Author: Lenore Alexander
Executive Director, LeahsLegacy
When a child dies from preventable medical error, it’s almost always more than one mistake. In the case of my daughter Leah, it was, in retrospect, what they call a perfect storm. And after years of reading about hospitals and medical error, and about Leah’s specific surgery, I have come to know just how many things were simply done wrong.
Leah knew her mommy very well. She would have known, without a doubt, that I would tackle this problem, even to prevent one more family from living through this nightmare. It took me some time, but, when I knew I was ready, I looked through all those medical mistakes and picked one thing, one area that I really believed I could help make a change in. A single, simple change that will save many lives.
And so now I am working to make continuous, electronic monitoring of post-operative patients on opioids the universal standard of care. Today, just like 11 years ago, once a patient is moved to a room on the general floor, the standard calls for her to be checked, either visually or electronically, every 2-4 hours. But when the patient is an 80-pound girl on an epidural of fentanyl, brain damage can occur in 3 minutes, with death soon after. A living patient can go cold and blue – as my Leah did – while waiting to be checked in 2-4 hours.
The logic behind this change is obvious, and any number of respected experts and organizations – including the Anesthesia Patient Safety Foundation – agree: Continuous monitoring is the safe, smart way to care for our children, our families.
Ensuring that monitoring is provided is the purpose of Leah’s Law. And my organization – LeahsLegacy – is currently working to see the law enacted in California. I am told that once California mandates monitoring, our prospects in other states, and even other countries, will significantly improve.
This is what I am doing to honor the life of my daughter, and to prevent one more family from needlessly losing a beloved kid.