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Slalom Mark Felts medical error healthcare safer

Mark Felts died on a Thursday, and he was back at work on Monday.

January 21, 2015

It was a serious medical error that killed him – and he was one of the lucky ones who survived the mistake. That’s probably because his wife was watching him while the nurse who had just given him the medicine was turned away, working on her computer.

“Look at him!” Kim Felts remembers screaming as her husband’s mouth fell open, his head fell to the side, and he started to turn blue.

Her husband’s next memory came about five minutes later, when he returned to life to find himself soaked in sweat and surrounded by “12 to 15 of my new best friends.” The hospital staff had managed to resuscitate him after he was given too much of the wrong pain medication while in the hospital for kidney stones.

“He keeps saying, ‘There’s a reason I got brought back.’”

As a principal consultant for healthcare in Slalom’s Dallas office, Felts, 49, already was devoting most of his working life to improving the healthcare system. But now, he feels like his purpose in life - and at Slalom - is to advocate for patients, and to prevent other families from going through what his family endured that day.

“If we don’t do anything, nothing will change,” he said. “I would like to consider myself a change agent.”

John Tobin, Slalom’s co-founder and the president of Slalom North America, said Felts has always been incredibly energetic and passionate about his work. But since the health scare, Tobin said Felts has developed an even more positive view of the world.

“It’s like he sees the world in a grateful, enlightened way,” Tobin said.

More than 200,000 deaths a year

The statistics are alarming.

Somewhere between 210,000 and 400,000 patients die each year at least partly as a result of preventable harm that occurs in hospitals, according to a report from the Journal of Patient Safety . That includes things like not giving the patient much-needed medication, providing the wrong instructions at discharge, or infecting the patient with another illness because of improperly sanitized equipment.

Felts is not included in those statistics.

“Even though I died, I just came back, so I was just a serious complication,” he said.

Serious complications are much more common – perhaps 10 to 20 times more non-fatal mistakes like that occur each year in hospitals, the Journal of Patient Safety report found.

Those deaths and complications have continued despite a concerted effort to improve patient safety, which has been underway since a landmark 1999 report drew widespread attention to the costly and deadly problem.

Experts cite a combination of mistakes that lead to patient safety lapses, ranging from communication problems to diagnostic errors.

“Unfortunately, these errors occur everywhere, and it’s not that one hospital is a (bad) hospital, or one nurse or one doctor. It really has to do with the system,” said Donna Montgomery, system director for nursing and patient care informatics at Baylor Scott & White Health North Division, located in the Dallas area.

Slalom Mark Felts medical error healthcare safer

‘A rough ride’

Felts said that in his case, he was given too much of a potent pain medication, which can have fatal consequences for people with renal issues.

He had woken up around 1 a.m. the night before, vomiting and in extreme abdominal pain. His wife called an ambulance, which took him to the hospital. There, he was diagnosed with kidney stones and put on a course of painkillers.

At one point, he said, the pain became so great that he was given a double dose of the medication. That’s when he died.

When he came to, Felts said the first thing he said was, “That was a rough ride.”

But just a few days later, after also undergoing surgery for the kidney stones, he was back at his desk. Felts – who had just returned to Slalom a month earlier – said he was simply impatient to get to work.

Felts had worked at Slalom from 2007 to 2009, before leaving to work full-time for a healthcare consultancy.

“I think Mark’s always wanted to make a difference in healthcare.”

He returned to Slalom in August of 2013. Paul Shultz, the head of Slalom’s Dallas office, said he had been courting Felts because of Felts’s healthcare expertise, but also because of his sheer will to win. Felts, said Shultz, is “a picture of tenacity, of drive.”

Even while he was still in the hospital, his wife, Kim, said he was already thinking about what he could learn from his own experience. She remembers him peppering the nurses and other staff about their working conditions. At first, they were hesitant to talk, she said, but eventually they opened up about feeling overworked and facing other stresses.

“I think Mark’s always wanted to make a difference in healthcare,” she said.

Felts isn’t naïve about what he’s up against. He said healthcare is the most complex industry he’s ever worked in, but he also believes that it is made up mostly of good people who genuinely want to help others.

Montgomery, who also serves as vice president of advocacy for the Dallas chapter of the Healthcare Information and Management Systems Society, said Felts, who is on her patient advocacy committee, stands out because he doesn’t get caught up in the politics or bureaucracy of the healthcare system. Instead, he focuses solely on how to make things better for patients.

“I think he’s thankful that he did not die, and he wants to use the time that he has to help educate people about how complex healthcare is, and how we really have a lot of work to do,” Montgomery said.

A winding path to the healthcare industry

The roundabout career path that would eventually land Felts at Slalom started with another health-related tragedy. Felts was a freshman in college when his mother was diagnosed with cancer. He dropped out of school to be closer to her, and never returned after she passed away.

Instead, Felts worked a series of odd jobs, ranging from selling women’s shoes to standup comedy, before joining the U.S. Coast Guard. After that, he worked in restaurants and bars, as a rock climbing instructor, and for a beer and wine distributor before landing a job with a computer training company.

Eventually, he worked his way up to managing a leadership and organizational effectiveness team for an education management company.

“Remember, this is a guy who didn’t finish college,” he said.

It was during those years that he was building his career that his family was briefly upended by another medical error.

When his youngest daughter was just two years old, Felts said she was prescribed the wrong dose of cough medicine, resulting in a scary night at the hospital as he and his wife watched their toddler come off the drugs.

“It was basically like she was on crack,” Felts said.

Felts’s children are now 13, 17, and 30, and he also has a two-year-old granddaughter.

In those hours following his death scare, he remembers thinking that he’d lived a good life, and had no complaints. But he also remembers thinking that he had a family to take care of, and more work to do.

“I’m just in a better way personally,” he said of his life following that awful day. “But from a job perspective, I feel like I never have enough time.”

            

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