Medical Malpractice: Three Clinical Case Studies Analyzed

Background: Medical Malpractice and Legal Context

Concerns over mounting healthcare expenses have resulted in increased inquiry into medical practices. With the rise of malpractice risk and medical liability to unprecedented levels, the field of medical law has influenced defensive medical practice as healthcare providers endeavor toward liability risk mitigation (Nahed et al., 2012).

Elements Needed to Prove Malpractice

Medical malpractice is associated with four fundamental elements, all of which must be present to form the basis for any claim. For any medical malpractice case to succeed, an attorney is required to prove all four aspects: duty, breach, causation, and damages (What are the Elements of a Medical Malpractice Claim?, n.d.).

Duty implies that healthcare professionals owe their patients the duty to take reasonable and appropriate action — that is, the practitioner is accountable for delivering some form of treatment or care to the patient. Breach implies that the practitioner in question has violated whatever duty was owed to a patient; in other words, the healthcare provider has fallen below or deviated from accepted standards of care. Causation implies that the healthcare provider's violation of care standards contributed to or caused some degree of harm to the patient. Finally, Damages implies that the practitioner's mistake resulted in actual patient harm.

Case 1: Operating Room Fall and Wrongful Death

Background

An elderly woman aged 86 allegedly fell, bottom first, from a table in the operating room of a large medical training center. The fall caused a severe head injury, culminating in her death seven days later. The Boston Globe reported in its January 29, 2008 issue that a gap in the orthopedic surgery table resulted in the fall; one of the nurses on duty had detached the safety strap fastened across the patient's torso when preparing to transfer her to an in-patient hospital bed. Surgical tables are designed for these procedures and have special boots for immobilizing patients' feet; the large opening present toward the lower half of the table is intended to enable easy access when taking X-rays. The Massachusetts State public health department investigated the case, and the patient's family filed a wrongful death lawsuit against a resident anesthesiologist, two nurses, and a resident orthopedic physician.

Elements Met or Not

In this case, each of the elements required for proving medical malpractice was met. The four defendants — the resident anesthesiologist, two nurses, and the resident orthopedic physician — owed a duty of care to the deceased patient. A breach of that duty was caused by the nurse who removed the torso safety strap, leading to the patient's fall and subsequent death from the resulting injury.

Legal Responsibility of the Nurses

The resident anesthesiologist informed investigators that, when the blood pressure cuff began deflating, he was standing at the head of the surgical table. He stated that he glanced up at the blood pressure monitor and was shocked to find, upon looking back down, that the patient had fallen (Saltzman, 2008). According to the investigation report, the hospital performed its own independent root cause analysis, whose results showed that the involved nurses and physicians were all absorbed in their respective tasks and that there was no verbal communication about the removal of the safety strap from the patient's torso. The nurse was responsible for ensuring proper communication before acting, rather than proceeding independently without consulting the rest of the team.

Perspective of Patient or Family

From the patient's perspective, or that of her family, it is entirely understandable that they would wish to take legal action and ensure such an incident does not recur with another patient. Filing a wrongful death claim, as the patient's family did, is therefore entirely appropriate. The lawsuit was filed in the Superior Court of Suffolk County and names four individuals who were present in the operating theater at the time of the incident as defendants: the resident anesthesiologist, the orthopedic resident, and two nurses (Saltzman, 2008).

Risk Management Perspective

A Boston Medical Center spokesperson stated that the Center's management extended sincere sympathy to the patient's family. Medical center procedures were improved to prevent similar accidents from occurring in the future, though the spokesperson did not specify exactly what changes were made (Saltzman, 2008). The hospital adopted a protocol requiring all doctors and nurses to hold patients prior to detaching any safety strap, and to ensure that individuals are present on either side of the operating table whenever a patient transfer is being carried out.

Legal Defense for Patient and Family

In this instance, legal proceedings will be pursued on grounds of proven medical negligence.

Legal Defense for Doctors, Nurses, and Hospital

The entire medical team might be able to argue in its defense that all team members were absorbed in their respective tasks related to the patient's surgical procedure, and that this circumstance contributed to the communication lapse that preceded the incident.

Product Liability

Product liability does not apply to this particular case.

Case 2: Burn Injuries from Misunderstood Discharge Instructions

Background

A Filipino male outpatient, aged 42, presented at a surgical center for a scheduled anal fistula repair. He received local "saddle" anesthesia — a form of anesthesia that acts on those areas of an individual's body that would be in contact with a saddle when seated. The surgery was successful. Upon discharge, he was instructed to take sitz baths using "tepid" (i.e., lukewarm) water. A month later, the patient returned to the center for an evaluation; during that examination, the surgeon noticed scarring on the patient's proximal thighs and buttocks, along with large patches of healed burns and accompanying skin changes. Upon questioning the man and his wife, the surgeon discovered that they had mistaken the word "tepid" for "scalding hot" and had used water at extreme temperatures for the sitz baths. The slow-resolving local saddle anesthesia — which can keep the body partially numb for approximately 24 hours — had blunted the patient's response to the scalding water.

Elements Met or Not

One cannot definitively state whether every malpractice element was met in this instance. During the operation, the patient received proper care. Nevertheless, the patient should have been provided with detailed and clear discharge instructions, as well as clear guidance for his follow-up appointment. This was the responsibility of every involved healthcare provider. The patient presents a particular challenge: a language barrier led him to misunderstand the healthcare terminology used, even though "tepid" is a commonly understood word in English. Instructions ought to be accompanied by illustrations and examples that make meaning unambiguous, and healthcare professionals should confirm that the patient has understood what was communicated.

Legal Responsibility of the Nurses

This case did not involve any nursing staff in a direct care capacity relevant to the discharge instructions.

Perspective of Patient and Family

The challenges of a language barrier and limited health literacy perceptibly contributed to the patient's misunderstanding of the physician's discharge instructions. From the patient's and his wife's perspective, it is understandably frustrating to fail to comprehend a healthcare professional's directions because of language barriers and unfamiliarity with medical terminology.

Risk Management Perspective

Despite personal follow-up not being necessary within 24 hours of discharge in most cases, hospitals must consider implementing special patient follow-up in cases where local or regional anesthesia has been administered. Such follow-up would enable monitoring of patient adherence to postoperative instructions, thereby helping to prevent unintentional injury such as what occurred here. Follow-up also helps alert healthcare professionals to unforeseen post-surgical neurological symptoms, which can range from minor neuropathies to acute complications (Kurreck & Twersky, 2012). The focus of follow-up should include early indicators of potential infection, particularly after continuous infusions using indwelling catheters.

Local or regional anesthesia is a key instrument in ambulatory anesthesia, aiding early patient discharge with effective pain control. However, it carries a certain degree of risk and is not appropriate for all scenarios and patients. In the case in question, a saddle block may have been an inadvisable choice given the patient's communication difficulty and limited health literacy, combined with the absence of timely follow-up. Proper procedures and policies will help facilities ensure patient safety, and the hospital where this incident occurred should consider implementing policies that incorporate these considerations (Kurreck & Twersky, 2012).

Legal Defense for Patient and Family

The patient and his family may adopt the defense of language barrier as the cause of his misunderstanding of the discharge instructions.

Legal Defense for Doctors, Nurses, and Hospital

The hospital can assert that it provided adequate care during the surgical process. The patient did not seek follow-up for a month after discharge, and the hospital may argue that it therefore cannot be held responsible for his injuries.

Product Liability

This case is not linked to any product liability.