Medmal Insider: Recent Episodes
CRICO
For more than 20 years, CRICO has analyzed claims and suits from the Harvard medical community to understand causes of error. We have learned that 67% of claims fall into four high risk areas: Diagnosis, Obstetrics, Surgery and Medication.
A delay in following a patient’s right kidney mass was complicated by the patient’s refusal of a CT scan and the providers’ incomplete and conflicting documentation of patient education and testing recommendations.
Expert review concluded that a more aggressive response to non-reassuring fetal heart rate tracings, such as a conversion to cesarean delivery, would have been appropriate. Coupled with a delay in the diagnosis and treatment of chorioamnionitis, the case was settled in the high range.
A patient died following a medication mixup in an understaffed medical ICU. A large settlement was reached on behalf of the RN who administered the wrong dose of the wrong medicine.
A cholecystectomy patient alleged that mishandling of her post-operative calls to the surgical practice and lack of follow-up caused her post-operative complications. Like many cases, how the surgical practice communicated with the patient after a complication occurred was a key aspect.
Parents alleged that a delayed diagnosis of a foreign body in their child’s nose caused preventable nosebleeds, nasal infection, nasal septal perforation, and the need for surgery. The malpractice claim named the pediatric group, two pediatricians, and a pediatric nurse practitioner, and was settled in the low range.
A patient sued her hand surgeon, claiming the surgical approach increased the chance that their finger wouldn’t fully heal from a prior fracture. The defense leaned on contemporaneous clinical notes and documentation of the consent process to achieve a defense verdict.
A 68-year-old male was admitted to the hospital after falling on ice and feeling short of breath. Two days after discharge, the patient arrived by ambulance at another hospital in septic shock. The patient filed a claim against the hospital, alleging that the failure to communicate a critical lab result required readmission and several weeks of follow-up treatment.
A 30-year-old woman experiencing her first pregnancy, presented to the Labor and Delivery unit. She was given the wrong drug and required an emergent C-section. The "five rights" of medication administration focuses on individual factors and not necessarily on system flaws. Many organizations are also promoting just culture, which encourages reporting near-misses and patient safety events, and focuses on psychological safety and promoting a non-punitive reporting culture.
A patient was imaged for abdominal pain, but the radiologist saw and reported an incidental finding of a nodule on the lower lung that was not pursued or revealed to the patient for 2 years. The cancer had metastasized, and the patient died from lung cancer 18 months later.
The patient’s family alleged that improper management of the patient under anesthesia resulted in cardiorespiratory arrest, permanent brain damage, and a persistent vegetative state. While the cause of the patient’s cardiac arrest is uncertain, the CRNA failed to note which medications and doses were administered during the procedure, and the case was settled for more than $1 million.
When hospitals and medical practices face charges of discrimination from employees, the consequences can include litigation, large payments, morale problems, and less quality care for the patients they serve. How an employer responds can make all the difference in outcomes. Based on closed claims in the Harvard medical system, two cases illustrate that point. We interview Megan Kures, of Hamel, Marcin, Dunn, Reardon and Shea, who offers some principles to follow.
Boston Attorney Megan Kures explains how a hospital should respond to a request for accommodation. Tip: it shouldn't be a knee-jerk no, and be sure to involve HR from the start.
Boston Attorney Megan Kures explains how a hospital should respond to a request for accommodation. Tip: it shouldn't be a knee-jerk no, and be sure to involve HR from the start.
After a state medical error disclosure and apology law went into effect in November 2012, health providers in Massachusetts have protections and rules to follow.
An otherwise healthy 50-year-old woman presented to the Emergency Department with atypical chest pain. Discharge and death the next morning followed.
The patient needed to be evaluated by a stroke team and a neurologist promptly to decide whether any treatment was indicated or possible. Triage should be the same whether the ER was empty or overcapacity.
The goal was to treat uncontrolled pain from tumors but the patient was left with unexpected hearing loss. The patient sued when she claimed the surgeon changed the side of the operation without consulting her. For ideas that might help prevent these negative outcomes, we talk with Douglas Smink, MD, MPH, an associate medical director for CRICO and the Chief of Surgery at Brigham and Women's Faulkner Hospital.
This OB patient's risk factors were not adequately considered, and the team's failure to follow protocols and secure back-up contributed to a lawsuit and a settlement of over $1 million.
Lessons in preventing tragic patient misunderstandings and multi-year legal entanglements.
In a lawsuit naming four physicians, the patient’s estate alleged negligent failure to restart anticoagulation after surgery, resulting in a stroke and ultimately, her death.
A young patient with multiple visits for the same complaints needed an accurate diagnosis sooner to survive.
The patient sued his oncologist and the hospital, claiming they mismanaged his post-op recover when a stent was left behind for a year, leading to complications that required additional surgery.
A pediatric practice struggled to satisfy the family of a boy after two years of appropriate primary care. What did they learn about communicating with patients and their families over routine medical matters?
OB case: communication between the primary provider and a phone consultant needed more clarity and changes in the patient's status needed a stronger response.
Medical malpractice cases are often lost when a defendant clinician does badly at trial or during the deposition.
Failure to supervise and confirm orders led to a preventable death and a search for system-level changes to how NPOs are communicated.
When a patient returns over and over again with the same symptom complex, the providers really need to start to think, "am I missing something?"
Fixated on flu symptoms, the nurse missed available information that indicated the patient should have been brought to urgent care to prevent an unnecessary tragedy.
A Psychiatric patient kills self with opioid prescribed by an internist for restless leg syndrome.
An 8-year-old girl experienced a tenfold dosing error of clotting factor, requiring admission and observation due to increased risk of stroke.
A fuller history or a record check might have helped this physician add MI to the differential diagnosis.
Fetal bradycardia forced an emergency C-section, but the family claimed the care team should have been more prepared.
Case: Multiple providers and the patient delayed a diagnosis of obstruction, resulting in lost kidney function
Case Study: Response to spine surgery complication injured the patient and relationships.
Despite multiple visits to her PCP, a 30-year-old woman without a spleen was never given prophylactic antibiotics or told the risks of a high fever.
Even though the patient identified a lump on her breast, it took more than a year to diagnose cancer. Family history-taking and proper imaging were lacking. CRICO interviews one of the authors of a Harvard breast care management algorithm, Michelle Specht, MD, to consider how following such a guideline could have helped the gynecologist and radiologist--and ultimately the patient.
As in many missed MI cases, the primary care physician did not order an EKG. Thomas Sequist, MD, of Atrius Health, describes where some of these cases typically go wrong, and how using a Framingham Risk Score can help with the evaluation process in the office practice.
A young woman presented to Labor and Delivery at 39.6 weeks with ruptured membranes and irregular contractions; a vaginal delivery was complicated by shoulder dystocia after prolonged induction of labor, resulting in a baby with low Apgars, respiratory distress, neonatal seizures, and permanent cognitive and developmental deficits. A lack of close collaboration between the nurse midwife and the covering obstetrician was blamed for a slow response to worrisome fetal heart rate tracings.
Medication error in the ER was preventable. Culture and communication problems compounded an error that required several surgeries and amputation.
Fragmented primary care in a large group practice that only treated the patient's acute problems before his death, missed several opportunities at better control of cardiac risk factors.
A top surgeon mistakenly performed carpal tunnel instead of trigger release procedure after multiple interruptions and personnel shift changes in OR.
Nation's "first malpractice crisis" resulted in 1821, after a horse fell on a man and the surgeon waited a month to visit his patient to see if his attempted hip reduction worked.
Lack of collaboration and poor documentation among the factors in large settlement with severely compromised infant.
The surgeon orchestrated a great recovery from a massive bleed that resulted in blindness, but the patient sued for answers.
The patient was under 50 and lack of communication between the PCP and GI about a sigmoidoscopy order contributed to a diagnostic failure.
Armed with its own malpractice data, a large group practice builds on an existing electronic record system to ensure that when its doctors order a referral, the referral actually takes place. (Audio file updated 03/22/2012)
The patient and his wife felt that the surgeon was not forthcoming with an explanation of what happened and seemed indifferent to the impact on his patient, following conversion to an open procedure and large blood loss.
A patient safety audience hears about how outside industry might fix a process breakdown before or after a wrong drug error.
A five-month-old girl was referred to the emergency department for evaluation of intermittent fevers and lethargy.
A documented discussion of risks and benefits of PSA testing may have prevented allegation of malpractice.
Protocols might have helped move conflict up chain of command, and improved monitoring.
Communication and documentation flaws compromised a case that featured allegations of poor assessment and monitoring both pre-op and post-op.
Systems could have helped one doctor to consider colon cancer screening, and another doctor to follow up on a referral.
A female patient wasn't screened for colon cancer, despite routine involvement with three physicians.
Postoperative decline required communication to bring the attending's wisdom to the bedside.
Despite several evaluations in the ED and PCP office, the cause of pulmonary symptoms eluded providers, led to unnecessary surgery, fear of cancer--and a mid-range settlement.
A case where a sign-out checklist or documentation of an order may have prevented the patient's poor outcome.
In this case, the liability was clear, and the institution and its malpractice insurer worked closely with the plaintiff, to reach a relatively speedy resolution for the patient.
Even though the cause of a brain hemorrhage was difficult to prove, the case was settled because management of the second twin's delivery was so difficult to defend.
A young patient didn't know about blindness risk before 12-hour, two-stage broken back surgery.
In this case, quicker identification of a compromised fetus required more precise EFM discussion, and a strategy for repeat examinations.
In this case, the patient presentation was 'atypical,' and the language and cultural divide between the providers and the family contributed to clinical issues not being resolved before discharge.
A lesion noted in a radiologist report was not followed before the patient died from metastatic lung cancer. In this case, communication miscues among an ordering physician specialist, the imaging specialist, and the PCP let the patient and the physicians down.
In this case, the patient and physician start out very optimistic, and experience increasing frustration with a problem the doctor is unable to solve. The question of when and how to seek a consult or refer the patient out, becomes a pivotal issue.
In this case, the facts suggest that a serious adverse outcome might be prevented by preparing for the worst, rather than expecting everything will go well.
Conference attendees were quickly engaged in analyzing a malpractice case, based on closed claims from the Harvard medical system. They were asked to identify system flaws and suggest changes in how care is organized to prevent future cases.
In this case the patient expected her providers to work together as a team during a scheduled routine procedure. And after experiencing a serious medical error, she would need her physicians to know what to say to her.
Although this case involves a pediatric patient, the patient safety themes regarding problems with diagnosis and communication cut across many specialties and patient populations.