Dr. Good: Sebastian Ferrero remains on our minds

This week marks the one-year anniversary of the death of Sebastian Ferrero as a result of a tragic medication error in our clinic. Although Sebastian is no longer with us, his influence on the way we practice medicine at the University of Florida remains foremost in our minds.

Michael L. Good, M.D., Interim Dean, College of Medicine

Michael L. Good, M.D., Interim Dean, College of Medicine

In the face of the worst tragedy a parent can experience, Horst and Luisa Ferrero have exhibited truly amazing courage. We are committed to learning from this experience and from them. The memory of their son serves as a constant reminder that delivering the highest-quality compassionate care and ensuring the utmost in patient safety must remain our top priority.

We seek to promote a culture of quality and safety in all our endeavors. Upholding these values is the responsibility of all who work in the UF College of Medicine and at Shands HealthCare. These ideals must permeate our organization and be championed by each and every individual who provides care to our patients.

During the past year, we have focused our efforts and energies on promoting quality and enhancing safety. Today, physician directors of quality and safety coordinate departmental and institutional quality improvement activities. A comprehensive Quality and Patient Safety curriculum has been implemented throughout the four-year medical student educational program, focusing the students’ attention on medical errors early and consistently throughout their education. On Oct. 29, we will welcome Mr. and Mrs. Ferrero, who will address first-year medical students during Patient Safety Grand Rounds. The Ferreros will share with the students the impact this tragedy has had on their lives.

At the Malcom Randall Veterans Administration Medical Center, residents now participate in a patient safety rotation under the direction of Dr. Larry Klima. The rotation includes joint commission activities, peer reviews and root cause analyses.

Our Medication Committee has established new processes for approving, administering and tracking intravenous infusions and other medications to reduce the possibility of medication errors. We are on schedule with installation of an electronic medical record system in UF’s ambulatory care clinics. At Shands at UF, “Rapid Cycle Teams” and the patient/family-initiated Condition “H” Partners in Care program have been implemented to quickly resolve clinical quality and safety issues in real-time.

On the research front, a new session on quality and safety was added to the college’s annual Research Day program. This year, Dr. Eric Thomas, recipient of the John M. Eisenberg Award for Patient Safety and Quality from the National Quality Forum and the Joint Commission, was the session’s plenary speaker. Next year, Dr. Darrell A. Campbell Jr., chief of clinical affairs at the University of Michigan Health System and the Henry King Ransom professor of surgery, will be our featured speaker. Dr. Campbell, a transplant surgeon, is responsible for the overall quality of care delivered at the University of Michigan Health System and has a special interest in patient safety. He is the recipient of the Michigan Hospital Association’s 2005 “Patient Safety and Quality Leadership Award” and of the 2007 Eisenberg Award.

The college continues to fund intramural Clinical Quality Education Grants through the Office of Continuing Medical Education, promoting faculty research in approaches to improved care. Seven grants were awarded last year, and the review process for next year’s funding will soon swing into action.

All of this is just a start. There is much, much more to do. But we are moving forward on this important journey.

As a faculty and as a health system, we need to always remember Sebastian Ferrero and his legacy at the University of Florida. This week, on the anniversary of his death, take extra time to remember him, and in doing so, renew your individual commitment to patient safety in your everyday activities.