Articles Posted in Hospital Errors

According to a report in Modern Healthcare, the University of Colorado Health and its flagship hospital, University of Colorado Hospital, reduced the sepsis mortality rate by 15% in less than one year. In 2016, about 10% of patients with sepsis died from it. At the University of Colorado Hospital, officials conducted an internal study and found that some septic patients did not receive the needed antibiotics quickly enough. According to CMS (Centers for Medicare and Medicaid Services), antibiotics should be given to patients with sepsis within three hours. The University of Colorado Health has found that patients regularly waited three hours or longer to get the needed antibiotic after sepsis was diagnosed.

At the University of Colorado Health, it was proven convincingly that if the patient receives antibiotics within an hour of the sepsis diagnosis, the sepsis death rate dropped by 50%. At the University of Colorado Hospital to reduce this response time, its officials developed a multi-step process that uses patients’ electronic medical records to identify patients who are at risk of sepsis. The electronic health records (EHR) monitors patients’ vital signs and alert a nurse of any abnormalities. The nurse then will check for other signs of sepsis and enter those symptoms into the EHR, which determines whether the patient has a low, medium or high probability of sepsis.

When patients are determined to have a medium or high probability of contracting sepsis, the hospital’s sepsis team, a group of caregivers made up of a nurse, pharmacist and a physician or advanced practitioner, who are dedicated to making quick sepsis diagnoses, are put into place. If the team determines that the patient is septic, antibiotics are immediately ordered and given. The prescription is marked as urgent to make sure that the pharmacist fills the order within the hour.
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Rebecca Gaither was transported by ambulance to West Suburban Hospital in Oak Park, Ill., on Nov. 27, 2012 with complaints of rear lower head pain and vision loss in her right eye. At the emergency room, she complained of a sudden onset of neck pain with an immediate episode of seeing stars in her right eye.

The triage nurse assessed her blood pressure as elevated and assigned her to the next available treatment bed. During examination by an emergency department doctor, Gaither, who was just 47 years old at the time, reported a sudden onset of lost bilateral vision and sharp neck pain while she was reaching for a phone. Following a normal neurological exam, the ER doctor ordered CT scans of the head and neck with and without contrast, for a suspected dissection of the left vertebral artery.

However, Gaither collapsed and became unresponsive before the scans were done. She was immediately transferred from West Suburban Medical to Loyola Medical Center in Maywood, Ill., where a CT angiogram showed a ruptured 1.6-centimeter aneurysm in the right ophthalmic artery, left vertebral artery dissection with arteriovenous fistula and extensive severe fibromuscular dysplasia.
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Russell Kazda, 50, developed a splinter wound in his right pinky finger. A hand specialist, Dr. James Schlenker, performed a surgical procedure to remove the splinter. In doing so, Dr. Schlenker opened Kazda’s palm to examine his tendon. About a week after this procedure, Kazda returned to Dr. Schlenker and was diagnosed as having an infection in that finger, which required debridements and skin grafting. Kazda now has significant disfigurement on his ring and pinky fingers resulting from that infection, which spread to the rest of his hand.

Kazda filed a lawsuit against Dr. Schlenker and his practice in the Circuit Court of Cook County, Ill., maintaining that the doctor chose not to diagnose the infection and correctly prescribe IV antibiotics.

The lawsuit claimed that the infection, pyogenic flexor tenosynovitis, was already present before Dr. Schlenker performed the procedure to remove the splinter. The lawsuit also asserted that the follow-up appointment with Dr. Schlenker should have been scheduled for the day after the surgery, which would have prevented the infection from spreading to the rest of Kazda’s hand.
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The Illinois Appellate Court for the 2nd District issued a Supreme Court Rule 23 Order in July 2017 that affirmed the jury’s finding in favor of Advocate Condell Medical Center in a medical malpractice death case. The court delivered its opinion on Oct. 4, 2017.

In this case, the appeals panel found issue with neither the trial judge’s admission of expert testimony nor a hospital lawyer’s ex parte conversation with a witness. The opinion echoes and makes legal precedent of the finding of a Supreme Court Rule 23 Order that the appeals court issued in July 2017.

Judith Caldwell, the daughter of Jeanette M. DeLuca, filed a medical malpractice lawsuit in March 2014 in Lake County, Ill., concerning the wrongful death of her 92-year-old mother who choked on food and died while receiving medical care from Advocate Condell Medical Center in Libertyville, Ill. Caldwell claimed in her lawsuit that Condell chose not to adequately monitor DeLuca after her procedure on April 23, 2013 and allowed her to eat without ensuring that her dentures were in her mouth and failed to ensure that she was sufficiently recovered from surgery to eat.
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Emilee Williams, a 21-year-old student, consulted an internist at Mercy Clinic Springfield Communities when she experienced tremors, balance and concentration problems, insomnia and panic attacks. She was diagnosed as having fatigue and depression and was prescribed medication.

Almost five months later, she returned to the clinic in a deteriorated condition and was re-diagnosed with simple anxiety.
The next month, when her symptoms worsened, Williams underwent an MRI that showed severe brain damage resulting from Wilson’s disease, a rare genetic inherited disorder in which excessive amounts of copper accumulate in the body, particularly in the liver, brain and eyes. Despite treatment, she still suffers from the effects of her brain injury, which affects her speaking and ability to walk among other deficits.

Williams sued Mercy Clinic Springfield alleging vicarious liability for the physician’s choosing not to timely diagnose Wilson’s disease and including her neurological condition on her differential diagnosis.
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Virginia Moraites, a 77-year-old retiree, underwent a total left knee replacement at Vista Medical Center East in Waukegan, Ill., on Oct. 13, 2009. The inpatient procedure was done by the defendant orthopedic surgeon, Dr. Gerard Goshgarian. On the morning after the surgery, Oct. 14, 2009, a nurse found that Moraites was unable to move her left foot. The foot felt cold and there were no detectable pulses in her foot.

The hospital’s nurse immediately called both Moraites’ internist and Dr. Goshgarian to report these findings. The internist responded first and ordered a STAT left leg arterial Doppler study as well as a vascular surgery consultation.

Vascular surgeon Dr. David Onsager sent his physician’s assistant to examine Moraites and also ordered ultrasound testing of the blood flow in her feet. Dr. Goshgarian came to bedside to examine Moraites, but he did not issue any additional orders and left to perform surgery on a different patient.
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Dawn Arrigoni, 35, went to the emergency room at Woodwinds Hospital complaining of vomiting, fever and abdominal pain. The nurses there attempted to place a peripheral IV but had trouble placing it.

A nurse practitioner then placed an intraosseous (IO) line. An intraosseous infusion line is used in the process of injecting directly into the marrow of the bone to provide a non-collapsible entry point into the systemic venous system of a patient. This method is often used to provide fluids and medication when an IV is not practicable as in this case. The IO line is considered an efficient method to provide intravenous fluids or medication.

Shortly after the IO line was put in place, Arrigoni complained of significant pain for which she was given the pain reliever Dilaudid. Over an hour and a half later, a nurse noted swelling in her lower left leg, which appeared to be pale in color. She continued to complain to the hospital staff of leg pain.
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James Woodard was 64 years old and underwent the first of a two-part elective back surgery at the University of New Mexico Hospital. While Woodard was hospitalized, he was unknowingly exposed to MRSA, an infectious process that is hard to eradicate and usually contracted in hospitals.

One month after the first surgical procedure, Woodard underwent pre-operative procedures at the same hospital in anticipation of the second portion of his back surgery. After his second surgery, a nasal swab was positive for MRSA. Blood cultures returned two weeks later confirmed this finding. Woodard developed spinal osteomyelitis, a bone infection, and had numerous treatments, including surgeries, antibiotics and debridement to try remove the infection. Woodard required 135 days of hospital care and treatment at a rehabilitation facility.

He still requires medical care and now requires a wheelchair because of his condition. Woodard had been a city employee who planned to retire in just a few years.
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Mark Brown was a 39-year-old high school wrestling coach who began experiencing dizziness, neck pain, blurred vision and nausea while at a wrestling practice. He went to a local hospital, and paramedics transferred him to Banner Good Samaritan Medical Center where he was given a CT scan without contrast as part of a stroke workup.

The next day, Brown was discharged with a diagnosis of benign positional vertigo.

On the way home from the hospital, he suffered a massive stroke that caused severe brain damage. As a result, he lost vision and experienced difficulties with walking and speaking, among other problems. Brown now requires 24-hour-a-day care.
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Antonio Marrero, 32, was seen at the Walanae Coast Comprehensive Center, which is a federally qualified health center. He went to the facility complaining of a sore throat.

Marrero was diagnosed with having a peritonsillar abscess, which required evaluation by an otolaryngologist. A health center physician decided to evaluate Marrero under sedation and subsequently administered the drug Etomidate. Etomidate is a short-acting intravenous drug used in general anesthesia and for sedation of patients for short procedures.

In this case when Etomidate was given, Marrero lost consciousness and died. The cause of death was determined to be oxygen deprivation resulting in anoxia.
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