MedMal Insider

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.

After an employee alleges age discrimination, conversations with their supervisor could be perceived as retaliation. An attorney at CRICO describes the pitfalls in these discrimination and retaliation cases and how to avoid some of them.

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.

One thing that seemed to be missing in this particular evaluation was a formal differential diagnosis that may have been present in the physician’s brain, but wasn’t documented, and there’s no evidence that it was really thought about.

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.

An otherwise healthy 50-year-old woman presented to the Emergency Department with atypical chest pain. Discharge the next morning was followed by death.

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.

In a lawsuit naming the Emergency Medicine physician and a nurse, the patient alleged that a dressing was applied too tightly, compromising the circulation and resulting in a gangrenous foot, requiring amputation. Despite an eventual defense verdict, some lessons show how to prevent this bad clinical result and a five-year legal ordeal.

How a clinician is coping with the impact of being sued can be a significant factor in how effective he or she is as a defendant. But getting clinicians to accept help is often a challenge.

Restarting heparin was not in the post-op instructions. In a lawsuit naming four physicians, the patient's estate alleged negligent failure to restart anticoagulation, resulting in a stroke and ultimately, her death. The case was settled for more than a million.

Despite multiple visits to her PCP with similar complaints over years, this young patient did not get a timely diagnosis of colon cancer and died. Dr. Carla Ford looks at the testing, communication among providers, and some diagnostic insights for the next patient.

A fatal PE misdiagnosis may have gone wrong from the very beginning. With analysis based on closed claims in the Harvard medical system, urgent care specialist Jonathan Einbinder explores ways an ordinary case with a tragic outcome might be prevented in the future.

The patient sued his oncologist and the hospital, claiming they mismanaged his post-op recovery when a stent was left behind for a year, leading to complications that required additional surgery.

In this case, 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?

In this case, communication between the primary provider and a phone consultant needed more clarity. Changes in the patient’s status needed a stronger response if a tragic outcome had any chance of being averted.

In this closed Harvard malpractice case, a patient fell during a radiology study because her risk status wasn’t communicated from the unit effectively. Hospitalist Adam Schaffer, MD, MPH, analyzes what went wrong and suggests some effective practices to prevent severe injury in places you don’t expect, with eyes on the patient.

In this case, a 75-year-old female was admitted to the ICU with respiratory failure. A misplaced feeding tube led to her death. ICU intensivist Dr. Laura Myers discusses lessons from this case about supervision and assessing a provider's competence with a new procedure.

The defendant’s role in a successful defense against a claim of malpractice is critical, but it isn’t easy. Clinician have to be able to follow advice from lawyers, cope with their own emotions, which often include anger or fear, and project competence and likability to potential jurors. These things—none of which are taught in medical school—can be a challenge to a medical professional. Sometimes malpractice cases have to be settled because the defendant clinician cannot adapt to the legal system.

In any complex medical system, malpractice cases can arise from failures in the referral process. Typically these are situations in ambulatory care where the doctor recommends that a patient see a specialist, but it either doesn't happen or nobody acts on the result. A new tool from The Institute for Healthcare Improvement and CRICO helps guide doctors and practices to prevent these referral errors and the harm from resulting diagnostic failures.

When a speech and swallowing evaluation showed the patient to be at risk for aspiration, the resident documented a plan that the patient be given nothing by mouth. But the NPO order was not entered into the system, a technician attempted to feed him, and he aspirated. This was not communicated to the attending. After transfer to the ICU, he succumbed to additional morbidities, including aspiration pneumonia.

A 26-year-old male presented to the emergency department with burning chest pain. After two more visits within four days for the same complaint, he died at home from acute coronary thrombosis. Did the clinicians’ frustration with the course of his condition lead them to blame the patient rather than reconsider their diagnosis?

A father called his son's pediatrician’s office on a winter week-end night and told the nurse practitioner that his nine-year-old had not felt well for three days. The nurse fixated on flu symptoms and told the father to push ginger ale. When the father checked on the boy 12 hours after the call, he had died from diabetic ketoacidosis and his diabetes mellitus was undiagnosed until autopsy.

The patient had a history of suicidality when her psychiatrist referred her to a sleep specialist. Three weeks after the second doctor increased her oxycodone dose to treat restless leg syndrome, the patient used the drug to kill herself.

In this case, an 8-year-old girl experienced a tenfold dosing error of clotting factor, requiring admission and observation due to increased risk of stroke. It could be said that the culture at this hospital both contributed to the error, and contributed to a good response by staff.

An 8-year old girl was treated over three years for a condition she never had. Multiple providers missed a test result that showed she had celiac disease, so it went untreated and she suffered. The resulting lawsuit resulted in a settlement against two of her doctors. This case study not only reviews the facts, but it also features suggestions from an expert reviewer on how to prevent similar mistakes managing test results.

A presumptive diagnosis during an office visit kept the doctor from broadening the differential to include a much more serious condition. Commentator Carla Ford, MD says, “These are the kinds of situations that our primary care providers and urgent care providers are faced with all the time.”

Language barrier, distraction, and poor planning caused a delay in treating fetal distress. The baby was born with deficits and the settlement was >$1 million.

Nearly 3 in 10 medical malpractice cases have identifiable problems with communication, according to a report by CRICO, the malpractice insurer for the Harvard medical institutions. Proven solutions highlighted a national gathering of patient safety leaders in Boston.

The crux of the case is that a detailed history and physical exam were not performed, and so a broad differential was not considered before the patient suffered a stroke.

In this case, we see issues that can arise in care that takes place across multiple institutions and providers, especially when the patient is self-referring. This patient was left with seriously-impaired kidney function, and he alleged a delay in diagnosis. Joining us is Dr. Carla Ford, who reviews medical malpractice claims for CRICO.

This review of a closed malpractice claim shows the risks when communication before, during, and after a surgical complication goes awry.

After a referral visit to a pulmonologist to follow up on a worrisome CT, none of the three parties—the PCP, the patient, and the pulmonologist—ever addressed the issue of the lung nodule again. The patient saw her primary care doctor several times for check-ups and minor issues over the next several years. The patient never returned to see the pulmonologist, and was not explicitly told by either doctor that she might have cancer. Four years after her visit with the pulmonologist, the patient became symptomatic from lung disease and was found to have inoperable cancer, metastatic to cervical spine. She died within months of her diagnosis.

During an initial physical for a new 38-year-old female patient, the PCP noted a normal breast exam, and recommendations for a screening mammogram and colonoscopy due to family history of colon cancer. A mammogram was never done, although the patient returned to this physician practice a dozen times over the next several years for episodic care. Then she presented with a self-identified lump, followed by a cancer diagnosis. Dr. Carla Ford discusses the patient safety and risk management implications.

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. A mishandled telephone triage delayed her trip to the ER, and the resulting pneumococcal sepsis led to permanent disabilities and a $1 million-plus settlement.

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.

Fetal heart rate tracings indicated earlier intervention after prolonged induction of labor. The obstetrician and nurse midwife were faulted for not working more closely together.

Medication error in the ER was preventable. Culture and communication problems compounded an error that required several surgeries and amputation.

Dr. Gordon Schiff discusses how to prevent a patient's heart attack, this practice would have needed better systems to monitor and identify chronic risk factors.

A top surgeon mistakenly performed carpal tunnel instead of trigger release procedure after multiple interruptions and personnel shift changes in OR.