Articles Posted in Hospital Errors

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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The Maryland State Appellate Court has ruled that the trial judge was correct in deciding whether a patient’s negligence lawsuit, that of Yolanda Harris, would go forward against a women’s health clinic even after she dropped claims against her doctor, the agent to the clinic.

The Maryland Court of Specials Appeals said that Harris did not forfeit her right to a lawsuit against Women First OB/GYN Associates LLC when she voluntarily dropped all claims against the clinic’s physician, Dr. McMillan who was alleged to have committed malpractice in a hysterectomy procedure for Ms. Harris.

It was ruled that the judgment against Women First could stand even though the clinic’s negligence was based entirely on Dr. McMillan’s acts or omissions. The legal issue on appeal was whether the principal, Women First, could be held liable for the acts of its agent, Dr. McMillan, who had already been voluntarily dismissed.
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This case arrived at the Illinois Appellate Court as an interlocutory appeal that came about from the plaintiff Eric Owens’s lawsuit against the defendant hospital, Louis A. Weiss Memorial Hospital, and its doctors related to the care received by Owens at the hospital’s emergency room in 2011. He initially named Dr. Ahmed Raziuddin as a defendant in the lawsuit as the physician who treated him in the emergency room based on Dr. Raziuddin’s name appearing in the hospital’s records as the treating physician.

However, it turns out that Dr. Raziuddin filed a motion to dismiss the lawsuit claiming that he was not the doctor treating Owens and that a Dr. Seema Elahi was actually the treating physician. That motion was granted.

Owens then amended his complaint adding Dr. Elahi as a party defendant replacing Dr. Raziuddin. Dr. Elahi then filed a motion to dismiss arguing that the statute of limitations had expired.

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Jenny Copsey, on behalf of her late husband, Lance Copsey, filed a lawsuit against a radiologist, Dr. John Park, claiming that he chose not to properly analyze radiological images, which purportedly contributed to the her late husband’s fatal stroke.

The state’s court of appeals said that the evidence of negligence by Copsey’s other physicians who previously settled out of the case was properly admitted by the trial court because it was essential to provide Dr. Park with a fair trial.

The decision stated: “Evidence of nonparty negligence was relevant and necessary in providing Dr. Park a fair trial as it tended to show he was not negligence; thus, the alleged prejudice did not outweigh its probative value.”
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After the death of 2-year-old Miranda Eid, Miranda’s parents, Mohammed and Lisa Eid, filed a lawsuit against Loyola University Medical Center alleging negligent medical treatment following her pacemaker replacement surgery.

Lisa Eid also sought damages for reckless infliction of emotional distress based on Loyola’s nurses leaving medical tubing in place when Miranda’s body was released for burial. The Cook County jury returned a verdict in favor of Loyola; the Eids appealed.

On appeal, the Eid family argued that (1) the jury’s verdict in favor of Loyola on the claims of medical negligence and reckless infliction of emotional distress was against the manifest way of the evidence; (2) the circuit court erroneously upheld Loyola’s claim of privilege under section 8-2101 of the Illinois Code of Civil Procedure (known as the Medical Studies Act) (735 ILCS 5/8-2101 et seq. (West 2012)) for information that was generated for the use of Loyola’s peer review committee when a designee of Miranda’s treatment and instructed another member of the committee to assemble information concerning the incident; (3) the circuit court improperly instructed the jury on the law concerning the claim of reckless infliction of emotional distress; and (4) defense counsel’s alleged improper remark during closing argument confused the jury, and the additional instructions the circuit court gave the jury did not correct the alleged confusion.
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Alice Mays was 54 when she entered the emergency room at Sinai-Grace Hospital. She was complaining of nausea and vomiting over a four-day period. After the emergency department medical providers tested her, it was revealed that she had a bowel obstruction. The emergency department staff then gave her saline and later brought her to surgery. The 5-hour operation performed by the surgeon, Dr. Jill Watras, involved removal of part of her large bowel.

She showed continuously low urine output, which prompted Dr. Watras to order aggressive hydration after the surgery.

For the next two days, Mays received a total of 30,000 mL of fluids. Nonetheless, she had little or no urine output. She eventually suffered respiratory depression, abdominal compartment syndrome and organ failure. She was returned to surgery but suffered cardiac arrest and brain damage. Mays died two months later. She was a graphic artist and is survived by her siblings.
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“Leaders must commit to creating and maintaining a culture of safety.” National Patient Safety Foundation. Free From Harm: Accelerating patient safety improvement for 15 years after To Err is Human.  2015 (accessed Dec. 8, 2016). This is just a part of the Sentinel Event Alert publication of The Joint Commission Issue 57, March 1, 2017.

The core of the publication is that leadership in hospitals and medicine generally have a priority to be “accountable for effective care while protecting the safety of patients, employees, and visitors. Competent and thoughtful leaders contribute to improvements in safety and organizational culture.”

This alert acknowledges that hospitals, doctors, nurses and health care professionals must do a better job of protecting their patients from harm. The article states that “The Joint Commission’s Sentinel Event Database reveals that leadership’s failure to create an effective safety culture is a contributing factor to many types of adverse events-from wrong site surgery to delays in treatment.” Smetzer, J, et al. Shaping systems for better behavioral choices: lessons learned from a fatal medication error. Joint Commission Journal on Quality and Patient Safety. 2010; 36: 152-164.
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