DEATHS LAUNCH NEW PROBE

State Health Department investigating after two children, 7 and 1, die following treatment at Stony Brook University HospitalBY RIDGELY OCHSNewsday Staff Writer
The recent unexpected deaths of two children at Stony Brook University Hospital have prompted investigations by the state Department of Health.The department is investigating the June 26 death of 7-year-old Tyler Poole of West Islip following routine adenoid surgery. It also is continuing to probe the May 13 death of 1-year-old Amee Martin of Mastic.Citing a federal confidentiality law, the hospital declined to identify Tyler or Amee, or to otherwise discuss the cases, but the families involved confirmed the basic facts of the cases.Amee's mother, Judee, said the hospital told her that her daughter died from an overdose of papaverine, a drug that expands blood vessels. Amee was brought to the hospital because she suddenly stopped breathing, her mother said. The drug, which is supposed to be diluted for children, was given at full strength, according to hospital sources. Martin, whose daughter had a previous breathing episode on March 2 and was saved by two Suffolk police officers, said she is awaiting a hospital report before deciding whether to discuss her daughter's case in detail. "The nurses in the pediatric intensive care unit were phenomenal," she said. "However, what happened should never have happened."The health department said it is "reviewing all aspects on the care the child received, including allegations of medication overdose." Richard Poole said his son Tyler's heart stopped for unknown reasons June 26 after "simple in-and-out" surgery to remove his adenoids. Although his son suffered from Duchenne muscular dystrophy, he said all precautions appeared to have been taken to ensure his son's safety. "I pray that is the case," said Poole, who added he hoped his son's death would raise awareness of the genetic disease, especially through the nonprofit group Parent Project Muscular Dystrophy.Health department spokesman Robert Kenny said the hospital reported Amee's death to the department. The state's investigation into Tyler's death was prompted by an inquiry from a Newsday reporter, though the hospital reported it after that inquiry was made.The state investigates any "unexpected" deaths - those unanticipated given the patient's diagnosis - as well as medication or surgery errors, all of which hospitals are required to report to the state, Kenny said. Complaints can also trigger an investigation.He also said it was not unusual for a hospital to have two ongoing investigations."We never want to see it but it's not out of the ordinary," said Kenny, who said he could not predict when the investigations would be completed. In 2002, the health department cited Stony Brook for a number of deficiencies following the death of 6-day-old Gianni Vargas of Brentwood, who died after he was given 10 times the proper dose of potassium chloride. The health department found that the staff did not follow proper procedures to ensure dilution of the potassium chloride, that there was a lack of coordination among various departments, and that the pharmacy computer system was unable to detect dosing errors.The 504-bed Stony Brook facility, Suffolk's largest hospital, is the only one in the county to provide highly specialized or "tertiary" care. Although it would not discuss the details of the current cases, the hospital defended its "outstanding record of patient safety." It cited an overall mortality rate of 1.78 percent from January to April of this year, which it said is lower than a 2.3 percent rate from a consortium of university hospital centers it uses as a benchmark. "This success was achieved even while caring for the region's most acute patients," the hospital said in a statement. However, Yosef Dlugacz, senior vice president for quality management for North Shore-Long Island Jewish Health System, questioned whether overall mortality is "a quality indicator to be used as a benchmark in comparing one hospital's performance against another hospital's performance." Dlugacz, who is publishing a book on health care quality measurements next month, said he prefers comparing outcomes from a particular diagnosis or procedure. That's how most hospital report cards are compiled.The hospital also defended its efforts to ensure patient safety. "Stony Brook University Hospital has patient care quality and safety as its first priority and participates in Patient Safety Net, an online reporting system that makes it possible for anyone in the hospital to anonymously report a patient safety concern or issue," the hospital said in a statement.It is also participating in a nationwide program designed by Stanford University and in the Institute for Healthcare Improvement's 100,000 Lives Campaign to reduce avoidable patient deaths. "We exceeded our goal and have, using risk-adjustment methods, saved an estimated 130 lives over the past 18 months," the statement said.Cases of concernCiting two recent deaths, a senior Stony Brook University Hospital surgeon has raised questions about "patient safety" there. Following are some cases that have prompted state reviews.June 26, 2006: Tyler Poole, 7, of West Islip, died after routine adenoid surgery. Cause of death is unknown. May 13, 2006: Amee Martin, 1, of Mastic, died from an apparent overdose of /papaverineSeptember 2003: "Baby Doe" of Suffolk County died of heart illness following cardiac surgery.February 2002: Gianni Vargas, 6 days old, of Brentwood, died after he was given 10 times the dose of potassium chloride. August 1995: Petra Fiel, 8 days old, of Ronkonkoma, was given 10 times the correct dose of morphine. She recovered.Medication errors statewide, 20055 Resulted in permanent harm to patient10 Resulted in near-death situation11 Resulted in death of patientSTATE HEALTH DEPARTMENT