Mother Driven to Improve Health Care System after Devastating Loss

by User Not Found | Aug 14, 2014

Leilani Schweitzer works as Patient Liaison in same hospital where her son died.

Vancouver, Canada − August 6, 2014   As Leilani Schweitzer says, she didn’t choose a career in health care; it chose her. Her previous careers were very different, in art and design. Yet nine years after she lost her son due to a series of medical mistakes, she works as a Patient Liaison – in the very hospital where he died.

Schweitzer will discuss her remarkable story about disclosure, transparency and apology, and what she has learned since Gabriel’s death at the 6th International Conference on Patient- and Family-Centered Care: Partnerships for Quality and Safety taking place in Vancouver, British Columbia, August 6-8. Hosted by the Institute for Patient- and Family-Centered Care, in partnership with the Canadian Foundation for Healthcare Improvement (CFHI) and Providence Health Care of British Columbia.

Working out of the Risk Management office at Stanford University Hospital & Clinic, Schweitzer navigates two worlds. One, she says, is black and white – the health care system’s legal and administrative take on medical errors. The other is grey – the emotional side of the patient’s and family’s experience.

“That’s a big gulf, and I do my best to try to bridge it,” she says.

She sums up her job this way: “It’s about how to take the best care of people when things haven’t gone as expected in health care.” In her case, her son Gabriel was first misdiagnosed at a hospital in her hometown of Reno. Doctors thought he had the stomach flu. In fact, Gabriel had hydrocephalus (“water in the brain”), and the shunt in his brain was failing.

That missed call was the first error. After Gabriel was admitted to a Stanford children’s hospital, he was attached to multiple machines. Every time he wiggled, the alarms would blare, making sleep difficult. Here’s what Schweitzer wrote about what happened next.

“The nurse could see how tired I was, and she wanted to take care of me too, so she did the logical thing, the human, compassionate thing – she turned off the sound. Unknowingly, she had turned off the alarms everywhere: at the bedside, the nurses’ station and her pager. The manufacturer of the monitors would later explain they didn’t think anyone would go through the trouble of nine screens to turn off the alarms, so they didn’t include a failsafe. The technology failed all of us. So when Gabriel’s heart stopped beating, there was no sound.”

The Reno hospital has never had a meaningful conversation with Schweitzer to this day. In contrast, she says that she was able to ask Stanford anything about what occurred, and sensed their empathy. Three years ago, she became the first person to fill the new Patient Liaison role.

Following errors, she says hospitals often fear litigation, and the health care professionals involved can worry about their license and reputation. Yet as Schweitzer notes, when you’re open and honest with patients, you’re far more likely to avoid confrontational proceedings.

She is mindful that people are “beautifully flawed”, and that errors will occur. When they do, the focus should always be on improvements, with the patient and family at the centre. Still, it’s important to look at all sides. “We can’t solve problems until we understand the stories of everyone in health care,” she says.

Schweitzer often considers what might have been. She has said that our humanness will continue to give us tremendous triumphs and inevitable tragedies – and also give us the drive to make things better when we fail.

“Leilani’s story is an extraordinary example of how patients and families can partner with staff to improve healthcare ,” says Beverly H. Johnson, President and CEO of the Institute for Patient- and Family-Centered Care. “By embracing Leilani’s involvement and including her in the solution, the hospital took the steps to ensure this situation never happens again.”



For more information, contact:

Elissa Freeman
For the Canadian Foundation for Healthcare Improvement
Cell: 416.565.5605

Holly Roy
Publicist, Western Canada
Cell: 780.991.2323