It was a small communication glitch between two people — the kind that goes on in hospitals every day. One person says one thing, a second person hears something different.
Most of the time, such mistakes go unnoticed, eventually get straightened out, or in any case, don’t cause lasting damage.
What happened on that cool, gray November Saturday nearly five years ago, though, changed 4-year-old MacKenzie Briant’s life forever. Friday, it also resulted in a $15.2 million medical-malpractice judgment against the University of Washington — one of the largest in state history.
For patient-safety experts, the award underscores the need to move more swiftly toward models of communication like those developed in the aviation industry, which long ago learned that miscues can cost lives.
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MacKenzie’s mother, Elaine Briant, can’t talk about that day in 2008 without breaking into tears. Her sobs punctuate the story.
It still seems incomprehensible to her that such a seemingly minor thing — a brief miscommunication between two doctors at Seattle Children’s about an over-the-counter nasal spray — could have had such disastrous consequences for her happy, scrappy 4-year old.
MacKenzie, born with a heart defect in 2004, had survived a heart transplant early in life. By 2008, before her injury, she had nearly caught up with her peers, delighting in the attention she received from her parents and giggling during “sword fights” with her older brother, Ethan, in their Snoqualmie home.
And though she had to be protected from germs because of the immune-suppressing drugs she took, MacKenzie had an independent spirit and a special way of making those measures her own, dubbing the ever-present hand sanitizer “handitizer.”
For her mother, MacKenzie’s early history makes what happened even more painful.
“Oh my God, she lived through half a heart for almost 4 months. She had a heart transplant, for God’s sake. She’s been a fighter and working so hard her whole life.”
Now 8, MacKenzie is unable to walk or talk or swallow, and doctors say she will require round-the-clock nursing care for the rest of her life.
All because two doctors, talking on the phone, didn’t make sure they understood each other.
MacKenzie catches a cold
In November 2008, MacKenzie caught a cold. She’d had them before, but as the mother of a transplant patient, Elaine Briant was extra careful. On Nov. 18 and 20, she took MacKenzie to her pediatrician, who found no serious problems.
By Saturday, two days later, Elaine was still concerned. MacKenzie’s stuffy nose wasn’t clearing up and it was making her very uncomfortable. Elaine called Seattle Children’s for advice. Dr. Cory Noel, the cardiology fellow who returned her call, asked a lot of questions to rule out a breathing obstruction.
Because MacKenzie was a heart-transplant patient, Noel called Dr. Yuk Law, the transplant cardiologist who had been following MacKenzie. He knew her transplanted heart had some issues, and said he told Noel that MacKenzie should not use Afrin nasal spray, which can elevate blood pressure.
Noel didn’t repeat back Law’s instructions. He gave MacKenzie’s mother a list of drugs that would be OK to use, including Afrin. She drove to a grocery store with MacKenzie in a car seat, got the medication and gave MacKenzie one squirt in each nostril.
On the drive home, she called her husband, John, in Portland, where he had been working. It was Ethan’s birthday, and he’d joined his dad to have a day of fun.
About 10 minutes after she’d given MacKenzie the nose spray, as she was about to turn onto Snoqualmie Parkway, Elaine heard MacKenzie make a strange noise. She looked back at MacKenzie and saw that she wasn’t breathing.
She slammed on the brakes, pulled MacKenzie out of her car seat, lay her flat on the van’s floor, flipped open her phone, fumbling to put it on speaker and dial 911, and began CPR.
In a panic, she couldn’t remember: Cover both MacKenzie’s mouth and her nose with her own mouth, or just her mouth? How hard should she push against her chest, with its precious transplanted heart?
By the time emergency workers got there a couple of minutes later, she was hysterical. In fast succession, there were unsuccessful attempts to get equipment working, mouth-to-mouth resuscitation and soon, paramedics.
One of the EMTs picked up MacKenzie in his arms and sprinted to the paramedics’ van, where they quickly put a breathing tube down MacKenzie’s airway, gave her some drugs and got her heart restarted.
At Seattle Children’s, the EMTs and paramedics stood to the side, their hands behind their backs. “They were so upset,” Elaine recalled. “A lot of them have children themselves.”
Dr. Law, who had been on the radio with the paramedics as they rushed to the hospital, met Elaine in the emergency room.
He told her that he’d warned Dr. Noel not to recommend Afrin, she recalled. But now, he cautioned, they must just focus on MacKenzie.
John and Ethan arrived from Portland that night. After five days, Elaine went home for the first time for a shower. When she returned, John met her in the hallway. The doctors had done scans, he told her, and they showed MacKenzie had significant brain damage. She remembers that moment as she melted to the floor. “I remember feeling like all the bones had left my body.”
MacKenzie was in the hospital for two months. When they took her home, she wasn’t the same girl.
The decision to sue
Elaine and John Briant, who works in electronics-manufacturing operations, “aren’t litigious,” she said.
But the official stance of the UW and Seattle Children’s — that MacKenzie’s injuries were not caused by the nasal spray but by breathing complications from her earlier transplant — plunged the family into constant battles with insurers, Elaine said.
The couple believed their daughter needed not only nursing care to turn her and massage her to keep her body from twisting and stiffening but cognitive therapy to help her develop as much as possible. “Having to fight like this for her is awful,”
They used their life savings for two trips to the Dominican Republic to get stem-cell treatments for MacKenzie, and believe that somewhere, someone will be able to help their daughter rebuild neuron pathways in her brain.
“I’m not going to give up hope that she can be better,” Elaine said. “I want her to feel joy. I want her to know I love her.”
In 2011, Elaine was diagnosed with Stage IV breast cancer. Often up at night with MacKenzie, she was getting desperate for more help. “I can’t go on — how can we survive?” she cried to her husband, who was often out of town for work.
Later that year, they filed the lawsuit. One of their attorneys, Ralph Brindley of the Luvera Law Firm,
called it one of the most “heartbreaking medical-negligence cases” he has ever seen.
Ironically, the University of Washington has been a pioneer in recognizing that communication is the “cornerstone of patient safety,” said Dr. Tom Gallagher, director of the UW Medicine Center for Scholarship in Patient Care Quality and Safety. “Most patient-safety problems result from communication breakdown.”
For some time, the UW has been improving medical-team communication in focused areas such as operating rooms, emergency departments and delivery rooms, he said, where such structured communication is critical.
In addition to checklists and protocols for “stopping the line” for a safety concern, another type of safer communication is the “closed loop,” pioneered in aviation, where the person receiving the instruction repeats it back to verify that the message has been understood.
This case, Gallagher said, highlights the need to expand such communication beyond the ER and the operating room. But it will take training, he added, for the closed-loop style to become ingrained in medical culture and the norm in all settings.
The UW, which is self-insured, does not plan to appeal the award.
At the trial in King County Superior Court, the lawyer representing Seattle Children’s and the University of Washington, which employed the doctors, was frank in his opening statement.
“The very first thing I want to say on behalf of both Seattle Children’s and University of Washington is we made a mistake,” Clarke Johnson said in court.
But that mistake, and the Afrin, were not responsible for MacKenzie’s “severe and devastating brain injury,” Johnson told the court.
The trial, replete with technical experts and material, took three weeks.
For six weeks afterward, Judge John Erlick weighed the testimony and evidence.
Friday, Erlick ruled the nose spray, given after “negligent advice,” did cause the cardiac arrest that left MacKenzie with brain damage.
He said the UW doctors at Seattle Children’s had failed in their duty to communicate with each other, and to properly advise Elaine Briant.
In the courtroom, as the judge announced the award, Elaine Briant began to cry softly. “I wish MacKenzie would be the way she was before,” she said afterward. “But now we will have the funds to take care of her, which is so important.”
Elaine and John Briant still take MacKenzie to Children’s. “I think it’s a wonderful hospital,” she said. Dr. Law is still their transplant cardiologist, and Elaine said he shares their grief.
She knows there was no maliciousness on the part of either doctor — that nobody ever wanted this to happen. “It was just a careless moment.”
Carol M. Ostrom: firstname.lastname@example.org or 206-464-2249. On Twitter @costrom