Medical malpractice cases are a superb learning opportunity for physicians, but rarely does that happen. Settlements are usually confidential and verdicts are shared mostly amongst attorneys. The goal of this publication is to change that, so all doctors have an opportunity to learn from these unfortunate and stressful events and improve patient safety.
Every 2-4 weeks we quickly distill a few med mal cases into a key teaching point or "Takeaway." Nothing fancy. Occasionally unconventional. Maybe even humorous. But always readable in about 3 minutes - on whatever device you prefer.
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Charles A. Pilcher MD Editor Medical Malpractice Insights
The 5 R's: Right Patient, Right Route, Right Time, Right Dose
4 for 5 not enough: Wrong DRUG kills patient
Facts: A 65 yo woman post-op recent brain surgery for a benign tumor arrives in the ED and requires anti-seizure medication. Fosphenytoin is ordered, but rocuronium is given. Patient experiences cardio-respiratory arrest, irreversible brain damage, and dies 2 days later. Hospital acknowledges the error to patient's family and apologizes. Investigation reveals that the correct medication was prescribed by the physician, properly entered into the hospital’s EHR, and received by the pharmacy, where a pharmacy worker inadvertently filled the bag with the wrong drug and a second pharmacy worker failed to detect the error.
Plaintiff: We're angry. How could this happen? We appreciate the apology.
Defense: We've never had anything like this happen before. It's our mistake.
Result: Hospital procedures are under review. Three staff members are placed on administrative leave and are receiving counseling. No lawsuit yet filed.
Takeaway: The "5 R's" are all important: right patient, drug, dose, route and time. Check them. Every time. In the pharmacy and at the bedside. An explanation and an apology are protected (effective July 2014) in Oregon, but are the right thing to do in any such situation. What if YOUR loved one were the victim?
Source: News media/public domain: McPherson v. St. Charles Hospital, Bend, OR.
Take a history. Do an exam. Don't rely on "incidentaloma"
Spinal epidural abscess, Part 2
John Doe v Anonymous - Washington (Part 1 appeared in the previous issue. The "Takeaway" in that case was that awareness, appropriate testing, and good documentation led to a defense verdict.) Facts: A 44 year old previously healthy man develops severe mid-back pain while at work. He presents to the ED, is treated symptomatically and released. Two days later he returns with pain in his "low back." Again he is symptomatically treated and released. In a matter of hours, he returns a third time, now using a cane to walk. A lumbar-only MRI is done and shows foraminal narrowing. Assuming this explains his [non-radicular] symptoms, he is again discharged and returns a fourth time the next day, now with L leg weakness and urinary retention. He is admitted and a neurosurgeon finds that no surgical emergency exists, ascribing the urinary retention to the patient's opioid pain med. On the third hospital day he is found paralyzed below the waist. A full-spine MRI reveals a large thoracic spinal epidural abscess. Despite surgical drainage, he is left with a neurogenic bladder/bowel and right leg weakness. The source of the infection is felt to be dental work done 2 months prior.
Plaintiff: You missed my diagnosis. The MRI was inadequate. A foraminal narrowing would not explain my symptoms. Surgery should have been done earlier.
Defense: Your symptoms were not classic. You looked well and had no fever. Earlier surgery wouldn't have changed the outcome.
Result: Mediation with confidential settlement.
Takeaway: Despite defense claims, this IS a typical presentation of a spinal epidural abscess. The classic triad of fever, spinal pain,and neurologic findings occurs in only about 10% of cases, at which point, even as noted by the defense, it is too late to matter. SEA is the subject of far too many lawsuits. Multiple visits for back pain in a previously healthy person should trigger suspicion, which should trigger a CRP/ESR and an MRI of the entire spine, especially in the presence of bowel or bladder symptoms. More from eMedicine ->
DANGER: "Stroke mimic" ahead
Assure stroke is ruled out when neuro sx are present
Facts: A 36 y.o. male with diabetes and hypertension comes to the ED for dizziness and poor speech lasting only 3 minutes. Despite no prior episode, he is diagnosed with hypoglycemia and released. He returns 2 days later with poor balance, dizziness, and slurred speech, which has resolved. CT is negative, he is again told he is hypoglycemic and is discharged. He returns that night with persistent left arm and leg paralysis. Repeat CT is again negative. He is admitted to a neurologist, who claims he was not told by the ED doc of the patient's paralysis. An MRI the next day shows no infarct, as read by the neurologist. The patient gets worse. He is transferred to another hospital, which notes a medullary infarct on the MRI at the first hospital. Patient is now quadriplegic.
Plaintiff: I gave you 2 chances to recognize my TIA. You didn't. On my third visit I had a stroke. The neurologist didn't see me, failed to recognize my stroke, and mis-read the MRI. I should have gotten tPA, but by the time someone figured it out, it was too late.
Defense: 1) ED: Hypoglycemia was a reasonable diagnosis. We're not negilgent. 2) Neurologist: I'm not required to immediately evaluate every patient. The MRI looked OK to me.
Result: Settlement for $10 million, of which $8 million was against the neurologist and hospital.
Takeaway: Be careful when diagnosing a "stroke mimic," especially in young people. When you're wrong, a lawsuit for “failure to give tPA” may follow (even though the merits of tPA continue to be debated.) Young people + bad outcomes = big awards. Most tPA lawsuits are for "failure to diagnose" and "loss of opportunity," not for complications of giving the drug. And a negative CT scan does not R/O a TIA or early stroke.
Source: News media/public domain: Backus v. Khan et al. – Illinois
I agreed to a colono-SCOPY, not a colono-STOMY!
Informed consent means informed consent
Anonymous v. Anonymous, New York Facts: A patient undergoes a colonoscopy for lower GI bleeding. During the procedure the bowel is torn. A general surgeon is called and a partial bowel resection and colostomy are performed. The patient recovers reasonably well, does some internet research, calls a plaintiff attorney and asks "Do I have a malpractice case?"
Plaintiff: I had a simple colonoscopy and now I'm pooping into a bag. This is no fun. You didn't warn me that this could happen.
Defense: You signed a consent to the procedure. It listed all sorts of risks, including this one. You were supposed to read it, not just sign it.
Result: No lawsuit filed. Attorney advised plaintiff that this would be a battle of "he said, she said," and that plaintiff would be unlikely to prevail.
Takeaway: It's called "informed consent" for a reason. Explaining the major risks, benefits and alternatives to patients before a procedure and assuring that the patient understands them is your most effective tool to prevent a malpractice claim.
Check out the archives of other issues of Medical Malpractice Insights on the archives page.
It's more likely that a common disease will appear in an uncommon fashion than that an uncommon disease will appear in a common fashion.
Greg Henry MD FACEP
Plaintiff attorneys are only exposing our medical culture for what it is - overly reliant on fallible humans. Aviation has learned that the best approach to plaintiff lawyers is to starve them. Redesign our processes and change our culture so these mistakes don’t happen.
John Brookman, retired airline pilot and safety officer
