution that claims it was changed forever by Sebastian Ferrero just 16 years earlier? Does "forever" has an expiration date in the Sunshine State?
What may have happened at UF Health is important for disclosure and apology advocates to understand. As we all know, there is lots of turnover in healthcare, and not only among front-line staff but also administrators, claims and risk, legal, etc. Moreover, healthcare organizations can change insurers or become self-insured, and so on. Plenty of healthcare systems are merging too. Indeed, American healthcare represents constant change. What shouldn't change, however, is the values and morals of your organization. When new people are brought on board, from a rookie nurse or a physician straight out of residency to a c-suite executive or attorney, do you make sure they understand and support your disclosure and apology program? This is an especially important question to ask with legal counsel, risk and claims folks, and any new insurance partnerships. Do the legal, claims, and insurance people understand and embrace your disclosure culture?
What also is interesting is the juxtaposition between the stories of Sebastian and Judy. In the early days of the disclosure movement, the skeptics informed us that disclosure and apology could not work on high stakes cases such as a death or crippling injury due to medical errors. Sebastian's story proved them wrong. Still, the skeptics were more comfortable saying "sorry" and offering fair compensation on smaller or low dollar cases. Yet, here we are in 2023 reading about some poor woman and her husband who are out of a lot of money for them -- $20K -- but it's truly pocket change to a large health system and said health system is playing stupid games and costing themselves much more in bad public relations.
Disclosure and apology works with all scenarios. Deaths and crippling injuries desperately need disclosure, and the healing and learning that come from these cases can be awe inspiring. Smaller value cases (that can't attract lawyers) need disclosure too, not only out of fairness and honoring the ethical principles of your institution, but also to grasp the quality improvements that can save lives and dollars down the road. UF Health has safety issues that need to be corrected. Today, they apparently gave a false positive for a cancer screening, perhaps tomorrow it will be a false negative for cancer screening which could kill someone. And what if that someone is a popular, well-known executive with a photogenic young family? Fix your crap, UF Health.
Sincerely,
- Doug
Doug Wojcieszak, MA, MS
Founder & President
Sorry Works!
618-559-8168 (direct dial)
doug@sorryworks.net