Articles Posted in Hospital Errors

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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This case involved a medical malpractice action for a lost chance. The parties jointly sought direct discretionary review under Washington law, RAP 2.3(b)(4), challenging two pretrial rulings:

(1) whether a court should use a “but for” or “substantial factor” standard of causation in loss of chance cases; and (2) whether evidence relating to a contributory negligence defense should be excluded based on the plaintiff’s failure to follow his doctor’s instructions.

The trial court decided that the “but for” standard applies and the contributory negligence defense was not appropriate in this case. “Traditional tort causation principles guide a loss of chance case.” Applying those established principles, under the circumstances here, the Supreme Court concluded a “but for” cause analysis was appropriate and affirmed the trial court’s ruling on that issue. The court reversed the trial court’s partial summary judgment dismissing the contributory negligence defense. The case was remanded for further proceedings.
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Melissa Bain, in her capacity as the personal representative of the estate of her deceased husband Christopher Heath (“Heath”), appealed the grant of summary judgment in favor of Colbert County Northwest Alabama Health Care Authority d/b/a Helen Keller Hospital (“HKH”). Dr. Preston Wigfall was the emergency room physician working at the hospital on the night Heath was taken to the emergency room.

This matter began because Heath complained he had a lump in his throat that would not go away. When the pain became unbearable, he was taken to the hospital’s emergency room. In his history was the fact that his father had died of an aneurysm at the age of 47 and that he also had hypertension. He was on high blood pressure medication.

In the ER there was no evidence that the nurses on duty bothered to review his medical history with him. Dr. Wigfall, who was the emergency room physician on duty that night, did not remember if he took Heath’s medical history. Nothing was recorded in that respect.
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In an important constitutional issue in this medical negligence and medical records case, the dispute was whether patients in the state of Florida have the right to access records under the Florida Constitution and its Amendment 7, specifically records relating to “adverse medical incidents.” These records are considered privileged and confidential under the Federal Patient Safety and Quality Improvement Act (“the Federal Act”) such that the Florida law was preempted by this federal law.

In the appeal of this case, it was concluded that adverse medical incident reports requested by patients pursuant to the Florida Amendment 7 to its constitution was not preempted by the Federal Act. The lower court in Florida held that the Federal Act did preclude access to medical records in the state of Florida, but the Florida Supreme Court reversed, holding that the Federal Act was never intended as a shield for the production of documents required by Amendment 7 and other provisions of Florida law. The court also stated that provisions of Florida law are not preempted by the Federal Act, which set up a voluntary system for hospitals to improve patient’s safety.

In this case, Southern Baptist Hospital of Florida cannot shield documents and medical records not privileged under state law or the state constitution by virtue of its unilateral decision of where to place the documents under the voluntary reporting system created by the Florida Act.
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On Oct. 30, 2009, J.S. (DOB: 5/7/09) suffered a bilateral tension pneumothorax at the defendant hospital, which resulted in a cardiopulmonary arrest for 23 minutes. A bilateral tension pneumothorax is a medical emergency, and it requires immediate treatment. This 6-month-old child was a post-cardiac surgical patient who suffered from chronic lung disease and was ventilator dependent. He was at an elevated risk of suffering from pneumothoraxes.

He also was born prematurely and was diagnosed with Down Syndrome. It was anticipated before this event that J.S. would have been discharged the next day.

By 9:30 p.m. that night, J.S.’s treating physicians should have entertained a differential diagnosis that included pneumothorax (collapsed lung) based upon J.S.’s clinical presentation (ashen colored, diminished and labored breathing), as well as pH of 7.15. The standard of care was a stat chest x-ray at bedside.
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Kristine Haveman, 38, collapsed at home and was brought to a nearby hospital in an unresponsive condition. The emergency room personnel examined her and ordered a CT scan. Doctors interpreted the scans as normal. That evening a neurologist diagnosed a thrombus in the left cerebral artery, which necessitated thrombolytic therapy.

Because of the delay in diagnosis and treatment, she suffered cognitive deficits resulting in problems with speech and word retrieval. She also has experienced fatigue and right-sided weakness. She had been a teacher who planned to return to work but is now unable to do so.

Haven filed a lawsuit against Dr. Kenneth Dirk, an emergency room physician and his employer, Oregon Emergency Physicians, claiming that these defendants’ negligence was the cause of an eight-hour delay in administering thrombolytic medication.The lawsuit claimed that the CT scan had been misinterpreted and that Haveman was wrongfully treated with Ativan for anxiety and emotional problems before the neurologist’s stroke diagnosis.
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Deborah Larkin, 42, underwent laparoscopic surgery. Over the next two days she complained of severe pain even with the use of medication. Larkin also developed tachycardia, low sodium levels, hypotension and an abnormally high white blood cell count.

A kidney physician, a nephrologist, diagnosed sepsis prompting the surgeon to order a swallow study which did not show any internal leakage. However, the laboratory results did show decreased CO2 and increased lactate levels.

Larkin’s conditioned worsened. She was transferred to intensive care the next day in respiratory distress with kidney failure. The surgeon performed exploratory surgery, which revealed that a 4-millimeter gastric leak was the cause of Larkin’s septic shock.
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When Chelsea Weekley was about five months old, she suffered a skull fracture. The fracture expanded over time and a cyst was formed on her skull. At age 17, Chelsea was hit on the head and suffered a loss of consciousness, blurred vision and dizziness.

After CT and MRI scans confirmed the extent of the skull fracture and cyst, Chelsea underwent a canaloplasty surgery to repair the fracture and the area where the cyst had formed. The surgery was done at Cardinal Glennon Children’s Hospital in St. Louis by the defendant Dr. Ann Flannery, a neurosurgeon, and by Dr. Raghuram Sampath, a neurosurgical resident.

Chelsea was discharged a day after the surgery and was found dead in her bed just three days later. An autopsy was completed, which found that Chelsea had died from a seizure brought about by the surgical damage.
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Robert Firkins was 67 and suffered from chronic renal disease and cardiac issues. Before having orthopedic surgery, he underwent an angiogram done by an interventional cardiologist, the defendant, Dr. Scott Harris. Dr. Harris, who had been instructed by Firkins’ treating nephrologist to use a minimum amount of contrast dye, used 160 milliliters of dye during the angiogram, which lasted 94 minutes.

After the procedure, Firkins developed atheroemboli, resulting in ischemia in his right lower leg, significantly increased creatinine levels and worsening kidney disease that now has necessitated dialysis three times each week. In addition, Firkins required a below-the-knee amputation a month after the angiogram.

Firkins and his wife sued Dr. Harris, claiming that he used an excessive amount of contrast dye and negligently performed the angiogram. The Firkins family claimed that the defendant doctor should have kept the dye under 100 milliliters and finish the procedure within 35 minutes. The lawsuit did not claim lost income.
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