On January 15, 2001, Justin Micalizzi, a healthy 11-year old boy, was taken into surgery to incise and drain a swollen ankle. He was dead by 7:55 the next morning, leaving behind two grieving and bewildered parents who desperately wanted to know why their son had died. But medical care was to fail them twice – first their son died and then no one would explain to them why.1
Justin’s mother, Dale Ann Micalizzi, has spent years searching for answers as to why her son died from what she had been told would be a 10-minute procedure. No one involved with the case would talk to the family, and Justin’s original medical records were incomplete and inaccurate. Depositions revealed some information that the family had not known, but the case was ultimately dropped for lack of evidence. Dale went on to become an international figure as a patient safety advocate, but despite her many contributions to the field she was never able to find out what had ultimately happened to Justin during the surgery.
Nine years and nine months after Justin’s death, Dale received a call from a physician with whom she worked on patient safety issues. He said that he was informed that a colleague of one of Justin’s providers confided that he couldn’t live with himself any longer, knowing that Dale was still searching for the truth. He went on to say that the hospital doctors, administrators, and attorneys had known from the beginning that Justin was overdosed on the medication phenylephrine after the physician reached for the wrong medication in error and used it in overdose proportions.
Dale wrote a letter to the physicians and administrator of the hospital in which she said, “Although this physician’s informant’s information was troubling, it was also healing. You see, parents blame themselves when something happens to their child. It was our duty to keep him safe. You may not understand this, but I could literally feel the burden of the unknown melting from my shoulders even though I have yet to hear the rest of the story.2
Dale shared this new information with the physicians who had helped her over the years and has presented the case study for multiple healthcare conferences, medical schools and Grand Rounds, while also authoring articles on the topics of patient safety, compassion and disclosure. She said, “Learning from the event is important to me. My child did not die in vain.” And, we can do better.
Justin’s HOPE Project at the Task Force for Global Health