A Mother’s Mission to End Preventable Medical Errors


At our March IDEA Series event on the challenges faced by nurses when working with unconnected and uncoordinated medical technologies and ways to improve patient care, I had the opportunity to sit down with Lenore Alexander, the president and founder of Leah’s Legacy. It’s an organization dedicated to preventing deaths from medical errors through education and advocacy. This mission is very personal for Lenore as she lost her own daughter, Leah, to a preventable medical error almost 13 years ago.

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After undergoing a successful surgery, Leah was taken to a post-operative room for recovery.  Over the course of two days, she received increasing doses of narcotics and anxiety medication, yet her vital signs weren’t being electronically monitored. Instead, the standard of care was a visual check from a nurse or doctor every four hours. After staying awake for 30 straight hours, Lenore fell asleep next to her daughter’s bed. When she awoke two hours later, her daughter had passed away from an overdose. No one knew she was receiving too much medication. Leah was 11 years old.

Lenore recounted the horrible tragedy saying, “She was dead in the bed next to me. She weighed 80 pounds; she had been overdosed on Fentanyl.” Lenore believes, as we do, that Leah’s tragic death could have been prevented with monitoring devices that connect with each other, share vital statistics and make critical care decisions based on that information. “If the monitor had detected how low her heart rate and respiration was becoming, it would have discontinued the medication,” she said.

At West Health, we believe that interoperability, the ability of health information to be shared seamlessly across medical devices and systems, could have saved Leah’s life and the lives of so many others who have died from preventable errors in the hospital. Achieving interoperability has the potential to prevent a significant number of the more than 400,000 Americans deaths  each year caused by medical errors.

For Leah, interoperability could have made all the difference. “No medical error is just one thing. I understand that. It’s a series of little mistakes that people don’t catch…this is so simple…I could have saved her,” said Lenore.

Since her daughter’s death, Lenore has been a vocal advocate for improving patient safety across the country. She has made it her life’s mission to have medical errors be recognized as an urgent, national crisis. In addition to ensuring that continuous patient monitoring is the standard of care for all post-operative procedures, Lenore believes patient education is also a critical component to helping prevent unnecessary hospital deaths.

In order to be an engaged patient, you need to be an educated patient, she said. If a patient does not have a basic understanding of the healthcare system and their role within it, it is difficult for him or her to be an advocate in their own care process. Enabling interoperability between medical devices and electronic health records (EHRs) will give patients more access to their healthcare data and help them manage their care.

The hard truth is that Leah didn’t have to die. The technology that could have saved her exists today, but medical device interoperability is not a reality. Every day, patients are put at risk because basic medical information from a variety of sensors and devices surrounding them in a hospital room, such as heart rate monitors, pulse oximeters and drug infusion pumps, can’t ‘talk’ to each other or the EHR. The opportunity exists to reduce hundreds of thousands of medical errors by connecting the existing technology together to create an automated, connected and coordinated healthcare system.

Lenore’s tragic story makes me more certain than ever that achieving medical interoperability to improve patient safety is of the utmost urgency. It’s all of our shared responsibility to make medical device and EHR interoperability ubiquitous to ensure that we don’t lose any more precious lives to medical errors. At West Health, we’re advocating for policymakers to ensure that any legislative or regulatory language to advance interoperability is not limited to EHRs but must also include regulated medical devices in order to achieve the full benefits of a connected healthcare environment.

Below is a video with a few highlights from my interview with Lenore. If you would like to share your story and join us in helping to transform the American healthcare experience, please email us at yourstory@westhealth.org.