Josh Barron

“My son is not a sentinel event!”

Ridley Barron, founder of Ridley Barron Ministries, uttered those words in sheer frustration and anger while sitting around a conference table with a group of hospital attorneys and administrators in the wake of his 17-month-old son’s death.

Only a few weeks before, his life had seemed pretty close to idyllic. In 2004, he was returning home to southeast Georgia on Good Friday after a spring break vacation to the beach with his wife, Sarah, and three children. Barron asked Sarah to take the wheel the last 45 minutes of the trip while he reviewed his Easter sermon.

Just 15 minutes from home, a Ford Explorer ran a stop sign and broadsided the family’s car. “My wife was killed instantly from the impact,” Barron said. When the seatbelt snapped, Joshua, the youngest of the couple’s three children, was thrown from the car still in his car seat. A passerby knew infant CPR and revived Josh at the scene before the family was transported to the local hospital. At the recommendation of the family pediatrician, Josh, who had sustained the most serious injuries of the surviving family members, was transferred three hours away to the much larger Memorial University Medical Center in Savannah, Ga.

Barron, who had a broken left shoulder and right wrist, was unable to drive and was grappling with where to bury Sarah since the family had recently decided to move to Middle Tennessee to start a new church. While he stayed at home over the weekend, his sister and a dear family friend who was a nurse took turns with Josh at the hospital. “Both said he had progressed nicely through the weekend, but he was still having seizures,” noted Barron. Still, when given phenytoin, he responded well.

While visiting Josh at the beginning of the following week, Barron had not been able to see the attending physician in person, but the two did have a phone conversation where the doctor assured him the baby was progressing. On Wednesday, Barron and his sister were running errands to prepare for Sarah’s funeral when his sister’s phone rang.

“I could tell from her end of the conversation something was wrong,” Barron recalled. Then his phone rang. A nurse asked if it was possible for him to return to the hospital. Barron explained that he was three hours away and began asking questions. Citing HIPAA regulations, the nurse refused to give him any details and became so flustered that she hung up on him. He quickly dialed back the hospital and reached the head nurse. “She said, ‘You and your family need to drop what you’re doing and get back here as quickly and safely as possible,’” Barron said.

When they arrived at the hospital, Barron was blocked from entering his son’s room and was led, instead, to a conference room. Resisting pressure from hospital administrators, Wayne Marchant, vice president of Risk Management, refused to claim the child was dying from the injuries sustained in the crash. “Wayne, because of his integrity, said, ‘I’m not going to do this. We have to be transparent,’” explained Barron, who remains close friends with Marchant to this day.

“They sat me down and admitted their mistake. That morning he’d had a seizure. Just like before, they called down … and just like before, they requested phenytoin from their pharmacy.” Tragically, that’s where the story veered from the standard of care. The pharmacist, who was alone in the dispensary, was rushing to get the dose ready for Josh. “In her hurry, she forgot to dilute it. What was sent up was five times the strength it was supposed to be.” The minute the floor nurse administered the adult dose, Josh’s heart stopped beating.

Although some medications can be diluted with charcoal or by inducing vomiting, phenytoin doesn’t fall into this category so there was little that could be done once the mistake was made. A pediatric cardiologist massaged Josh’s chest to keep his heart beating until his father could get to the hospital to say ‘goodbye.’

Barron’s brother-in-law Keith, an attorney who often represents physicians and healthcare facilities in malpractice suits, asked him what he wanted to communicate to the hospital. Barron replied, “No. 1, I want you to make sure the pharmacist knows I forgive her. She may very well be the one who kept my son alive the first five days. No. 2, while I thought they owed me something for what they’d done to my family, I was not going to sue them.”

Within a few weeks, Memorial’s administrators and legal representatives asked for a conference to discuss the hospital's response to the event. In the days following the crash, Barron had been told his son was getting better. Now he was getting a very different story. “Your son probably would have died anyway,” he was told. “‘If he lived, he would have been a vegetable. As a vegetable, he couldn’t get an education so he wouldn’t have been able to work. Therefore, his life was basically worth nothing.’ You can imagine as a parent how offensive that was. I told them, ‘If you want to add up his value, you’re going to lose. My son’s smile was worth a million dollars to me.’” Barron was also growing increasingly agitated by references to the ‘sentinel event.’ “I told them, ‘I don’t want you talking about my son like he’s a statistic.’”

The end result was that Barron, who had been adamant in his conviction not to sue and to forgive, found himself telling his brother-in-law to forget it and go after the hospital. Although Keith calmed him, Barron said he walked out of the room and began questioning everything he believed. “For crying out loud, Lord, I work for you, and this is what I get?” he wondered. Eventually, Barron began to work through his anger. “I said if He would help me, and He would give me the strength to do it, I was going to try to bring good from this.”

Six months after the awful meeting, when Barron and his two surviving children plus his sister and brother-in-law had all moved to Nashville, Keith called to say Wayne Marchant and the head attorney for Memorial would like to meet with them. Although Barron dreaded it, he agreed. This meeting couldn’t have been more different in tone from the first one. The small group came to a settlement within 30 minutes and even went to lunch together.

Apologizing in advance, Marchant had one more favor to ask of Barron. “I was wondering if you’d be willing to come talk with us? We’ve never had the face of a victim before,” Barron recalled Marchant saying. “I laughed and said, ‘You think this is your great idea, but God and I already negotiated it.’”

That ‘one time’ talk turned out to be much more. Marchant asked him to speak again at another hospital and then at another. Word spread and Barron began sharing the victim’s perspective with hospital leaders and staff around the country.

“I think hospitals have a lot to learn in how they approach the table,” Barron said. “The minute a medication error happens, I feel like hospitals take an adversarial stance. They put up walls and retreat into the fortress.” While Barron said he understood the instinct given America’s litigious nature, he believes that attitude inflicts even more harm. “By being more open and human, you won’t avoid every lawsuit, but you might save some and have better relations. I also believe we’re not going to change the culture by acting the way the culture expects us to. You change the culture by acting differently.”

One of the things Barron stresses when he talks about patient safety isn’t the quest for humans to never again make a mistake. “Errors are going to happen. The push for me is not perfection. The push for me is that we have enough safety nets in place so that when the error happens, it doesn’t get to the patient.”

He also stresses that even safety conscious hospitals can drop the ball. In 2004, when Josh was killed by a medication error, Memorial was ranked the 12^th safest hospital in America. “The hospital’s reputation was great, but I came to you one time, and you failed me. That’s all that matters to me. Until we all get to zero (errors reaching patients), there is work to be done,” Barron said.

In the years since the accident, Barron founded Ridgeview Community Church in Franklin. Late last month, he resigned his position as pastor to focus full time on his work around patient safety and outreach. In 2007, he remarried and is the father of four in their swirled … a term the children prefer to ‘blended’ … family.

He is quick to tell those he addresses that this is not his story. “It’s Josh’s. This is therapy for me. It lets me know my son’s 17 months counted for something.”

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