Video summary
The video recounts the tragic story of Grant Lars Visscher, a newborn who suffered a fatal cardiac arrest due to a medical error involving a feeding tube. Born with a heart defect, Grant was initially doing well and was expected to go home in just a few days. However, the situation turned dire when a nurse attempted to insert a nasogastric tube into his stomach; instead of finding the correct placement, the tube entered his lung. Despite the parents' urgent warnings that his lips were turning blue and the observation of him blowing bubbles—classic signs of aspiration—the nurse proceeded with the feeding, leading to Grant's lungs filling with formula and his eventual death.
This heartbreaking incident served as a catalyst for significant changes in patient safety protocols within the medical institution. The narrative highlights how the family felt dismissed when their concerns were initially ignored by staff who believed the procedure was routine and benign. Following this tragedy, the hospital recognized that at least 25% of children are at risk from misplaced feeding tubes, prompting a complete overhaul of policies regarding nasogastric tube placement. The new guidelines emphasize that no one should consider such procedures harmless if there is any doubt, encouraging healthcare providers to remove the tube immediately and speak up rather than continuing with the administration of feedings.
The story also underscores the critical importance of fostering a culture of transparency and trust between medical staff and families. Although the family expressed deep grief over their son's passing, they appreciated the honesty shown by the hospital after the incident. The video illustrates that while no healthcare worker intends to harm a patient, errors can still occur, and it is essential for institutions to admit mistakes and commit to doing better. By maintaining open communication and validating parental concerns, medical teams can create an environment where safety is prioritized above all else, ensuring that families feel supported and heard during their most vulnerable moments.
Read the full video transcript
[music]
When I was 18 weeks pregnant, they
discovered he actually had a heart
defect. And so we knew when he was born,
he would be going into heart surgery. It
was a big sense of relief when they
said, you know, he did great.
The nurse went to put in a feeding tube
and uh put it in through his nose and um
she started to struggle and his color
seemed to be he seemed paler and he
started blowing bubbles and when we
brought it up to the nurse [music] she
came in and looked at him and um just
said, "Well, he's just a fussy baby."
You know, I did tell her that, you know,
the nurse previously struggled and had
to put it under [music] X-ray. And I
felt a little dismissed when she was
telling me, "Well, I've done this for 20
[music] years and it should be fine."
Right before she starts to do this, we
tell her, you know, "Hey, his lips are
turning blue."
She finishes what she's doing and
[music] getting the feed and then starts
to look and he starts blowing lots of
bubbles. [music]
And at this point, she hits the call
light and then she looked at me and she
says, "I need you to run out in the hall
and ask for help."
And so I ran out in the hall and I
scream, "My son is turning blue. I need
help." And I think there was probably
over 20 people surrounding his bed doing
everything [music] they could.
And then at 9:00 or a little bit after,
I hear the doctor call.
She says, "We're going to call it. He's
passed away."
>> Right there, you just break down. You
know, you just
This isn't supposed to happen.
>> He was doing so well. They said he was
going home in a couple days. What
happened?
Grant unfortunately had a cardopulmonary
arrest because the tube was in his lung
and not in his stomach. [music]
And um his lungs got filled with
formula.
and we attempted to resuscitate Grant
and unfortunately we lost [music] him.
Patient safety is what helps to drive
our practice. [music] What is the best
for the patient? What is the safest for
the patient? And are we doing our best
for our patients and our families when
we're taking care of them? Through our
study, [music] we've discovered there
are probably at least 25% of children
that are at risk um of a misplaced
feeding tube and something needs to be
done [music] about it.
>> Diana has,
you know, taken that by the scruff of
the neck and have turned it [music] into
amazing things. The work that Diana has
done both here inside children's as well
as nationally as an advocate [music] in
particular around the processes related
to placing NG tubes has been
extraordinary
>> because of our change to the policy we
were able to prevent further harm on
[music] these patients. It's that
maintaining and it's really making our
nurses, our physicians, [music]
and realizing we should not consider
this a benign procedure and that if you
ever have doubt with that tube, it's
okay to take it out and it's okay to
raise concern and speak up. You know,
maybe if that one nurse had stopped and
didn't put that last feed, maybe there
would have been enough time to
resuscitate Grant and that he'd [music]
be with us today. I'll never know. But
maybe if she had paused and listened
[music] to us, maybe he would have.
>> I see that parents appreciate that.
[music] And a lot of times parents will
say to us, "We're not happy about what
happened, but we're very thankful that
you were honest with us."
>> Having that trusting, transparent
relationship is the key to having good
care of anybody, whether it be a child,
a family, or an adult.
>> No one comes to work wanting to harm any
patient or family, but it calls us to do
better. And I and I really feel this
work has has really highlighted that in
our institution is we knew that we could
do better.
>> [music]