Shelley Amonett looked at photos of her daughter, Jessica Zeppa, who was married to a soldier. Zeppa suffered a miscarriage and died in 2010 of complications from severe sepsis after being sent home from Reynolds Army Community Hospital four times.

Raymond McCrea Jones • New York Times,

Jon Guill, who served in Iraq, prepared formula for his son, Justen, who was born brain-damaged at a military hospital after prenatal distress allegedly went unaddressed, in Elgin, Okla., May 16, 2014. Internal documents obtained from military hospitals depict a military medical-care system in which scrutiny is sporadic and avoidable errors are chronic. (Brandon Thibodeaux/The New York Times)

Feed Loader,

Justen Guill, 5, above, born brain-damaged at a military hospital after prenatal distress allegedly went unaddressed, was held by his mother. Below, Jon Guill, who served in Iraq, prepared his son Justen’s formula.

Photos by Brandon Thibodeaux • New York Times,

At military hospitals, chronic errors and lax oversight plague care

  • Article by: Sharon LaFraniere and Andrew W. Lehren
  • New York Times
  • June 28, 2014 - 9:41 PM

– Jessica Zeppa, five months pregnant, the wife of a soldier, showed up four times at Reynolds Army Community Hospital here in pain, weak and fighting a fever. The last time, she said she was not leaving until she could get warm.

Without reviewing her file, nurses sent her home anyway, with an appointment to see an oral surgeon to extract her wisdom teeth.

Zeppa returned the next day, in an ambulance. She was airlifted to a civilian hospital, where despite relentless efforts to save her and her baby, she suffered a miscarriage and died Oct. 22, 2010, of complications from severe sepsis, a bodywide infection.

Medical experts hired by her family said later that she most likely would have survived had the medical staff at Reynolds properly diagnosed and treated her.

“She was 21 years old,” her mother, Shelley Amonett, said. “They let this happen. This is what I want to know: Why did they let it slip? Why?”

The hospital doesn’t know, either. Since 2001, the Defense Department has required military hospitals to conduct safety investigations when patients unexpectedly die or suffer severe injury. The object is to expose and fix systemic errors. There is no evidence of such an inquiry into Zeppa’s death.

The Zeppa case is emblematic of persistent lapses in protecting patients that emerged from an examination of the nation’s military hospitals, the hub of a sprawling medical network — entirely separate from the scandal-plagued veterans system — that cares for 1.6 million active-duty service members and their families.

Internal documents depict a system in which scrutiny is sporadic and avoidable errors are chronic.

Records indicate that the mandated safety investigations often go undone: From 2011 to 2013, medical workers reported 239 unexpected deaths, but only 100 inquiries were forwarded to the Pentagon’s patient-safety center, where analysts recommend how to improve care.

Higher complication rates

At the same time, by several measures considered crucial barometers of patient safety, the military system has consistently had higher than expected rates of harm and complications in two central parts of its business — maternity care and surgery.

More than 50,000 babies are born at military hospitals each year, and they are twice as likely to be injured during delivery as newborns nationwide, the most recent statistics show. And their mothers were more likely to hemorrhage after childbirth than mothers at civilian hospitals, according to a 2012 Pentagon analysis.

In surgery, half of the system’s 16 largest hospitals had higher than expected rates of complications over a recent 12-month period, the American College of Surgeons found in 2013. Four of the busiest hospitals have done poorly on that metric year after year.

Little known beyond the confines of the military community, the Pentagon’s medical system has recently been pushed into the spotlight. In May, Defense Secretary Chuck Hagel ordered a review of all military hospitals, saying he wanted to know if they had the same problems that have shaken the veterans system.

Defense Department health officials say their hospitals deliver treatment that is as good as or better than civilian care, while giving military doctors and nurses the experience they may one day need on the battlefield. They described their patient-safety system as evolving but robust, even if regulations are not always followed to the letter.

“We strive to be a perfect system, but we are not a perfect system, and we know it,” said Dr. Jonathan Woodson, assistant secretary of defense for health affairs. “We must learn from our mistakes and take corrective actions to prevent them from reoccurring.”

The military lags behind many civilian hospital systems in protecting patients from harm. The reasons, military doctors and nurses said, are rooted in a compartmentalized system of leadership, a culture of interservice secrecy and an overall failure to make patient safety a top priority.

Some doctors and nurses complain that no one listens to their safety warnings. One staff member recalled filing roughly 50 reports of safety problems since 2007, each time providing contact information. Only once, the worker said, did a supervisor respond, and then only to express irritation at the fusillade of filings.

Communication issues

When patients die unexpectedly, medical workers often cite a breakdown in communications.

Katie Guill checked into the hospital at Fort Leonard Wood, Mo., on Christmas morning 2008, expecting to give birth to a healthy baby boy. She left with an infant so severely brain-damaged that at age 5, he cannot crawl, speak or swallow. He is fed through a pump.

In the three hours before a doctor finally delivered their son, Justen, by Caesarean section, the Guills said in a lawsuit, a monitor sounded 32 alerts that the baby’s heart rate had slowed. The suit also said the nurse had warned the doctor on duty four times that the baby was in distress before he arrived at her bedside.

The government settled the case for $10 million, but Pentagon records give no indication that a safety investigation was conducted. Nor is there a record of any action against the doctors and nurses involved.

“We don’t know what went wrong because no one has ever told us,” said Justen’s father, Jon Guill, who served 18 months in Iraq.


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