September 7 - the return to full program

Following the September 7, 1994, Wiseman Committee meeting, the members of the pediatric cardiac surgery team prepared to return to a fully operational program. Some team members still harboured significant concerns about the program's ability to provide appropriate care for patients with heart defects of high complexity. As was the case before the original slowdown of May 17, that concern rested almost exclusively with the nurses and the anaesthetists.

Although the program had been through a hiatus in providing care for patients with complex anomalies, it was obvious that little had been learned from the experience of earlier in the year; once again, little time was spent in preparation for the return to high-risk operations.

While a number of significant issues had been identified during the committee process, none of the procedures that had been in place before May 17 were altered when the program returned to full operation in September. Case selection and preparation had been raised as a significant issue at the committee. Despite this, there was no recommendation for any additional or improved pre-operative meetings that would involve pediatric cardiac surgery team members other than the cardiologist and the surgeon.

Communication had clearly been flagged as a serious issue; yet nothing was put into place to address issues of communication on an ongoing basis. No debriefing sessions were held after difficult cases, a small step that would have gone a long way to addressing any concerns that arose intra-operatively.

The concerns expressed by the PICU and NICU staff, about procedures being performed in their units for which they were ill-prepared, had not been addressed. Preparation of the cardiac bins-which had begun as early as April-had not been completed.

The Wiseman Committee's interim report would have left the department heads, to whom it was sent, with the impression that all matters of concern had been addressed and resolved during meetings of the committee. Unfortunately, this was a false impression.