Deadly Errors (11 page)

Pausing with a dramatic flourish, Vericelli, turned to his right side where Arthur Benson, Maynard Medical Center CEO, sat at military attention. “And this brings me to my next point. I thank Mr. Benson for allowing his medical center to be used as the clinical trial site for the Med-InDx product evaluation. Most of you have no idea of the cost in time and personnel a study of this magnitude and nature requires. Although in the final analysis the Maynard Medical Center will reap the benefit of acquiring a world class Clinical Information System, the medical center has spent millions of dollars over the past three years phasing in this entire complex system.” He paused, nodding his head slightly. “Yes, millions. Think about the increased IT staff required to install and convert the software to the present computer networks and then to train every one of the three thousand employees—the doctors, nurses, admitting clerks, pharmacists, just to name a few—who use the various components of the CIS in their day-to-day activities.”

He sipped water from the glass next to the podium while deciding the appropriate words to best conclude the press conference. Slowly he set down the glass and raised his head for proper emphasis and raised his voice like a Baptist preacher reaching the climax of his Sunday sermon. “The ground breaking report from the Institute of Medicine opened our eyes to the risks every man, woman, and child takes when being cared for in hospitals, doctors’ offices, or emergent care facilities. The know-how to prevent these errors exists in the form of electronic medial record systems. We now need to focus on making sure that health care organizations are actually taking these preventive steps.”

He turned first to Bernie Levy, shook his hand, then did the same with Arthur Benson before strutting from the boardroom.

T
YLER’S BEEPER STARTED chirping. He didn’t recognize the number but the exchange indicated the call back number was within the medical center. Tyler reached for his cell phone.

“Doctor Mathews, Joe Delaney. I’m reading histology of one of yours marked urgent. From last night? A patient by the name of Childs?”

Tyler wasn’t sure if he wanted to hear the answer now that Larry was dead, but he had to sooner or later. He sucked a deep breath. “Let’s hear it.” His chest tightened.

“Don’t have much of anything definitive to tell you since most of the specimen shows nothing more than some nonspecific necrosis, but there are a few sections with blood vessel showing changes consistent with radiation necrosis. As I understand it, the differential diagnosis includes tumor, a viral infection, and radiation necrosis. That correct?”

Not wanting to bias the pathologist’s opinion, he gave a noncommittal, “Yes.”

“Well then. I’d have to say there’s nothing to suggest either tumor or a viral infection. The latter, as you know, can’t be totally excluded until the EM studies,” electron microscope, “are completed, but … well … I’ll let the entire pile of chips ride on radiation necrosis.”

Tyler’s gut tightened as he thought again about the apparent radiation dose mix up. Jim Day hadn’t called back yet. How many hours had it been?

The pathologist asked, “Anything else I can help you with long as you got me on the line?”

Tyler’s mind refocused. “No, nothing more. Thanks for getting back to me so soon. I appreciate it.”

Tyler replaced the cell phone in his white coat and picked up his latte. Cold. He set it back down just as a premonition burst into his consciousness. At first it was nothing more than amorphous foreboding, a feeling that something awful, something he had no control over, would trample his new life—especially now that there was hope of getting back with Nancy. Then, he realized what the feeling was.
Because I’ve lived this before
, he thought.
Therefore it isn’t really déjà vu. Is it?

He thought about calling Nancy and talking over the situation. But what was there to discuss? A simple case of paranoia? A residual feeling from California?

Tyler stopped rotating the latte cup on his desk. Regardless of who was responsible for the radiation overdose to Larry Childs’s brain, the result was the same: a disastrous complication resulting in death. At the very least, he should file a report with the study Principle Investigator, Nick Barber, who in turn, should notify the NIH bureaucrat with overall study responsibility. That person would file an immediate written report with the DMSB—the data monitoring and safety board—who would review the problem within 24 hours and quite possibly shut down the entire study.

Jesus, what have I done?

Tyler looked up a telephone number and dialed.

“D
O ME A favor and pull up the data sheet on study patient MMC-LC1.”

Nick Barber said, “Hold on a sec.”

Tyler heard the click of computer keys in the background.

“Okay, got it.”

“What was the treatment dose?”

It took a few seconds before Nick answered, “Ten gray. Why?”

Tyler realized the skin on his arms and neck carried a patina of sweat in spite of the relative chilly office.

“We have a real bitch of a problem, Nick.” A drop of sweat rolled into the corner of his eye, stinging, trigging a series of blinks.

Tyler stared at his hand computer on the desk in front of him, the notes on Childs still visible on the screen.

Nick said nothing, leaving Tyler with the task of continuing.

Tyler sucked another deep breath.

“Our records show he was given two hundred gray.”

Tyler heard Nick draw a very deep breath. “Holy Mother of Christ.”

He went on to describe in detail Larry Childs’s clinical course. “I have no idea how this happened,” Tyler felt compelled to add. His heartbeats were clearly audible in each ear now as rhythmic swishes.

“Christ,” Nick Barber muttered. “How could you have let this happen?”

“Let it happen?” The rototiller started in his gut. “I just found out about it.”

“My point exactly.” Another pause. “I need to report this to Margaret Heit.”

Tyler recognized the name. The NIH section chief unfortunate enough to hold their grant in her portfolio.

“Nick?”

“Yes.”

“I think a hacker may have been in our system.”

Nick gave a sarcastic grunt. “A hacker? Yeah sure, Tyler. Whatever.” He hung up.

D
OG TIRED AFTER a full night up doing cases, Michelle looked forward to a lingering soak in a hot Jacuzzi tub filled with bubble bath before taking a two hour nap. She opened her condo front door with a sigh of relief then locked it behind her. She dropped her purse on the granite kitchen countertop and headed straight for the bathroom, but stopped.

A man, a stranger, stood just inside the bedroom door.

D
URING HIS SHORT tenure at Maynard Medical Center Tyler had never walked this hall of thick maroon carpet and surreal serenity. The ordered stillness proved a sharp contrast to the operating rooms or patient floors. No crash carts, stretchers, or half-folded wheel chairs littering the hall. No nurses in Brownian motion. The galvanized HVAC air held no trace of feces, tincture of benzoine, or dirty dressings. No cacophony of beepers cutting through dozens of simultaneous conversations. The wall on his left displayed precisely aligned parallel rows of 8×10 photographs of the Board of Directors, past and present, each tastefully framed in brushed silver.

Tyler found the correct office number. An engraved brass plaque to the right of the open door read Jill Richardson, Vice President of Risk Management. Inside, an anorexic-looking mid-thirties male with a moussed brown crew cut and goatee glanced up as Tyler entered. “May I help you?” A tasteful faux mahogany desk sign identified him as Tony Colello, secretary.

“Is Ms. Richardson in?”

The man frowned. “Do we have an appointment?”

“No.”

The secretary smirked. “I’m so very sorry, Ms. Richardson’s day is absolutely chock-a-block. You will just have to make an appointment.”

“Look, this is extremely important. I need to report a patient death.”

J
ILL RICHARDSON GLANCED once again at the Movado Elliptica adorning her left wrist and hurried down the hall. The weekly Senior Steering Team meeting had exceeded the designated two hours by an additional fifteen minutes—which now limited her ability to sift through the ever-accumulating stack of pink While You Were Out notes, voice mails, and emails before her meeting in forty-five minutes with that bitch union representative from Local 188. Goddamned self-serving nurses were crying foul by claiming that staffing pattern changes—using skilled nursing assistants to do some of the menial tasks previously done by RNs—placed inpatients at increased risk. Bullshit of course, but bullshit that once stated, had to be negotiated. With contract renewals only three months away, the butt-ugly Bull-Dyke union representative elected last year by the militant nurses was saber rattling again. Loudly. The bitch.

Rounding the corner to her outer office, she would have run smack into a man coming from the opposite direction but he gently grasped her upper arms, said, “Whoa,” and stopped her.

“Thank you,” she muttered, adjusting the sleeves of her black Donna Karan suit. Once back together, she looked more closely at the white coat and scrub suit standing directly in front of her, recognized him without placing the name. A good five inches taller and sixty pounds heavier than her 5’6” 115-pound frame, the thing that struck her was his eyes. Not their color, but a gentleness and intelligence deep beyond the hazel iris.

“Ms. Richardson, Tyler Mathews. I need to talk with you. It concerns a complication that may put us at risk.” He reached out to shake hands.

She glanced again at her watch, judged the ever accumulating mound of work on her desk and the meeting and decided she just didn’t have time right now. “Can it wait until this afternoon or tomorrow morning?”

“No. A patient died this morning. A totally preventable death that probably qualifies as a sentinel event.”

The last two words blew away any time concerns. “Yes, of course, that is important. Please come in.” She extended an arm toward her office door while ignoring Tony’s admonishing frown.

She followed Mathews in to her cramped office, “Have a seat,” and noticed him glance at the massive L-shaped desk with matching credenza. Those and the floor to ceiling bookcases left little room for her task chair and two visitor chairs. “Atrocious, isn’t it. An inheritance from my predecessor. Apparently a man with a sense of design but lacking any sense of proportion. It does allow a lot of surface area, however.” She noticed him admiring her lesser glass pieces on small risers. “Original Dale Chihuly … during his time as Artist In Residence at Pilchuck.” She believed these gave the room a personal feminine touch while leaving the sense of power the furniture created.