Medical Error: Death of Infant (Twin) 6 Days After Birth

Bob Latino blatino at RELIABILITY.COM
Fri Jun 30 17:05:13 UTC 2017

This is a case in which a twin infant died 6 days after a healthy birth.  There are a series of sequential errors that occurred in this case, including misdiagnosis (maybe even missed diagnosis, but I will let you the professionals tell me).

This case hit home for me because the father in this case was my best friend growing up.  He is a clinician as well and works in a 1000+ bed acute care, teaching hospital.  His daughter, Lola, died as a result of medical errors that occurred where he worked.

I present these videos to the group in the interest of awareness, as to the perspective of such an event from the family's point of view.  Listen how the family notices the smallest nuances about how the hospital staff treated them during and after this incident.  See how impactful those observations were to these young parents.

These videos are provided with permission from the family.  I'd be interested in how other clinicians view this sequence of events and to know how preventable was Lola's death?

1. Lola's Song Promo Video. Event Summary (6:50 minutes)

2. Full Case Presentation to Med Students (including medical record review) - (~34 minutes)

We all know these types of cases happen far too often.  I still remember listening to Sorrel King's first presentation with Peter Pronovost after her daughter Josie died from medical error at Hopkins ( .  That story, and this one, will live with me forever.

Thank you.
Bob Latino

Robert J. Latino, CEO
Reliability Center, Inc.
blatino at
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