Lessons Learned Program
P.O. Box 019132 (R-58)
Miami, FL 33101
305-243-1500

Program Overview

Learning Lessons from Medical Mistakes

On 3/09/03 Laurayne Gordon received exciting news; she would be going home from the hospital rehabilitation unit in just three days. She began packing her things not knowing she would never see her home again. After having several surgeries on her back to relieve pain, Laurayne Gordon was admitted to the hospital’s Spinal Rehab Unit. She was treated for pain management and was receiving rehabilitation to use a walker when she developed a hospital acquired infection from the pain medication pump. On 3/10/03 she woke up confused with purelrant drainage coming from the surgical area on her back. It was MSSA infection. The nurses had noted the surgical area to be clean for the past two weeks including 3/9/03. The infection had gotten so bad that Laurayne had a heart attack on 3/10/03. She was rushed to the Neurosurgical Unit where against the advise of the Infectious Disease Specialist, she was treated for MRSA instead being treated for MSSA. The drugs used were inferior to treat MSSA. Due to this and her doctors’ lack of knowledge, the MSSA infection got worst and Laurayne continued to deteriorate. On 3/18/03 she died of respiratory failure and cardiopulmonary arrest due to MSSA infection, never making it home and never being fully relieved of pain.

Turning Tragedy Into Truth: Laurayne Gordon’s death became our tragedy and an inspiration to find a vehicle to reveal the truth. In our investigation into her death two years afterwards we were challenged with how to make a family’s loss a significant lesson in medical mistakes. How do we become transparent in order to fully reveal the ugly truth of repeated human error, neglect and carelessness that robbed a family of their loving mother? The family sought legal counsel in their search for the truth. An opportunity to make a change with how such events had been previously handled occurred in 2005 with the creation of a new University of Miami Medical Group/ Office of Patient Protection and Risk Prevention. With the creative assistance of the family’s attorney Scott Sheftall a solution was found that comforted the family. Their mother’s tragic death would become public and hopefully something positive could be created. With the family and their attorney’s generous donation a special educational program began at the end of 2006. Below is the details of the beginning “ of the “Laurayne Gordon’s Lessons Learned Program” for the University of Miami Physicians. This is one institution’s journey of turning tragedy into truth.

Summary of Project/ Initiative: The originating Laurayne Gordon Family/attorney Scott Sheftall donation will sponsor the first of a series of patient safety educational programs to be presented by the University of Miami Medical Group’s Office of Physician-Patient Advocacy and Office of Patient Protection and Risk Prevention. The Laurayne Gordon project will create a mandatory educational program for Miller School of Medicine physicians regarding in-patient infection prevention and control, with particular focus on the treatment of Methicillin- sensitive Staphylococcus aureus ( MSSA). This topic was chosen by the Gordon family-- her surviving husband and three adult children – to make public the cause of Laurayne Gordon’s untimely death at the age of 71 from a nosocomial infection and through that disclosure help to prevent a similar tragedy for others. University of Miami and Jackson Memorial Hospital nurses will also be offered this educational opportunity on a voluntary basis.

The initial project funding will support the development of live lectures, for both physicians and nurses. It will also provide continuing educational credits, sponsor educational handouts, and provide meals and refreshments during these lectures. Also included in the originating design is the creation and development of an on-line educational alternative for the healthcare practitioner. Finally, the originating donation will also allow the development of a “University of Miami Medical Group (UMMG) Laurayne Gordon’s Lessons Learned” website. This resource will recognize the sponsorship of the Laurayne Gordon family/ attorney Scott Sheftall donation; will provide a link to the online version of the MSSA educational program; and will include links to additional educational materials either maintained by the UMMG or available on the world-wide web that are related to patient protection and risk prevention issues.