Medicolegal Issues

In September 2007, a 23-year-old man drank a six-pack of beer, had an argument with his girlfriend, and punched a plate-glass window with both fists. He sustained lacerations to his right arm. The man removed a large piece of glass from his arm, resulting in significant bleeding. He then wrapped a belt around his arm to stop the blood flow and went to the emergency department of the local hospital, where he was treated by Dr. S.

Dr. S. removed glass fragments from the patient’s arm, sutured it, and instructed him to follow up with his family physician in one to two weeks. When the patient saw another clinician, Dr. A., for suture removal, he reported worsening neurologic symptoms in his right arm. An appointment with an orthopedist was made, which the patient subsequently canceled.

About two months later, a retained glass fragment was removed by orthopedist Dr. R. The plaintiff alleged negligence by Dr. S. for his failure to remove all the glass fragments at the initial presentation. The plaintiff claimed that as a result he suffered a median nerve injury.

The defendant claimed that the nerve injury was most likely inflicted when the plaintiff removed the piece of glass himself before going to the hospital. The defendant also claimed that the plaintiff had been negligent in his failure to seek follow-up treatment as recommended. The defendant further maintained that the physician who removed the retained glass fragment had not determined it to be in the proximity of the median nerve.

Continue for the outcome... 

OUTCOME

A jury returned a verdict for the plaintiff that totaled $460,595. The defendant filed a motion for judgment notwithstanding the verdict and for a new trial. A confidential settlement was reached prior to a hearing on the motion.

Continue for David Lang's comments... 

COMMENT

Patients and jurors expect foreign bodies to be discovered and removed with 100% precision. However, any clinician who has removed a foreign body knows that trying to locate one can be difficult under the best of circumstances.

Further, in cases in which a foreign body is not near a sensitive structure and is not likely to cause additional injury, removal may not be indicated (eg, retained bullet fragments not near a joint). In this case, the foreign body is glass and the location is described as the “arm,” which in all likelihood means the proximal forearm. So we have a potentially sharp item contained within a small space holding many sensitive structures.

Apparently, radiographs were not obtained. While some foreign bodies are radiolucent and generally considered “invisible,” glass is not necessarily one of them. There is a myth that glass is never visible on x-ray and another that glass is visible on x-ray only if there is sufficient “lead content” in it to make it so. Contrary to these beliefs, glass may be visible on standard x-ray, whether or not there is lead in it.

Here, it would have been reasonable to obtain radiographs to identify foreign bodies prior to closing the wound. The glass may have been visible and if detected, the emergency physician could have made a decision either to remove the glass or refer the patient if it was located deeply, next to a sensitive structure. Despite radiographic and physical exam findings, it is always important to remind patients that retained foreign bodies are possible and that follow-up is required. Schedule follow-up and document what the patient was told.

But what about foreign bodies that are almost always radiolucent on a standard film? Wood can be maddening: invisible on x-ray and hard to remove because unlike glass, metal, or stone, there is no confirming “scratch” or “clink” when wood is contacted with a localizing needle. Wood is also virtually guaranteed to suppurate if not removed.

Radiolucent or radiopaque is often considered an inherent quality of an object. But what is visible and what is invisible depends on radiographic technique. For foreign bodies generally considered radiolucent (eg, wood), consider a “soft-tissue technique,” which may demonstrate the foreign body, particularly if it is relatively large. While a positive image can be helpful, a negative one cannot rule out the presence of a foreign body. If available, ultrasound is also useful in detecting radiolucent foreign bodies and should be exploited by those skilled in its use.

In sum, jurors hate foreign bodies left in patients, be they items left in after surgery or not removed following an injury. Do your best, while explaining the limitations of removal efforts and the need for follow-up in complicated cases and self-monitoring in all cases. Instruct patients to return promptly for worsening signs and symptoms. Document that you informed the patient that 100% removal is never guaranteed and that they have agreed to return as scheduled or as needed. —DML

In September 2007, a 23-year-old man drank a six-pack of beer, had an argument with his girlfriend, and punched a plate-glass window with both fists. He sustained lacerations to his right arm. The man removed a large piece of glass from his arm, resulting in significant bleeding. He then wrapped a belt around his arm to stop the blood flow and went to the emergency department of the local hospital, where he was treated by Dr. S.

Dr. S. removed glass fragments from the patient’s arm, sutured it, and instructed him to follow up with his family physician in one to two weeks. When the patient saw another clinician, Dr. A., for suture removal, he reported worsening neurologic symptoms in his right arm. An appointment with an orthopedist was made, which the patient subsequently canceled.

About two months later, a retained glass fragment was removed by orthopedist Dr. R. The plaintiff alleged negligence by Dr. S. for his failure to remove all the glass fragments at the initial presentation. The plaintiff claimed that as a result he suffered a median nerve injury.

The defendant claimed that the nerve injury was most likely inflicted when the plaintiff removed the piece of glass himself before going to the hospital. The defendant also claimed that the plaintiff had been negligent in his failure to seek follow-up treatment as recommended. The defendant further maintained that the physician who removed the retained glass fragment had not determined it to be in the proximity of the median nerve.

Continue for the outcome... 

OUTCOME

A jury returned a verdict for the plaintiff that totaled $460,595. The defendant filed a motion for judgment notwithstanding the verdict and for a new trial. A confidential settlement was reached prior to a hearing on the motion.

Continue for David Lang's comments... 

COMMENT

Patients and jurors expect foreign bodies to be discovered and removed with 100% precision. However, any clinician who has removed a foreign body knows that trying to locate one can be difficult under the best of circumstances.

Further, in cases in which a foreign body is not near a sensitive structure and is not likely to cause additional injury, removal may not be indicated (eg, retained bullet fragments not near a joint). In this case, the foreign body is glass and the location is described as the “arm,” which in all likelihood means the proximal forearm. So we have a potentially sharp item contained within a small space holding many sensitive structures.

Apparently, radiographs were not obtained. While some foreign bodies are radiolucent and generally considered “invisible,” glass is not necessarily one of them. There is a myth that glass is never visible on x-ray and another that glass is visible on x-ray only if there is sufficient “lead content” in it to make it so. Contrary to these beliefs, glass may be visible on standard x-ray, whether or not there is lead in it.

Here, it would have been reasonable to obtain radiographs to identify foreign bodies prior to closing the wound. The glass may have been visible and if detected, the emergency physician could have made a decision either to remove the glass or refer the patient if it was located deeply, next to a sensitive structure. Despite radiographic and physical exam findings, it is always important to remind patients that retained foreign bodies are possible and that follow-up is required. Schedule follow-up and document what the patient was told.

But what about foreign bodies that are almost always radiolucent on a standard film? Wood can be maddening: invisible on x-ray and hard to remove because unlike glass, metal, or stone, there is no confirming “scratch” or “clink” when wood is contacted with a localizing needle. Wood is also virtually guaranteed to suppurate if not removed.

Radiolucent or radiopaque is often considered an inherent quality of an object. But what is visible and what is invisible depends on radiographic technique. For foreign bodies generally considered radiolucent (eg, wood), consider a “soft-tissue technique,” which may demonstrate the foreign body, particularly if it is relatively large. While a positive image can be helpful, a negative one cannot rule out the presence of a foreign body. If available, ultrasound is also useful in detecting radiolucent foreign bodies and should be exploited by those skilled in its use.

In sum, jurors hate foreign bodies left in patients, be they items left in after surgery or not removed following an injury. Do your best, while explaining the limitations of removal efforts and the need for follow-up in complicated cases and self-monitoring in all cases. Instruct patients to return promptly for worsening signs and symptoms. Document that you informed the patient that 100% removal is never guaranteed and that they have agreed to return as scheduled or as needed. —DML

In September 2007, a 23-year-old man drank a six-pack of beer, had an argument with his girlfriend, and punched a plate-glass window with both fists. He sustained lacerations to his right arm. The man removed a large piece of glass from his arm, resulting in significant bleeding. He then wrapped a belt around his arm to stop the blood flow and went to the emergency department of the local hospital, where he was treated by Dr. S.

Dr. S. removed glass fragments from the patient’s arm, sutured it, and instructed him to follow up with his family physician in one to two weeks. When the patient saw another clinician, Dr. A., for suture removal, he reported worsening neurologic symptoms in his right arm. An appointment with an orthopedist was made, which the patient subsequently canceled.

About two months later, a retained glass fragment was removed by orthopedist Dr. R. The plaintiff alleged negligence by Dr. S. for his failure to remove all the glass fragments at the initial presentation. The plaintiff claimed that as a result he suffered a median nerve injury.

The defendant claimed that the nerve injury was most likely inflicted when the plaintiff removed the piece of glass himself before going to the hospital. The defendant also claimed that the plaintiff had been negligent in his failure to seek follow-up treatment as recommended. The defendant further maintained that the physician who removed the retained glass fragment had not determined it to be in the proximity of the median nerve.

Continue for the outcome... 

OUTCOME

A jury returned a verdict for the plaintiff that totaled $460,595. The defendant filed a motion for judgment notwithstanding the verdict and for a new trial. A confidential settlement was reached prior to a hearing on the motion.

Continue for David Lang's comments... 

COMMENT

Patients and jurors expect foreign bodies to be discovered and removed with 100% precision. However, any clinician who has removed a foreign body knows that trying to locate one can be difficult under the best of circumstances.

Further, in cases in which a foreign body is not near a sensitive structure and is not likely to cause additional injury, removal may not be indicated (eg, retained bullet fragments not near a joint). In this case, the foreign body is glass and the location is described as the “arm,” which in all likelihood means the proximal forearm. So we have a potentially sharp item contained within a small space holding many sensitive structures.

Apparently, radiographs were not obtained. While some foreign bodies are radiolucent and generally considered “invisible,” glass is not necessarily one of them. There is a myth that glass is never visible on x-ray and another that glass is visible on x-ray only if there is sufficient “lead content” in it to make it so. Contrary to these beliefs, glass may be visible on standard x-ray, whether or not there is lead in it.

Here, it would have been reasonable to obtain radiographs to identify foreign bodies prior to closing the wound. The glass may have been visible and if detected, the emergency physician could have made a decision either to remove the glass or refer the patient if it was located deeply, next to a sensitive structure. Despite radiographic and physical exam findings, it is always important to remind patients that retained foreign bodies are possible and that follow-up is required. Schedule follow-up and document what the patient was told.

But what about foreign bodies that are almost always radiolucent on a standard film? Wood can be maddening: invisible on x-ray and hard to remove because unlike glass, metal, or stone, there is no confirming “scratch” or “clink” when wood is contacted with a localizing needle. Wood is also virtually guaranteed to suppurate if not removed.

Radiolucent or radiopaque is often considered an inherent quality of an object. But what is visible and what is invisible depends on radiographic technique. For foreign bodies generally considered radiolucent (eg, wood), consider a “soft-tissue technique,” which may demonstrate the foreign body, particularly if it is relatively large. While a positive image can be helpful, a negative one cannot rule out the presence of a foreign body. If available, ultrasound is also useful in detecting radiolucent foreign bodies and should be exploited by those skilled in its use.

In sum, jurors hate foreign bodies left in patients, be they items left in after surgery or not removed following an injury. Do your best, while explaining the limitations of removal efforts and the need for follow-up in complicated cases and self-monitoring in all cases. Instruct patients to return promptly for worsening signs and symptoms. Document that you informed the patient that 100% removal is never guaranteed and that they have agreed to return as scheduled or as needed. —DML

Obstetricians, obstetric nurses, nurse managers, and obstetric department heads are almost always well-trained, hard working, highly motivated individuals dedicated to providing the best possible care for their patients. Nevertheless, errors in the provision of care are all too common.^1–3 Even though these errors are confined to a small percentage of patient interactions, they engender profound consequences: injuries to mothers or their babies, higher costs to treat associated complications, and medical-legal suits that can entangle both clinicians and plaintiffs for years.

Why do such errors occur when it is the goal of well-trained and dedicated practi-tioners to provide error-free care? There are several reasons:

• The provision of medical care in the early 21st Century is an enormously complex endeavor.
• Physicians and nurses are human beings and, therefore, do not—and never will—perform perfectly all the time, in every situation, with every patient.
• The systems within which care providers work and the tools with which they work are often suboptimal and inefficient and are not designed to maximize patient safety.
• Financial constraints on hospital systems and physician practices dictate that obstetricians and obstetric nurses care for as many patients as possible in limited periods of time.

How then can obstetrics professionals seek to eradicate or at least decrease the number of medical errors that occur during the provision of maternity care?

To accomplish this, we must address the core issues at the root of these medical errors. Solutions must be implemented to 1) simplify the often unnecessary complexity of delivering medical care and 2) create systems and tools that minimize errors and catch those that do occur before they can cause harm.

Yet, how is this to be accomplished? In this article, I describe eight tools developed over time by clinicians who have worked in the field of obstetric patient safety. These tools provide some answers and concrete starting points.

TOOL 1: CONTINUING EDUCATION
William Osler once said, “It is astonishing with how little reading a doctor can practice medicine, but it is not astonishing how badly he may do it.”

As the years out of residency and nursing school accumulate, clinicians—both obstetricians and obstetric nurses—find it all too easy to continue to practice pretty much the way they did during training. However, medical science changes, new protocols improve on the old, and new techniques and medications are introduced yearly into the practice arena. If a clinician is to deliver the best possible care, he or she has to keep abreast of these developments in obstetrics and refresh his or her memory from time to time about things learned long ago. Such acquisition of new and review of old obstetric knowledge can be achieved only through ongoing study.

There are many ways continuing education can be accomplished. You can read new editions of textbooks when they are published or follow an obstetric journal through its yearly cycle. Cutting-edge, clinically oriented, interactive courses in all major areas of obstetrics are available to clinicians online. The recertification criteria of the American College of Obstetricians and Gynecologists (ACOG), state licensing requirements, and individual obstetric department recredentialing requirements often mandate such continuing education.

TOOL 2: SIMULATION PROGRAMS
Most obstetric emergencies, especially the most dangerous ones, occur infrequently, making it difficult for the many members of any labor and delivery unit to have their skills sharply honed to best deal with them. This is less of a problem at busy institutions where, simply due to the numbers of patients cared for, such emergencies are encountered on a regular basis. But at smaller facilities they are, fortunately, rare. The only way a unit can maintain its competency to handle such situations when they do arise—and they will—is to practice them in simulation mode.

There is now an increasing amount of literature demonstrating that simulation programs are effective not only at improving the knowledge base of obstetrics providers but also at improving Apgar scores, reducing admissions to neonatal intensive care units (NICUs), and preventing brachial plexus injuries.⁴

An effective simulation program should contain the following features:

• a thorough, didactic review of the clinical aspects of emergency care for all of the major obstetric emergencies (postpartum hemorrhage, shoulder dystocia, eclamptic seizure, maternal collapse, and urgent cesarean section)
• practice drills for the above
• training in teamwork and communication skills
• frequent repetition, ideally with each major obstetric emergency being covered twice per year.

Many institutions have developed simulation training centers. While these can be excellent teaching facilities, something is lost if simulation training is not done on the actual unit where obstetricians and obstetric nurses will encounter emergencies. Simulation programs also should be time-efficient and should be scheduled to make it easy for obstetrics personnel to participate. For greater convenience and knowledge retention, it is better to have short simulation programs at frequent intervals than day-long programs once per year or every other year.

Related Article: How simulation can train, and refresh, physicians for critical OB events  Robert Gherman, MD; Andrew Satin, MD; Roxane Gardner, MD, MPH

TOOL 3: INTERNAL AUDITS
It is a mantra in business that you can’t fix what you can’t measure. And while obstetric units usually keep track of such things as rates of cesarean section, elective induction at less than 39 weeks, and admission to the NICU, it is rare that data are kept on other extremely important information. For instance, how often is an induction started with no indication for it written in the admission note? How often is the vacuum or forceps applied with no note documenting the reason or the discussion of risks and benefits with the patient? How often does estimated fetal weight go unnoted in the medical record of a mother with gestational diabetes?

An audit program, either in computer format or with manual collection on paper, is a vital tool for each labor and delivery unit to use in assessing the quality of the care it provides. Such an audit, by covering a sufficiently large number of clinical data points, can give tremendous insight into the specifics of the unit’s performance over the range of obstetric care situations. It will show where things are being done well and where they are not. The audit becomes even more valuable if it is designed so that each of the measured data points can be evaluated for individual clinician performance as well as for the labor and delivery unit as a whole.

Similar audits also should be conducted in individual physician offices and obstetric clinics. Many of the errors that occur in providing obstetric care occur prenatally: tests not performed, lack of follow-up of known problems, or poor communication with patients or with the labor and delivery unit.

One of the major benefits of audit programs that are conducted on a regular basis—every 6 months or annually are common intervals—is that trends in performance in each area of care can be evaluated. As deficiencies are pointed out to providers, their compliance with best care practices should improve from cycle to cycle.

TOOL 4: BEST PRACTICE PROTOCOLS
Medicine is now well past the point where protocols are seen as “restrictive” or “advocating cookbook medicine.” Well-designed protocols summarize best practices derived from evidence-based studies and the consensus of obstetric experts. They serve as convenient reminders to physicians in various clinical situations so that these clinicians do not have to rely solely on what they happen to remember about caring for a given condition. Protocols also provide a certain uniformity of care, which in itself decreases the likelihood of errors being made.

Each obstetric department should have a set of protocols to cover the most common obstetric situations, such as:

• premature rupture of membranes
• instrumental vaginal deliveries
• oxytocin administration.

Each unit does not have to devise its own protocols; ACOG and nearby academic institutions are excellent sources for protocols that can be replicated and implemented so that they do not have to be created de novo.

Related Article: More strategies to avoid malpractice hazards on labor and delivery  Martin L. Gimovsky, MD; Alexis C. Gimovsky, MD (January 2011)

TOOL 5: SAFETY CHECKLISTS
Just as well-designed protocols can serve as convenient reminders of best practices, low-tech physical checklists can be kept at nursing stations and in labor and delivery rooms to serve as reminders of best practices during obstetric emergencies. For instance, having a laminated set of easy-to-read protocols for postpartum hemorrhage, eclamptic seizure, maternal collapse, and shoulder dystocia in a delivery room can allow a charge nurse or other supervisor to check to make sure all proper procedures are being performed by the team actually administering care to a patient in crisis, with nothing important overlooked.

Related Article: Develop and use a checklist for 3rd- and 4th-degree perineal lacerations
 Robert L. Barbieri, MD (Editorial, August 2013)

TOOL 6: COMPLETE DOCUMENTATION
Almost as many lawsuits are lost because of poor documentation as are lost because of inappropriate medical care. The obstetric literature,¹ and my own experience with the medical-legal system, clearly demonstrate the need for appropriate, careful documentation of the events that transpire during patient care. Notes do not have to be especially long or verbose—but they must contain all relevant information and describe the obstetrician’s thinking at various decision points.

Documentation can be inadequate because of time constraints, poor understanding of the events that transpired, or simply a lack of remembering to include salient points that should be covered in a clinical note.

Clinicians can be prompted to include key aspects of care in the medical record by using prepared templates. Such templates are easy to fill out, remind clinicians to document information that would otherwise not get recorded, and result in a much more complete patient chart. By using a template, a clinician would never forget to record the head-to-body delivery interval after a shoulder dystocia or whether a fetal heart rate was obtained in the operating room just prior to starting a cesarean section.

Related Article: Sound strategies to avoid malpractice hazards on labor and delivery
 Martin L. Gimovsky, MD, and Alexis C. Gimovsky, MD (December 2010)

TOOL 7: SMART MEDICAL RECORDS
In obstetrics we are fortunate that there is a limited range of issues that recur repeatedly, such as gestational hypertension, placental abruption, and fetal distress. One soon gains experience in managing these conditions and, with the help of best-practice protocols, optimal care almost always can be provided.

Still, many clinical presentations can pose diagnostic challenges, especially in atypical cases. Moreover, clinicians managing a patient’s care may not immediately remember the best means of evaluating and treating a certain condition in specific circumstances. For example, at 3:00 am it may be difficult to recall whether it is nifedipine or labetalol that should be avoided with asthmatic patients or which antibiotic formulation is currently recommended for prophylaxis in a patient with premature rupture of membranes at 30 weeks’ gestation who is allergic to penicillin.

Smart medical records, already widely used in other fields of medicine, are an antidote to this problem. When certain diagnoses, physical findings, clinical details, or laboratory data are entered into specific fields in an electronic medical record, templates that have been added to the record automatically appear to show relevant information, such as tests that should be performed, treatments that should be administered, and alternative diagnoses that should be considered. Such reminders are not presented as obligations or “hard stops”; they are usually displayed in the form of easily dismissible pop-ups or “reminder bubbles” that appear on the screen and serve solely to jog memory and provide information.

Such smart electronic medical record features can be provided either by the main electronic medical record vendor or added as subprograms by other providers.

Related Article: EHRs and medicolegal risk: How they help, when they could hurt Martin L. Gimovsky, MD; Baohuong N. Trans, DO (March 2013)

TOOL 8: MATERNITY UNIT ON-SITE CONSULTATIONS
Every labor and delivery unit has its own culture, a combination of institutional history and the personality of the doctors and nurses working there. Some units function efficiently, have the most modern equipment, and provide superb medical care. Other units have less than adequate facilities, remain entrenched in older practices, and have disruptive or uncooperative personnel that interfere with the smooth running of the unit. Moreover, each maternity unit, based on its resources, patient population, and staff skills, devises its own solutions to the same sorts of problems that all other obstetric units share. Unfortunately, there is little collaboration between units to discuss common problems and trade best practices. The result is that all too often each unit invents its own “wheel” when many excellent “wheels” already have been developed for the same issues around the country.

An on-site visit by an outside consultant—an obstetrician, an obstetric nurse, or both—can identify ongoing institutional problems, point out care deficiencies the unit may not be aware of, and provide resources and ideas to help solve the issues identified. Moreover, an outside consultant can offer unbiased and authoritative opinions to help move initiatives that may be stalled by local personalities or institutional politics.

Some features that a well-conducted on-site consultation will evaluate are:

• adequacy of obstetric triage
• capacity to perform stat cesarean sections 24/7
• 24-hour availability of obstetricians, anesthesiologists, pediatricians, and operating room teams
• preparation for handling various obstetric emergencies
• oxytocin administration protocols and compliance
• adequacy of physician and nurse charting
• ongoing skills assessment of fetal heart-rate monitor interpretation
• presence of practitioners whose disruptive behavior compromises the safety of the unit
• preparation for nonmedical emergencies, such as infant abduction, natural disaster; fire; shooter; or disruptive patients, visitors, or staff.

IMPLEMENTATION CAN EQUAL SAFER CARE
As long as people have babies, less than desirable outcomes will occasionally occur. As long as care providers are human beings, the provision of obstetric care will continue to be imperfect.

It is up to those entrusted with the responsibility of caring for mothers and their babies to provide as much support and backup as possible to obstetricians and obstetric nurses, all of whom sincerely desire to do everything possible to deliver safe care to their patients.

Tools for providing such support and backup are available and can be implemented fairly easily on most obstetric units. They do involve an expenditure of both time and money. However, the most important requirement for success is an institutional willingness to 1) acknowledge that the care a given unit provides can be improved, 2) perform an in-depth evaluation of the quality of care currently being administered, and 3) move ahead with the sorts of tools discussed in this article that will enable clinicians to provide optimal care for mothers and babies. 

SHARE YOUR EXPERIENCE!
Did implementation of a tool described in this article solve a problem or improve performance for your obstetric unit? Tell us about it by emailing to: [email protected] Please include your name, city, and state.

Obstetricians, obstetric nurses, nurse managers, and obstetric department heads are almost always well-trained, hard working, highly motivated individuals dedicated to providing the best possible care for their patients. Nevertheless, errors in the provision of care are all too common.^1–3 Even though these errors are confined to a small percentage of patient interactions, they engender profound consequences: injuries to mothers or their babies, higher costs to treat associated complications, and medical-legal suits that can entangle both clinicians and plaintiffs for years.

Why do such errors occur when it is the goal of well-trained and dedicated practi-tioners to provide error-free care? There are several reasons:

• The provision of medical care in the early 21st Century is an enormously complex endeavor.
• Physicians and nurses are human beings and, therefore, do not—and never will—perform perfectly all the time, in every situation, with every patient.
• The systems within which care providers work and the tools with which they work are often suboptimal and inefficient and are not designed to maximize patient safety.
• Financial constraints on hospital systems and physician practices dictate that obstetricians and obstetric nurses care for as many patients as possible in limited periods of time.

How then can obstetrics professionals seek to eradicate or at least decrease the number of medical errors that occur during the provision of maternity care?

To accomplish this, we must address the core issues at the root of these medical errors. Solutions must be implemented to 1) simplify the often unnecessary complexity of delivering medical care and 2) create systems and tools that minimize errors and catch those that do occur before they can cause harm.

Yet, how is this to be accomplished? In this article, I describe eight tools developed over time by clinicians who have worked in the field of obstetric patient safety. These tools provide some answers and concrete starting points.

TOOL 1: CONTINUING EDUCATION
William Osler once said, “It is astonishing with how little reading a doctor can practice medicine, but it is not astonishing how badly he may do it.”

As the years out of residency and nursing school accumulate, clinicians—both obstetricians and obstetric nurses—find it all too easy to continue to practice pretty much the way they did during training. However, medical science changes, new protocols improve on the old, and new techniques and medications are introduced yearly into the practice arena. If a clinician is to deliver the best possible care, he or she has to keep abreast of these developments in obstetrics and refresh his or her memory from time to time about things learned long ago. Such acquisition of new and review of old obstetric knowledge can be achieved only through ongoing study.

There are many ways continuing education can be accomplished. You can read new editions of textbooks when they are published or follow an obstetric journal through its yearly cycle. Cutting-edge, clinically oriented, interactive courses in all major areas of obstetrics are available to clinicians online. The recertification criteria of the American College of Obstetricians and Gynecologists (ACOG), state licensing requirements, and individual obstetric department recredentialing requirements often mandate such continuing education.

TOOL 2: SIMULATION PROGRAMS
Most obstetric emergencies, especially the most dangerous ones, occur infrequently, making it difficult for the many members of any labor and delivery unit to have their skills sharply honed to best deal with them. This is less of a problem at busy institutions where, simply due to the numbers of patients cared for, such emergencies are encountered on a regular basis. But at smaller facilities they are, fortunately, rare. The only way a unit can maintain its competency to handle such situations when they do arise—and they will—is to practice them in simulation mode.

There is now an increasing amount of literature demonstrating that simulation programs are effective not only at improving the knowledge base of obstetrics providers but also at improving Apgar scores, reducing admissions to neonatal intensive care units (NICUs), and preventing brachial plexus injuries.⁴

An effective simulation program should contain the following features:

• a thorough, didactic review of the clinical aspects of emergency care for all of the major obstetric emergencies (postpartum hemorrhage, shoulder dystocia, eclamptic seizure, maternal collapse, and urgent cesarean section)
• practice drills for the above
• training in teamwork and communication skills
• frequent repetition, ideally with each major obstetric emergency being covered twice per year.

Many institutions have developed simulation training centers. While these can be excellent teaching facilities, something is lost if simulation training is not done on the actual unit where obstetricians and obstetric nurses will encounter emergencies. Simulation programs also should be time-efficient and should be scheduled to make it easy for obstetrics personnel to participate. For greater convenience and knowledge retention, it is better to have short simulation programs at frequent intervals than day-long programs once per year or every other year.

Related Article: How simulation can train, and refresh, physicians for critical OB events  Robert Gherman, MD; Andrew Satin, MD; Roxane Gardner, MD, MPH

TOOL 3: INTERNAL AUDITS
It is a mantra in business that you can’t fix what you can’t measure. And while obstetric units usually keep track of such things as rates of cesarean section, elective induction at less than 39 weeks, and admission to the NICU, it is rare that data are kept on other extremely important information. For instance, how often is an induction started with no indication for it written in the admission note? How often is the vacuum or forceps applied with no note documenting the reason or the discussion of risks and benefits with the patient? How often does estimated fetal weight go unnoted in the medical record of a mother with gestational diabetes?

An audit program, either in computer format or with manual collection on paper, is a vital tool for each labor and delivery unit to use in assessing the quality of the care it provides. Such an audit, by covering a sufficiently large number of clinical data points, can give tremendous insight into the specifics of the unit’s performance over the range of obstetric care situations. It will show where things are being done well and where they are not. The audit becomes even more valuable if it is designed so that each of the measured data points can be evaluated for individual clinician performance as well as for the labor and delivery unit as a whole.

Similar audits also should be conducted in individual physician offices and obstetric clinics. Many of the errors that occur in providing obstetric care occur prenatally: tests not performed, lack of follow-up of known problems, or poor communication with patients or with the labor and delivery unit.

One of the major benefits of audit programs that are conducted on a regular basis—every 6 months or annually are common intervals—is that trends in performance in each area of care can be evaluated. As deficiencies are pointed out to providers, their compliance with best care practices should improve from cycle to cycle.

TOOL 4: BEST PRACTICE PROTOCOLS
Medicine is now well past the point where protocols are seen as “restrictive” or “advocating cookbook medicine.” Well-designed protocols summarize best practices derived from evidence-based studies and the consensus of obstetric experts. They serve as convenient reminders to physicians in various clinical situations so that these clinicians do not have to rely solely on what they happen to remember about caring for a given condition. Protocols also provide a certain uniformity of care, which in itself decreases the likelihood of errors being made.

Each obstetric department should have a set of protocols to cover the most common obstetric situations, such as:

• premature rupture of membranes
• instrumental vaginal deliveries
• oxytocin administration.

Each unit does not have to devise its own protocols; ACOG and nearby academic institutions are excellent sources for protocols that can be replicated and implemented so that they do not have to be created de novo.

Related Article: More strategies to avoid malpractice hazards on labor and delivery  Martin L. Gimovsky, MD; Alexis C. Gimovsky, MD (January 2011)

TOOL 5: SAFETY CHECKLISTS
Just as well-designed protocols can serve as convenient reminders of best practices, low-tech physical checklists can be kept at nursing stations and in labor and delivery rooms to serve as reminders of best practices during obstetric emergencies. For instance, having a laminated set of easy-to-read protocols for postpartum hemorrhage, eclamptic seizure, maternal collapse, and shoulder dystocia in a delivery room can allow a charge nurse or other supervisor to check to make sure all proper procedures are being performed by the team actually administering care to a patient in crisis, with nothing important overlooked.

Related Article: Develop and use a checklist for 3rd- and 4th-degree perineal lacerations
 Robert L. Barbieri, MD (Editorial, August 2013)

TOOL 6: COMPLETE DOCUMENTATION
Almost as many lawsuits are lost because of poor documentation as are lost because of inappropriate medical care. The obstetric literature,¹ and my own experience with the medical-legal system, clearly demonstrate the need for appropriate, careful documentation of the events that transpire during patient care. Notes do not have to be especially long or verbose—but they must contain all relevant information and describe the obstetrician’s thinking at various decision points.

Documentation can be inadequate because of time constraints, poor understanding of the events that transpired, or simply a lack of remembering to include salient points that should be covered in a clinical note.

Clinicians can be prompted to include key aspects of care in the medical record by using prepared templates. Such templates are easy to fill out, remind clinicians to document information that would otherwise not get recorded, and result in a much more complete patient chart. By using a template, a clinician would never forget to record the head-to-body delivery interval after a shoulder dystocia or whether a fetal heart rate was obtained in the operating room just prior to starting a cesarean section.

Related Article: Sound strategies to avoid malpractice hazards on labor and delivery
 Martin L. Gimovsky, MD, and Alexis C. Gimovsky, MD (December 2010)

TOOL 7: SMART MEDICAL RECORDS
In obstetrics we are fortunate that there is a limited range of issues that recur repeatedly, such as gestational hypertension, placental abruption, and fetal distress. One soon gains experience in managing these conditions and, with the help of best-practice protocols, optimal care almost always can be provided.

Still, many clinical presentations can pose diagnostic challenges, especially in atypical cases. Moreover, clinicians managing a patient’s care may not immediately remember the best means of evaluating and treating a certain condition in specific circumstances. For example, at 3:00 am it may be difficult to recall whether it is nifedipine or labetalol that should be avoided with asthmatic patients or which antibiotic formulation is currently recommended for prophylaxis in a patient with premature rupture of membranes at 30 weeks’ gestation who is allergic to penicillin.

Smart medical records, already widely used in other fields of medicine, are an antidote to this problem. When certain diagnoses, physical findings, clinical details, or laboratory data are entered into specific fields in an electronic medical record, templates that have been added to the record automatically appear to show relevant information, such as tests that should be performed, treatments that should be administered, and alternative diagnoses that should be considered. Such reminders are not presented as obligations or “hard stops”; they are usually displayed in the form of easily dismissible pop-ups or “reminder bubbles” that appear on the screen and serve solely to jog memory and provide information.

Such smart electronic medical record features can be provided either by the main electronic medical record vendor or added as subprograms by other providers.

Related Article: EHRs and medicolegal risk: How they help, when they could hurt Martin L. Gimovsky, MD; Baohuong N. Trans, DO (March 2013)

TOOL 8: MATERNITY UNIT ON-SITE CONSULTATIONS
Every labor and delivery unit has its own culture, a combination of institutional history and the personality of the doctors and nurses working there. Some units function efficiently, have the most modern equipment, and provide superb medical care. Other units have less than adequate facilities, remain entrenched in older practices, and have disruptive or uncooperative personnel that interfere with the smooth running of the unit. Moreover, each maternity unit, based on its resources, patient population, and staff skills, devises its own solutions to the same sorts of problems that all other obstetric units share. Unfortunately, there is little collaboration between units to discuss common problems and trade best practices. The result is that all too often each unit invents its own “wheel” when many excellent “wheels” already have been developed for the same issues around the country.

An on-site visit by an outside consultant—an obstetrician, an obstetric nurse, or both—can identify ongoing institutional problems, point out care deficiencies the unit may not be aware of, and provide resources and ideas to help solve the issues identified. Moreover, an outside consultant can offer unbiased and authoritative opinions to help move initiatives that may be stalled by local personalities or institutional politics.

Some features that a well-conducted on-site consultation will evaluate are:

• adequacy of obstetric triage
• capacity to perform stat cesarean sections 24/7
• 24-hour availability of obstetricians, anesthesiologists, pediatricians, and operating room teams
• preparation for handling various obstetric emergencies
• oxytocin administration protocols and compliance
• adequacy of physician and nurse charting
• ongoing skills assessment of fetal heart-rate monitor interpretation
• presence of practitioners whose disruptive behavior compromises the safety of the unit
• preparation for nonmedical emergencies, such as infant abduction, natural disaster; fire; shooter; or disruptive patients, visitors, or staff.

IMPLEMENTATION CAN EQUAL SAFER CARE
As long as people have babies, less than desirable outcomes will occasionally occur. As long as care providers are human beings, the provision of obstetric care will continue to be imperfect.

It is up to those entrusted with the responsibility of caring for mothers and their babies to provide as much support and backup as possible to obstetricians and obstetric nurses, all of whom sincerely desire to do everything possible to deliver safe care to their patients.

Tools for providing such support and backup are available and can be implemented fairly easily on most obstetric units. They do involve an expenditure of both time and money. However, the most important requirement for success is an institutional willingness to 1) acknowledge that the care a given unit provides can be improved, 2) perform an in-depth evaluation of the quality of care currently being administered, and 3) move ahead with the sorts of tools discussed in this article that will enable clinicians to provide optimal care for mothers and babies. 

SHARE YOUR EXPERIENCE!
Did implementation of a tool described in this article solve a problem or improve performance for your obstetric unit? Tell us about it by emailing to: [email protected] Please include your name, city, and state.

Obstetricians, obstetric nurses, nurse managers, and obstetric department heads are almost always well-trained, hard working, highly motivated individuals dedicated to providing the best possible care for their patients. Nevertheless, errors in the provision of care are all too common.^1–3 Even though these errors are confined to a small percentage of patient interactions, they engender profound consequences: injuries to mothers or their babies, higher costs to treat associated complications, and medical-legal suits that can entangle both clinicians and plaintiffs for years.

Why do such errors occur when it is the goal of well-trained and dedicated practi-tioners to provide error-free care? There are several reasons:

• The provision of medical care in the early 21st Century is an enormously complex endeavor.
• Physicians and nurses are human beings and, therefore, do not—and never will—perform perfectly all the time, in every situation, with every patient.
• The systems within which care providers work and the tools with which they work are often suboptimal and inefficient and are not designed to maximize patient safety.
• Financial constraints on hospital systems and physician practices dictate that obstetricians and obstetric nurses care for as many patients as possible in limited periods of time.

How then can obstetrics professionals seek to eradicate or at least decrease the number of medical errors that occur during the provision of maternity care?

To accomplish this, we must address the core issues at the root of these medical errors. Solutions must be implemented to 1) simplify the often unnecessary complexity of delivering medical care and 2) create systems and tools that minimize errors and catch those that do occur before they can cause harm.

Yet, how is this to be accomplished? In this article, I describe eight tools developed over time by clinicians who have worked in the field of obstetric patient safety. These tools provide some answers and concrete starting points.

TOOL 1: CONTINUING EDUCATION
William Osler once said, “It is astonishing with how little reading a doctor can practice medicine, but it is not astonishing how badly he may do it.”

As the years out of residency and nursing school accumulate, clinicians—both obstetricians and obstetric nurses—find it all too easy to continue to practice pretty much the way they did during training. However, medical science changes, new protocols improve on the old, and new techniques and medications are introduced yearly into the practice arena. If a clinician is to deliver the best possible care, he or she has to keep abreast of these developments in obstetrics and refresh his or her memory from time to time about things learned long ago. Such acquisition of new and review of old obstetric knowledge can be achieved only through ongoing study.

There are many ways continuing education can be accomplished. You can read new editions of textbooks when they are published or follow an obstetric journal through its yearly cycle. Cutting-edge, clinically oriented, interactive courses in all major areas of obstetrics are available to clinicians online. The recertification criteria of the American College of Obstetricians and Gynecologists (ACOG), state licensing requirements, and individual obstetric department recredentialing requirements often mandate such continuing education.

TOOL 2: SIMULATION PROGRAMS
Most obstetric emergencies, especially the most dangerous ones, occur infrequently, making it difficult for the many members of any labor and delivery unit to have their skills sharply honed to best deal with them. This is less of a problem at busy institutions where, simply due to the numbers of patients cared for, such emergencies are encountered on a regular basis. But at smaller facilities they are, fortunately, rare. The only way a unit can maintain its competency to handle such situations when they do arise—and they will—is to practice them in simulation mode.

There is now an increasing amount of literature demonstrating that simulation programs are effective not only at improving the knowledge base of obstetrics providers but also at improving Apgar scores, reducing admissions to neonatal intensive care units (NICUs), and preventing brachial plexus injuries.⁴

An effective simulation program should contain the following features:

• a thorough, didactic review of the clinical aspects of emergency care for all of the major obstetric emergencies (postpartum hemorrhage, shoulder dystocia, eclamptic seizure, maternal collapse, and urgent cesarean section)
• practice drills for the above
• training in teamwork and communication skills
• frequent repetition, ideally with each major obstetric emergency being covered twice per year.

Many institutions have developed simulation training centers. While these can be excellent teaching facilities, something is lost if simulation training is not done on the actual unit where obstetricians and obstetric nurses will encounter emergencies. Simulation programs also should be time-efficient and should be scheduled to make it easy for obstetrics personnel to participate. For greater convenience and knowledge retention, it is better to have short simulation programs at frequent intervals than day-long programs once per year or every other year.

Related Article: How simulation can train, and refresh, physicians for critical OB events  Robert Gherman, MD; Andrew Satin, MD; Roxane Gardner, MD, MPH

TOOL 3: INTERNAL AUDITS
It is a mantra in business that you can’t fix what you can’t measure. And while obstetric units usually keep track of such things as rates of cesarean section, elective induction at less than 39 weeks, and admission to the NICU, it is rare that data are kept on other extremely important information. For instance, how often is an induction started with no indication for it written in the admission note? How often is the vacuum or forceps applied with no note documenting the reason or the discussion of risks and benefits with the patient? How often does estimated fetal weight go unnoted in the medical record of a mother with gestational diabetes?

An audit program, either in computer format or with manual collection on paper, is a vital tool for each labor and delivery unit to use in assessing the quality of the care it provides. Such an audit, by covering a sufficiently large number of clinical data points, can give tremendous insight into the specifics of the unit’s performance over the range of obstetric care situations. It will show where things are being done well and where they are not. The audit becomes even more valuable if it is designed so that each of the measured data points can be evaluated for individual clinician performance as well as for the labor and delivery unit as a whole.

Similar audits also should be conducted in individual physician offices and obstetric clinics. Many of the errors that occur in providing obstetric care occur prenatally: tests not performed, lack of follow-up of known problems, or poor communication with patients or with the labor and delivery unit.

One of the major benefits of audit programs that are conducted on a regular basis—every 6 months or annually are common intervals—is that trends in performance in each area of care can be evaluated. As deficiencies are pointed out to providers, their compliance with best care practices should improve from cycle to cycle.

TOOL 4: BEST PRACTICE PROTOCOLS
Medicine is now well past the point where protocols are seen as “restrictive” or “advocating cookbook medicine.” Well-designed protocols summarize best practices derived from evidence-based studies and the consensus of obstetric experts. They serve as convenient reminders to physicians in various clinical situations so that these clinicians do not have to rely solely on what they happen to remember about caring for a given condition. Protocols also provide a certain uniformity of care, which in itself decreases the likelihood of errors being made.

Each obstetric department should have a set of protocols to cover the most common obstetric situations, such as:

• premature rupture of membranes
• instrumental vaginal deliveries
• oxytocin administration.

Each unit does not have to devise its own protocols; ACOG and nearby academic institutions are excellent sources for protocols that can be replicated and implemented so that they do not have to be created de novo.

Related Article: More strategies to avoid malpractice hazards on labor and delivery  Martin L. Gimovsky, MD; Alexis C. Gimovsky, MD (January 2011)

TOOL 5: SAFETY CHECKLISTS
Just as well-designed protocols can serve as convenient reminders of best practices, low-tech physical checklists can be kept at nursing stations and in labor and delivery rooms to serve as reminders of best practices during obstetric emergencies. For instance, having a laminated set of easy-to-read protocols for postpartum hemorrhage, eclamptic seizure, maternal collapse, and shoulder dystocia in a delivery room can allow a charge nurse or other supervisor to check to make sure all proper procedures are being performed by the team actually administering care to a patient in crisis, with nothing important overlooked.

Related Article: Develop and use a checklist for 3rd- and 4th-degree perineal lacerations
 Robert L. Barbieri, MD (Editorial, August 2013)

TOOL 6: COMPLETE DOCUMENTATION
Almost as many lawsuits are lost because of poor documentation as are lost because of inappropriate medical care. The obstetric literature,¹ and my own experience with the medical-legal system, clearly demonstrate the need for appropriate, careful documentation of the events that transpire during patient care. Notes do not have to be especially long or verbose—but they must contain all relevant information and describe the obstetrician’s thinking at various decision points.

Documentation can be inadequate because of time constraints, poor understanding of the events that transpired, or simply a lack of remembering to include salient points that should be covered in a clinical note.

Clinicians can be prompted to include key aspects of care in the medical record by using prepared templates. Such templates are easy to fill out, remind clinicians to document information that would otherwise not get recorded, and result in a much more complete patient chart. By using a template, a clinician would never forget to record the head-to-body delivery interval after a shoulder dystocia or whether a fetal heart rate was obtained in the operating room just prior to starting a cesarean section.

Related Article: Sound strategies to avoid malpractice hazards on labor and delivery
 Martin L. Gimovsky, MD, and Alexis C. Gimovsky, MD (December 2010)

TOOL 7: SMART MEDICAL RECORDS
In obstetrics we are fortunate that there is a limited range of issues that recur repeatedly, such as gestational hypertension, placental abruption, and fetal distress. One soon gains experience in managing these conditions and, with the help of best-practice protocols, optimal care almost always can be provided.

Still, many clinical presentations can pose diagnostic challenges, especially in atypical cases. Moreover, clinicians managing a patient’s care may not immediately remember the best means of evaluating and treating a certain condition in specific circumstances. For example, at 3:00 am it may be difficult to recall whether it is nifedipine or labetalol that should be avoided with asthmatic patients or which antibiotic formulation is currently recommended for prophylaxis in a patient with premature rupture of membranes at 30 weeks’ gestation who is allergic to penicillin.

Smart medical records, already widely used in other fields of medicine, are an antidote to this problem. When certain diagnoses, physical findings, clinical details, or laboratory data are entered into specific fields in an electronic medical record, templates that have been added to the record automatically appear to show relevant information, such as tests that should be performed, treatments that should be administered, and alternative diagnoses that should be considered. Such reminders are not presented as obligations or “hard stops”; they are usually displayed in the form of easily dismissible pop-ups or “reminder bubbles” that appear on the screen and serve solely to jog memory and provide information.

Such smart electronic medical record features can be provided either by the main electronic medical record vendor or added as subprograms by other providers.

Related Article: EHRs and medicolegal risk: How they help, when they could hurt Martin L. Gimovsky, MD; Baohuong N. Trans, DO (March 2013)

TOOL 8: MATERNITY UNIT ON-SITE CONSULTATIONS
Every labor and delivery unit has its own culture, a combination of institutional history and the personality of the doctors and nurses working there. Some units function efficiently, have the most modern equipment, and provide superb medical care. Other units have less than adequate facilities, remain entrenched in older practices, and have disruptive or uncooperative personnel that interfere with the smooth running of the unit. Moreover, each maternity unit, based on its resources, patient population, and staff skills, devises its own solutions to the same sorts of problems that all other obstetric units share. Unfortunately, there is little collaboration between units to discuss common problems and trade best practices. The result is that all too often each unit invents its own “wheel” when many excellent “wheels” already have been developed for the same issues around the country.

An on-site visit by an outside consultant—an obstetrician, an obstetric nurse, or both—can identify ongoing institutional problems, point out care deficiencies the unit may not be aware of, and provide resources and ideas to help solve the issues identified. Moreover, an outside consultant can offer unbiased and authoritative opinions to help move initiatives that may be stalled by local personalities or institutional politics.

Some features that a well-conducted on-site consultation will evaluate are:

• adequacy of obstetric triage
• capacity to perform stat cesarean sections 24/7
• 24-hour availability of obstetricians, anesthesiologists, pediatricians, and operating room teams
• preparation for handling various obstetric emergencies
• oxytocin administration protocols and compliance
• adequacy of physician and nurse charting
• ongoing skills assessment of fetal heart-rate monitor interpretation
• presence of practitioners whose disruptive behavior compromises the safety of the unit
• preparation for nonmedical emergencies, such as infant abduction, natural disaster; fire; shooter; or disruptive patients, visitors, or staff.

IMPLEMENTATION CAN EQUAL SAFER CARE
As long as people have babies, less than desirable outcomes will occasionally occur. As long as care providers are human beings, the provision of obstetric care will continue to be imperfect.

It is up to those entrusted with the responsibility of caring for mothers and their babies to provide as much support and backup as possible to obstetricians and obstetric nurses, all of whom sincerely desire to do everything possible to deliver safe care to their patients.

Tools for providing such support and backup are available and can be implemented fairly easily on most obstetric units. They do involve an expenditure of both time and money. However, the most important requirement for success is an institutional willingness to 1) acknowledge that the care a given unit provides can be improved, 2) perform an in-depth evaluation of the quality of care currently being administered, and 3) move ahead with the sorts of tools discussed in this article that will enable clinicians to provide optimal care for mothers and babies. 

SHARE YOUR EXPERIENCE!
Did implementation of a tool described in this article solve a problem or improve performance for your obstetric unit? Tell us about it by emailing to: [email protected] Please include your name, city, and state.

A 50-year-old man sustained a rope-burn injury to his left hand during a fishing trip in early August 2004. He subsequently presented to an orthopedic facility with complaints of a hand infection and was eventually referred to orthopedic surgeon Dr. W.

One week later, Dr. W administered a steroid injection, which caused the infection to worsen. The patient claimed that the steroid injection was contraindicated by the underlying infection. Dr. W referred the patient to Dr. C for infectious disease management.

In November 2004, Dr. W performed an incision and drainage procedure, and specimens were sent for pathology study and cultures. The pathology results were sent to both Dr. W and Dr. C, but the culture results were sent only to Dr. W. Other specimens were sent for culture in November 2004 and January 2005.

The results from the first culture, received by Dr. W in three reports, indicated “Mycobacterium,” “rare presumptive Mycobacterium mar­inum,” and “Myocbacterium marinum.” Dr. W did not forward these results to Dr. C and allegedly did not review the last report. Dr. C treated the plaintiff for a fungal infection based on the results of the second culture. After the third specimen in January 2005 grew acid-fast bacilli, Dr. C was informed that the patient likely had an infection caused by M. marinum.

The patient alleged that the 44-day delay in diagnosis and treatment of the M. marinum infection allowed the infection to worsen. The patient was hospitalized for one week at a major clinic and underwent three debridement surgeries to his left hand. He subsequently underwent five months of physical therapy and received long-term intravenous antibiotics for the infection.

The patient lacks full range of motion in his hand and is unable to fully open the fingers or make a tight fist. He has a trigger finger, surgical scars, and painful nodules. The hand is also extremely intolerant to temperature. The plaintiff claimed that the debridement surgeries would have been unnecessary if the initial culture reports had been acted upon in a timely manner.

The defendants claimed Dr. W saw no evidence of infection at the first office visit and that there was no sign of infection when the steroid injection was administered. The defendants claimed that the hand’s condition did not worsen after the injection and that the plaintiff was referred to Dr. C when a second fishing trip led to a flare-up that eluded diagnosis. Dr. W maintained that, during the procedure that produced the first cultures, he instructed the circulating nurse to have all lab results sent to both himself and Dr. C. Dr. W believed that Dr. C had been sent the results when he saw both their names on the pathology reports.

Continue reading to see the outcome... 

OUTCOME

A $215,000 verdict was returned. The surgical center at which the procedure was performed that produced the first culture settled prior to trial for $200,000.

Continue reading for David M. Lang's commentary... 

COMMENT

This case raises three issues: 

First, hand infections can be problematic and are often trivialized by the initially consulted clinician. The presentation of certain hand infections, such as paronychiae and felons, generally will be straightforward. Paronychiae are usually managed by the clinician who first sees the patient. Felon management is more difficult, but it still may be drained in ambulatory settings by experienced clinicians. Deeper and more troublesome infections of the hand should raise immediate concern; these include tendon sheath infection, septic arthritis, and deep space hand infections. Hand cases can become complicated, and prompt referral to a specialist is usually warranted for all but the most basic infections.

Second, clinicians must always be on the lookout for important clues pointing to an oddball cause. Here, the overlooked clue was the significance of the patient’s fishing trip. While M. marinum seems obscure, the specific bacteria is known to cause tendon sheath infections when a patient’s hand is punctured by fish spines or when a simple wound is contaminated with stagnant water in nature or from an aquarium.¹ Many of us are familiar with the fungal infection sporotrichosis, which can occur after a gardener is stuck by a rose thorn. Asking about a patient’s hobbies and activities may provide a context for an injury.

Third, communication breakdown is something clinicians often just don’t “get.” After receiving the culture report, the orthopedist should have called the infectious diseases physician to discuss the unusual case. This is particularly true in light of the fact that the orthopedic surgeon injected the hand with steroids, which may have worsened the patient’s condition. Jurors would have the expectation that the case would be followed closely. Everyone is busy, but unusual cases such as this one require a quick call to help the patient and avert liability. Pick up the phone.

Furthermore, the defense strategy here seems misplaced.  The defense argued that the orthopedic surgeon saw no evidence of infection but administered a steroid injection for inflammation. But how can you tell the difference from external observation alone? We’ve all been trained in the classic signs and symptoms of calor (heat), dolor (pain), rubor (redness), and tumor (swelling). But both infectious and noninfectious inflammation will produce these, so the cause would not be readily distinguishable without further investigation.

In sum, take hand infections seriously. Thanks to television shows such as House, lay jurors expect clinicians to puzzle together facts to arrive at an obscure diagnosis. So, before we discharge a patient with a common condition, it is useful to ask about the patient’s job and hobbies. We might also ask the generic question “Were you doing anything unusual?” You may just save a patient and solve a puzzle at the same time.

Finally, communication with other clinicians in complicated cases is required and expected by jurors. —DML

Reference

1. American Society for Surgery of the Hand. Hand infections. www.assh.org/Public/HandConditions/Pages/HandInfections.aspx. Accessed January 9, 2014.

A 50-year-old man sustained a rope-burn injury to his left hand during a fishing trip in early August 2004. He subsequently presented to an orthopedic facility with complaints of a hand infection and was eventually referred to orthopedic surgeon Dr. W.

One week later, Dr. W administered a steroid injection, which caused the infection to worsen. The patient claimed that the steroid injection was contraindicated by the underlying infection. Dr. W referred the patient to Dr. C for infectious disease management.

In November 2004, Dr. W performed an incision and drainage procedure, and specimens were sent for pathology study and cultures. The pathology results were sent to both Dr. W and Dr. C, but the culture results were sent only to Dr. W. Other specimens were sent for culture in November 2004 and January 2005.

The results from the first culture, received by Dr. W in three reports, indicated “Mycobacterium,” “rare presumptive Mycobacterium mar­inum,” and “Myocbacterium marinum.” Dr. W did not forward these results to Dr. C and allegedly did not review the last report. Dr. C treated the plaintiff for a fungal infection based on the results of the second culture. After the third specimen in January 2005 grew acid-fast bacilli, Dr. C was informed that the patient likely had an infection caused by M. marinum.

The patient alleged that the 44-day delay in diagnosis and treatment of the M. marinum infection allowed the infection to worsen. The patient was hospitalized for one week at a major clinic and underwent three debridement surgeries to his left hand. He subsequently underwent five months of physical therapy and received long-term intravenous antibiotics for the infection.

The patient lacks full range of motion in his hand and is unable to fully open the fingers or make a tight fist. He has a trigger finger, surgical scars, and painful nodules. The hand is also extremely intolerant to temperature. The plaintiff claimed that the debridement surgeries would have been unnecessary if the initial culture reports had been acted upon in a timely manner.

The defendants claimed Dr. W saw no evidence of infection at the first office visit and that there was no sign of infection when the steroid injection was administered. The defendants claimed that the hand’s condition did not worsen after the injection and that the plaintiff was referred to Dr. C when a second fishing trip led to a flare-up that eluded diagnosis. Dr. W maintained that, during the procedure that produced the first cultures, he instructed the circulating nurse to have all lab results sent to both himself and Dr. C. Dr. W believed that Dr. C had been sent the results when he saw both their names on the pathology reports.

Continue reading to see the outcome... 

OUTCOME

A $215,000 verdict was returned. The surgical center at which the procedure was performed that produced the first culture settled prior to trial for $200,000.

Continue reading for David M. Lang's commentary... 

COMMENT

This case raises three issues: 

First, hand infections can be problematic and are often trivialized by the initially consulted clinician. The presentation of certain hand infections, such as paronychiae and felons, generally will be straightforward. Paronychiae are usually managed by the clinician who first sees the patient. Felon management is more difficult, but it still may be drained in ambulatory settings by experienced clinicians. Deeper and more troublesome infections of the hand should raise immediate concern; these include tendon sheath infection, septic arthritis, and deep space hand infections. Hand cases can become complicated, and prompt referral to a specialist is usually warranted for all but the most basic infections.

Second, clinicians must always be on the lookout for important clues pointing to an oddball cause. Here, the overlooked clue was the significance of the patient’s fishing trip. While M. marinum seems obscure, the specific bacteria is known to cause tendon sheath infections when a patient’s hand is punctured by fish spines or when a simple wound is contaminated with stagnant water in nature or from an aquarium.¹ Many of us are familiar with the fungal infection sporotrichosis, which can occur after a gardener is stuck by a rose thorn. Asking about a patient’s hobbies and activities may provide a context for an injury.

Third, communication breakdown is something clinicians often just don’t “get.” After receiving the culture report, the orthopedist should have called the infectious diseases physician to discuss the unusual case. This is particularly true in light of the fact that the orthopedic surgeon injected the hand with steroids, which may have worsened the patient’s condition. Jurors would have the expectation that the case would be followed closely. Everyone is busy, but unusual cases such as this one require a quick call to help the patient and avert liability. Pick up the phone.

Furthermore, the defense strategy here seems misplaced.  The defense argued that the orthopedic surgeon saw no evidence of infection but administered a steroid injection for inflammation. But how can you tell the difference from external observation alone? We’ve all been trained in the classic signs and symptoms of calor (heat), dolor (pain), rubor (redness), and tumor (swelling). But both infectious and noninfectious inflammation will produce these, so the cause would not be readily distinguishable without further investigation.

In sum, take hand infections seriously. Thanks to television shows such as House, lay jurors expect clinicians to puzzle together facts to arrive at an obscure diagnosis. So, before we discharge a patient with a common condition, it is useful to ask about the patient’s job and hobbies. We might also ask the generic question “Were you doing anything unusual?” You may just save a patient and solve a puzzle at the same time.

Finally, communication with other clinicians in complicated cases is required and expected by jurors. —DML

Reference

1. American Society for Surgery of the Hand. Hand infections. www.assh.org/Public/HandConditions/Pages/HandInfections.aspx. Accessed January 9, 2014.

A 50-year-old man sustained a rope-burn injury to his left hand during a fishing trip in early August 2004. He subsequently presented to an orthopedic facility with complaints of a hand infection and was eventually referred to orthopedic surgeon Dr. W.

One week later, Dr. W administered a steroid injection, which caused the infection to worsen. The patient claimed that the steroid injection was contraindicated by the underlying infection. Dr. W referred the patient to Dr. C for infectious disease management.

In November 2004, Dr. W performed an incision and drainage procedure, and specimens were sent for pathology study and cultures. The pathology results were sent to both Dr. W and Dr. C, but the culture results were sent only to Dr. W. Other specimens were sent for culture in November 2004 and January 2005.

The results from the first culture, received by Dr. W in three reports, indicated “Mycobacterium,” “rare presumptive Mycobacterium mar­inum,” and “Myocbacterium marinum.” Dr. W did not forward these results to Dr. C and allegedly did not review the last report. Dr. C treated the plaintiff for a fungal infection based on the results of the second culture. After the third specimen in January 2005 grew acid-fast bacilli, Dr. C was informed that the patient likely had an infection caused by M. marinum.

The patient alleged that the 44-day delay in diagnosis and treatment of the M. marinum infection allowed the infection to worsen. The patient was hospitalized for one week at a major clinic and underwent three debridement surgeries to his left hand. He subsequently underwent five months of physical therapy and received long-term intravenous antibiotics for the infection.

The patient lacks full range of motion in his hand and is unable to fully open the fingers or make a tight fist. He has a trigger finger, surgical scars, and painful nodules. The hand is also extremely intolerant to temperature. The plaintiff claimed that the debridement surgeries would have been unnecessary if the initial culture reports had been acted upon in a timely manner.

The defendants claimed Dr. W saw no evidence of infection at the first office visit and that there was no sign of infection when the steroid injection was administered. The defendants claimed that the hand’s condition did not worsen after the injection and that the plaintiff was referred to Dr. C when a second fishing trip led to a flare-up that eluded diagnosis. Dr. W maintained that, during the procedure that produced the first cultures, he instructed the circulating nurse to have all lab results sent to both himself and Dr. C. Dr. W believed that Dr. C had been sent the results when he saw both their names on the pathology reports.

Continue reading to see the outcome... 

OUTCOME

A $215,000 verdict was returned. The surgical center at which the procedure was performed that produced the first culture settled prior to trial for $200,000.

Continue reading for David M. Lang's commentary... 

COMMENT

This case raises three issues: 

First, hand infections can be problematic and are often trivialized by the initially consulted clinician. The presentation of certain hand infections, such as paronychiae and felons, generally will be straightforward. Paronychiae are usually managed by the clinician who first sees the patient. Felon management is more difficult, but it still may be drained in ambulatory settings by experienced clinicians. Deeper and more troublesome infections of the hand should raise immediate concern; these include tendon sheath infection, septic arthritis, and deep space hand infections. Hand cases can become complicated, and prompt referral to a specialist is usually warranted for all but the most basic infections.

Second, clinicians must always be on the lookout for important clues pointing to an oddball cause. Here, the overlooked clue was the significance of the patient’s fishing trip. While M. marinum seems obscure, the specific bacteria is known to cause tendon sheath infections when a patient’s hand is punctured by fish spines or when a simple wound is contaminated with stagnant water in nature or from an aquarium.¹ Many of us are familiar with the fungal infection sporotrichosis, which can occur after a gardener is stuck by a rose thorn. Asking about a patient’s hobbies and activities may provide a context for an injury.

Third, communication breakdown is something clinicians often just don’t “get.” After receiving the culture report, the orthopedist should have called the infectious diseases physician to discuss the unusual case. This is particularly true in light of the fact that the orthopedic surgeon injected the hand with steroids, which may have worsened the patient’s condition. Jurors would have the expectation that the case would be followed closely. Everyone is busy, but unusual cases such as this one require a quick call to help the patient and avert liability. Pick up the phone.

Furthermore, the defense strategy here seems misplaced.  The defense argued that the orthopedic surgeon saw no evidence of infection but administered a steroid injection for inflammation. But how can you tell the difference from external observation alone? We’ve all been trained in the classic signs and symptoms of calor (heat), dolor (pain), rubor (redness), and tumor (swelling). But both infectious and noninfectious inflammation will produce these, so the cause would not be readily distinguishable without further investigation.

In sum, take hand infections seriously. Thanks to television shows such as House, lay jurors expect clinicians to puzzle together facts to arrive at an obscure diagnosis. So, before we discharge a patient with a common condition, it is useful to ask about the patient’s job and hobbies. We might also ask the generic question “Were you doing anything unusual?” You may just save a patient and solve a puzzle at the same time.

Finally, communication with other clinicians in complicated cases is required and expected by jurors. —DML

Reference

1. American Society for Surgery of the Hand. Hand infections. www.assh.org/Public/HandConditions/Pages/HandInfections.aspx. Accessed January 9, 2014.

In March 2005, a 59-year-old woman underwent cataract surgery performed by an ophthalmologist. After the procedure, a chronic detached retina was found. The patient’s pain persisted, and she underwent three subsequent retinal surgeries. Her left eye is still painful.

The plaintiff alleged negligence in the ophthalmologist’s failure to refer her either for a B-scan ocular ultrasound or to a retinal specialist prior to determining whether cataract surgery would be appropriate. Since the plaintiff was not a good candidate for retinal surgery, she claimed the cataract surgery was unnecessary.

The defendant argued that the patient eventually underwent surgery to repair her detached retina, and the cataract surgery (in addition to the retinal surgery) was required to restore any meaningful vision.

OUTCOME

A $678,483 verdict was returned.

COMMENT

This is an interesting case: The plaintiff did not allege that the cataract surgery itself was negligent, but rather inappropriate because she had a chronic detached retina and couldn’t benefit from the procedure. The jury agreed, concluding that the standard of care required the ophthalmologist to confirm that the retina was viable prior to the surgery. 

The lesson here? For surgical services, take reasonable efforts to ensure the patient will receive the benefit of those services.

Nationally, there is growing media attention on “unnecessary surgeries.” For example, last summer, a 22-year-old semiprofessional baseball player, Jonathan Stelly, made headlines after a Louisiana cardiologist implanted a pacemaker in him following a single syncopal episode. Several cardiologists who subsequently reviewed the case determined that placement of the pacemaker was grossly inappropriate. The offending cardiologist is now in prison, serving a sentence for Medicare fraud after billing for dozens of similar unnecessary procedures.

As the federal government becomes more involved in health care, we can expect aggressive auditing that seeks to ferret out “unnecessary” or “inappropriate” surgeries. The question is, who makes that determination?

Do your part to protect yourself, your practice, and most importantly, your patient. Communicate all surgical procedure risks, expectations, and limitations to the patient. Discuss and document all options, especially nonsurgical ones. Be particularly cautious in “borderline” cases in which either the indication for surgery is a close call or the benefit is uncertain or minimal.

Should you find yourself trap­ped in a practice in which surgeries are performed that are clearly fraudulently inappropriate, it is your ethical duty to get out of the practice and make reasonable ­efforts to stop the fraudulent ­activity. —DML

In March 2005, a 59-year-old woman underwent cataract surgery performed by an ophthalmologist. After the procedure, a chronic detached retina was found. The patient’s pain persisted, and she underwent three subsequent retinal surgeries. Her left eye is still painful.

The plaintiff alleged negligence in the ophthalmologist’s failure to refer her either for a B-scan ocular ultrasound or to a retinal specialist prior to determining whether cataract surgery would be appropriate. Since the plaintiff was not a good candidate for retinal surgery, she claimed the cataract surgery was unnecessary.

The defendant argued that the patient eventually underwent surgery to repair her detached retina, and the cataract surgery (in addition to the retinal surgery) was required to restore any meaningful vision.

OUTCOME

A $678,483 verdict was returned.

COMMENT

This is an interesting case: The plaintiff did not allege that the cataract surgery itself was negligent, but rather inappropriate because she had a chronic detached retina and couldn’t benefit from the procedure. The jury agreed, concluding that the standard of care required the ophthalmologist to confirm that the retina was viable prior to the surgery. 

The lesson here? For surgical services, take reasonable efforts to ensure the patient will receive the benefit of those services.

Nationally, there is growing media attention on “unnecessary surgeries.” For example, last summer, a 22-year-old semiprofessional baseball player, Jonathan Stelly, made headlines after a Louisiana cardiologist implanted a pacemaker in him following a single syncopal episode. Several cardiologists who subsequently reviewed the case determined that placement of the pacemaker was grossly inappropriate. The offending cardiologist is now in prison, serving a sentence for Medicare fraud after billing for dozens of similar unnecessary procedures.

As the federal government becomes more involved in health care, we can expect aggressive auditing that seeks to ferret out “unnecessary” or “inappropriate” surgeries. The question is, who makes that determination?

Do your part to protect yourself, your practice, and most importantly, your patient. Communicate all surgical procedure risks, expectations, and limitations to the patient. Discuss and document all options, especially nonsurgical ones. Be particularly cautious in “borderline” cases in which either the indication for surgery is a close call or the benefit is uncertain or minimal.

Should you find yourself trap­ped in a practice in which surgeries are performed that are clearly fraudulently inappropriate, it is your ethical duty to get out of the practice and make reasonable ­efforts to stop the fraudulent ­activity. —DML

In March 2005, a 59-year-old woman underwent cataract surgery performed by an ophthalmologist. After the procedure, a chronic detached retina was found. The patient’s pain persisted, and she underwent three subsequent retinal surgeries. Her left eye is still painful.

The plaintiff alleged negligence in the ophthalmologist’s failure to refer her either for a B-scan ocular ultrasound or to a retinal specialist prior to determining whether cataract surgery would be appropriate. Since the plaintiff was not a good candidate for retinal surgery, she claimed the cataract surgery was unnecessary.

The defendant argued that the patient eventually underwent surgery to repair her detached retina, and the cataract surgery (in addition to the retinal surgery) was required to restore any meaningful vision.

OUTCOME

A $678,483 verdict was returned.

COMMENT

This is an interesting case: The plaintiff did not allege that the cataract surgery itself was negligent, but rather inappropriate because she had a chronic detached retina and couldn’t benefit from the procedure. The jury agreed, concluding that the standard of care required the ophthalmologist to confirm that the retina was viable prior to the surgery. 

The lesson here? For surgical services, take reasonable efforts to ensure the patient will receive the benefit of those services.

Nationally, there is growing media attention on “unnecessary surgeries.” For example, last summer, a 22-year-old semiprofessional baseball player, Jonathan Stelly, made headlines after a Louisiana cardiologist implanted a pacemaker in him following a single syncopal episode. Several cardiologists who subsequently reviewed the case determined that placement of the pacemaker was grossly inappropriate. The offending cardiologist is now in prison, serving a sentence for Medicare fraud after billing for dozens of similar unnecessary procedures.

As the federal government becomes more involved in health care, we can expect aggressive auditing that seeks to ferret out “unnecessary” or “inappropriate” surgeries. The question is, who makes that determination?

Do your part to protect yourself, your practice, and most importantly, your patient. Communicate all surgical procedure risks, expectations, and limitations to the patient. Discuss and document all options, especially nonsurgical ones. Be particularly cautious in “borderline” cases in which either the indication for surgery is a close call or the benefit is uncertain or minimal.

Should you find yourself trap­ped in a practice in which surgeries are performed that are clearly fraudulently inappropriate, it is your ethical duty to get out of the practice and make reasonable ­efforts to stop the fraudulent ­activity. —DML

Uterine rupture after unplanned VBAC
A 34-year-old woman went into labor 9 days before a scheduled repeat cesarean. She gave birth vaginally to a healthy baby.

After delivery, the mother complained of sharp abdominal pain that she rated 10/10 on the pain scale; pain was unrelieved by morphine. Moderate bleeding was noted. After the ObGyn performed a manual exploration and curette procedure, uterine scar rupture was ruled out and the patient was treated for uterine atony. For 90 minutes, the patient was hypotensive and tachycardic with moderate bleeding. Her hemoglobin and hematocrit levels dropped lower than before delivery, and she went into cardiac arrest. After resuscitation, she received a blood transfusion. A second ObGyn took over her care.

Although the patient received 7 U each of packed red blood cells (PRBC) and fresh frozen plasma (FFP) over the next 5 hours, she continued to have low hemoglobin and hematocrit values. Bleeding was noted as sporadic. Shortly after a decision was made to perform a hysterectomy, the patient experienced cardiac arrest and was successfully resuscitated. At surgery, a uterine rupture was noted. She received 14 U each of PRBC and FFP during surgery. Bleeding stopped after the hysterectomy, but the patient remained on a ventilator for 9 days, suffered renal failure and adrenal insufficiency, and went into cardiac arrest twice more.

The patient suffered brain damage and has poor memory function. She had to relearn to walk, talk, and perform normal life tasks. She underwent a kidney transplant because of permanent kidney damage and will require additional kidney transplants during her lifetime.

PATIENT’S CLAIM The ObGyn failed to recognize uterine scar rupture and perform an immediate hysterectomy. The operative report from the hysterectomy used the words uterine scar “rupture” and “dehiscence” interchangeably as the source of bleeding and hemorrhagic shock.

DEFENDANTS’ DEFENSE The patient’s injury was a prior uterine scar “dehiscence” and not a complete rupture; conservative measures were appropriate.

VERDICT A $4 million Virginia verdict was returned that was reduced to $2 million under the state cap.

Woman in vegetative state after cystectomy
Two days after ovarian cystectomy, a 55-year-old woman was returned to the operating room for primary repair of a colon injury. Postoperatively, a colovesical fistula developed. During a third operation, the patient suffered cardiac arrest and sustained brain damage due to lack of oxygen. She remains in a vegetative state.

PATIENT’S CLAIM The colon injury was not detected or treated in a timely manner. A temporary colostomy should have been performed. Metoprolol tartrate, given after the third operation, caused cardiac arrest.

DEFENDANTS’ DEFENSE A settlement was reached during trial.

VERDICT A $2.725 million New Jersey settlement was reached with two physicians, a nurse, and the hospital. A third physician was released from liability.

Breast surgery leaves triangular areola
Cosmetic breast surgery on a 37-year-old woman included insertion of implants, a mastopexy, and reduction of the areolae. After surgery, one areola appeared triangularly shaped. After several months, the patient saw another plastic surgeon who surgically removed the undesirable tissue to reshape the areola.

PATIENT’S CLAIM Postoperatively, the plastic surgeon explained that the patient’s nipples were surrounded by hyperpigmented tissue that had to be removed during a second operation. The patient signed a consent to surgery, but the document did not explain that additional procedures could be necessary.

PHYSICIAN’S DEFENSE The signed consent form included language that additional procedures could be necessary. The plastic surgeon would have performed a free correction of the areola, but the procedure could not occur until the patient’s breasts had healed. In the meantime, the patient went to another surgeon.

VERDICT A New York defense verdict was returned.

Operative report contested
A gynecologist performed a hysterectomy on a 43-year-old woman. Two days after surgery, she was found to have an obstruction of the left ureter and a bladder injury. Extensive treatment was required to treat the injury.

PATIENT’S CLAIM Surgery was performed in a negligent manner. The surgical report states that the arteries were clamped and sutured before the ureters had been identified. The ureter injury was caused by the improper use of a clamp.

DEFENDANTS’ DEFENSE The gynecologist claimed that the proper sequence was used during surgery; an assisting physician may have erroneously documented the sequence of events. Surgery was complicated by fibroids that distorted the patient’s anatomy. The injury was a known risk of the procedure. Damage to the ureter could have been caused by a kink in the ureter or by treatment given later by a urologist.

VERDICT A $526,088 verdict was returned.

Was CP a result of poor communication?
The on-call ObGyn was notified that a woman was about to deliver at the hospital. The attending resident monitored labor and delivery until the ObGyn arrived. A cesarean delivery was performed. The child suffered hypoxic ischemic encephalopathy with brain damage and cerebral palsy.

PARENTS’ CLAIM A delay in performing cesarean delivery caused the child’s injuries. The ObGyn, who was not present during labor, failed to properly instruct the resident.

DEFENDANTS’ DEFENSE The ObGyn claimed the resident’s interpretation of the fetal monitoring strips misled her to believe that there was no emergency. Cesarean delivery was immediately performed upon the ObGyn’s arrival.

VERDICT The hospital and resident settled for an undisclosed amount before trial. An Ohio defense verdict was returned for the ObGyn.

Was excessive electrocautery used?
A 52-year-old woman underwent supracervical hysterectomy with bilateral salpingo-oophorectomy. She developed a vaginal-peritoneal fistula and a chronic abscess with pain; additional operations were required.

PATIENT’S CLAIM The ObGyn used excessive electrocauterization during the first operation, leading to fistula development. An adhesive barrier prevented fistula healing. The patient would not have had her ovaries removed had she known the consequences, including hot flashes and painful sexual intercourse.

PHYSICIAN’S DEFENSE Surgery was properly performed; excessive electrocautery was not used. The adhesive barrier was correctly applied and did not cause injury. Fistula development is a known complication of the procedure. Appropriate consent was obtained.

VERDICT An Illinois defense verdict was returned.

Why did child have brain damage?
At 25 weeks’ gestation, a mother was found to have genital herpes and received medication. Gestational diabetes was diagnosed at 29 weeks’ gestation and treated with diet. At 38 weeks’ gestation, the patient came to her prenatal visit with scabies on her abdomen, hands, and feet; a scabicide was prescribed. The resident in charge of her care planned to induce labor between 39 and 40 weeks’ gestation.

Meconium was present when the membranes were broken. When fetal heart-rate monitors showed nonreassuring heart tones, an emergency cesarean delivery was performed.

The baby required resuscitation due to a low heart rate. She experienced a seizure at 4 hours of life. Head imaging was consistent with a herpes infection or an hypoxic ischemic event. The child has cerebral palsy with speech and motor deficits.

PATIENT’S CLAIM The resident failed to respond to signs of fetal distress and call in the attending physician. Cesarean delivery should have been performed earlier.

DEFENDANTS’ DEFENSE The baby recovered well after being slightly depressed at birth; umbilical cord blood gases were in the normal range. There was no hypoxic ischemic event during labor. The baby’s injuries were due to infection.

VERDICT A New York defense verdict was returned.

Diaphragmatic hernia missed on fetal US
At 19 weeks’ gestation, a 25-year-old woman underwent fetal ultrasonography at a radiology clinic. The radiologist’s report indicated that the standard fetal structural survey was “unremarkable.” When the child was born, catastrophic impairment and deformity were present due to a diaphragmatic hernia.

PARENTS’ CLAIM The parents claimed wrongful birth. The radiologist missed a diaphragmatic hernia that was evident on the ultrasound.

DEFENDANTS’ DEFENSE The case was settled before trial.

VERDICT A $333,664 net Florida settlement was reached after deduction of attorney’s fees.

Was breast cancer missed on screening mammogram?
Screening mammography conducted in July 2009 was reported by a radiologist as being unchanged when compared to studies from the previous 2 years. Several months later, the patient discovered a lump in her right breast that was diagnosed as cancer. She underwent a lumpectomy in July 2010, followed by chemotherapy. The patient’s cancer metastasized and she developed lymphedema.

PATIENT’S CLAIM The 2009 mammography showed an abnormality in the right breast that was not present on earlier films. Further testing and treatment in 2009 would have prevented metastasis.

PHYSICIAN’S DEFENSE There was no negligence; the 2009 mammogram was properly read. Treatment and outcome would have been the same regardless of the timing of diagnosis.

VERDICT A $140,919 Michigan verdict was returned.

Premature twin has CP
Born at 26 weeks’ gestation, one twin was in critical condition. She was taken to the pediatric intensive care unit, where she remained for 46 days, and was then transferred to a long-term care center. She suffers from cerebral palsy.

PARENTS’ CLAIM Prompt treatment would have reduced or eliminated some of the effects of cerebral palsy. The birth hospital did not have pulmonary surfactant or nitric oxide with high-frequency jet-ventilation therapy that would have improved the newborn’s respiration. The baby should have been immediately transferred to a facility where this treatment was available. The parents requested a transfer, but it was denied.

DEFENDANTS’ DEFENSE The child was given every appropriate method of treatment; she was adequately oxygenated. Nitric oxide was not FDA-approved for use in this case. The child’s disabilities were a result of her prematurity.

VERDICT A New York defense verdict was returned.

Benign findings after radiation had started
After a 45-year-old woman found a lump in her right breast in October 2006, a pathologist interpreted biopsy results as ductal carcinoma in situ. A general surgeon and an oncologist both recommended partial mastectomy and lymphadenectomy with radiotherapy and possible tamoxifen treatment. Surgery was performed in November 2006, and radiation treatment began in early December.

The oncologist required that slides be reviewed by pathologists at her cancer center before determining if tamoxifen was appropriate. The pathology report indicated that the patient did not have breast cancer, but had atypical ductal hyperplasia. When the patient learned she did not have cancer, she immediately halted radiation therapy, but had already suffered radiation burns on her breast.

PATIENT’S CLAIM The oncologist was notified that the patient did not have cancer in mid-December, but did not tell the patient until January, when they met to discuss tamoxifen therapy. The patient is now at risk for sarcoma, changes in breast tissue, and rib fractures because of radiation therapy. Partial mastectomy and lymphadenectomy are proper treatment for atypical ductal hyperplasia, but radiation therapy is not. The patient is depressed and anxious.

DEFENDANTS’ DEFENSE The oncologist claimed the patient was not informed of the change in diagnosis because radiation treatment is acceptable treatment for atypical ductal hyperplasia; there was no reason for treatment to be stopped.

The pathologist stated that cell variation between ductal carcinoma and atypical ductal hyperplasia is so slight that two pathologists could reach different conclusions reading the same slide. His interpretation was appropriate. The patient was not clinically depressed; she never sought treatment.

VERDICT A $150,000 Pennsylvania verdict was returned against the oncologist. A defense verdict was returned for the pathologist.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

WE WANT TO HEAR FROM YOU. Tell us what you think.

Uterine rupture after unplanned VBAC
A 34-year-old woman went into labor 9 days before a scheduled repeat cesarean. She gave birth vaginally to a healthy baby.

After delivery, the mother complained of sharp abdominal pain that she rated 10/10 on the pain scale; pain was unrelieved by morphine. Moderate bleeding was noted. After the ObGyn performed a manual exploration and curette procedure, uterine scar rupture was ruled out and the patient was treated for uterine atony. For 90 minutes, the patient was hypotensive and tachycardic with moderate bleeding. Her hemoglobin and hematocrit levels dropped lower than before delivery, and she went into cardiac arrest. After resuscitation, she received a blood transfusion. A second ObGyn took over her care.

Although the patient received 7 U each of packed red blood cells (PRBC) and fresh frozen plasma (FFP) over the next 5 hours, she continued to have low hemoglobin and hematocrit values. Bleeding was noted as sporadic. Shortly after a decision was made to perform a hysterectomy, the patient experienced cardiac arrest and was successfully resuscitated. At surgery, a uterine rupture was noted. She received 14 U each of PRBC and FFP during surgery. Bleeding stopped after the hysterectomy, but the patient remained on a ventilator for 9 days, suffered renal failure and adrenal insufficiency, and went into cardiac arrest twice more.

The patient suffered brain damage and has poor memory function. She had to relearn to walk, talk, and perform normal life tasks. She underwent a kidney transplant because of permanent kidney damage and will require additional kidney transplants during her lifetime.

PATIENT’S CLAIM The ObGyn failed to recognize uterine scar rupture and perform an immediate hysterectomy. The operative report from the hysterectomy used the words uterine scar “rupture” and “dehiscence” interchangeably as the source of bleeding and hemorrhagic shock.

DEFENDANTS’ DEFENSE The patient’s injury was a prior uterine scar “dehiscence” and not a complete rupture; conservative measures were appropriate.

VERDICT A $4 million Virginia verdict was returned that was reduced to $2 million under the state cap.

Woman in vegetative state after cystectomy
Two days after ovarian cystectomy, a 55-year-old woman was returned to the operating room for primary repair of a colon injury. Postoperatively, a colovesical fistula developed. During a third operation, the patient suffered cardiac arrest and sustained brain damage due to lack of oxygen. She remains in a vegetative state.

PATIENT’S CLAIM The colon injury was not detected or treated in a timely manner. A temporary colostomy should have been performed. Metoprolol tartrate, given after the third operation, caused cardiac arrest.

DEFENDANTS’ DEFENSE A settlement was reached during trial.

VERDICT A $2.725 million New Jersey settlement was reached with two physicians, a nurse, and the hospital. A third physician was released from liability.

Breast surgery leaves triangular areola
Cosmetic breast surgery on a 37-year-old woman included insertion of implants, a mastopexy, and reduction of the areolae. After surgery, one areola appeared triangularly shaped. After several months, the patient saw another plastic surgeon who surgically removed the undesirable tissue to reshape the areola.

PATIENT’S CLAIM Postoperatively, the plastic surgeon explained that the patient’s nipples were surrounded by hyperpigmented tissue that had to be removed during a second operation. The patient signed a consent to surgery, but the document did not explain that additional procedures could be necessary.

PHYSICIAN’S DEFENSE The signed consent form included language that additional procedures could be necessary. The plastic surgeon would have performed a free correction of the areola, but the procedure could not occur until the patient’s breasts had healed. In the meantime, the patient went to another surgeon.

VERDICT A New York defense verdict was returned.

Operative report contested
A gynecologist performed a hysterectomy on a 43-year-old woman. Two days after surgery, she was found to have an obstruction of the left ureter and a bladder injury. Extensive treatment was required to treat the injury.

PATIENT’S CLAIM Surgery was performed in a negligent manner. The surgical report states that the arteries were clamped and sutured before the ureters had been identified. The ureter injury was caused by the improper use of a clamp.

DEFENDANTS’ DEFENSE The gynecologist claimed that the proper sequence was used during surgery; an assisting physician may have erroneously documented the sequence of events. Surgery was complicated by fibroids that distorted the patient’s anatomy. The injury was a known risk of the procedure. Damage to the ureter could have been caused by a kink in the ureter or by treatment given later by a urologist.

VERDICT A $526,088 verdict was returned.

Was CP a result of poor communication?
The on-call ObGyn was notified that a woman was about to deliver at the hospital. The attending resident monitored labor and delivery until the ObGyn arrived. A cesarean delivery was performed. The child suffered hypoxic ischemic encephalopathy with brain damage and cerebral palsy.

PARENTS’ CLAIM A delay in performing cesarean delivery caused the child’s injuries. The ObGyn, who was not present during labor, failed to properly instruct the resident.

DEFENDANTS’ DEFENSE The ObGyn claimed the resident’s interpretation of the fetal monitoring strips misled her to believe that there was no emergency. Cesarean delivery was immediately performed upon the ObGyn’s arrival.

VERDICT The hospital and resident settled for an undisclosed amount before trial. An Ohio defense verdict was returned for the ObGyn.

Was excessive electrocautery used?
A 52-year-old woman underwent supracervical hysterectomy with bilateral salpingo-oophorectomy. She developed a vaginal-peritoneal fistula and a chronic abscess with pain; additional operations were required.

PATIENT’S CLAIM The ObGyn used excessive electrocauterization during the first operation, leading to fistula development. An adhesive barrier prevented fistula healing. The patient would not have had her ovaries removed had she known the consequences, including hot flashes and painful sexual intercourse.

PHYSICIAN’S DEFENSE Surgery was properly performed; excessive electrocautery was not used. The adhesive barrier was correctly applied and did not cause injury. Fistula development is a known complication of the procedure. Appropriate consent was obtained.

VERDICT An Illinois defense verdict was returned.

Why did child have brain damage?
At 25 weeks’ gestation, a mother was found to have genital herpes and received medication. Gestational diabetes was diagnosed at 29 weeks’ gestation and treated with diet. At 38 weeks’ gestation, the patient came to her prenatal visit with scabies on her abdomen, hands, and feet; a scabicide was prescribed. The resident in charge of her care planned to induce labor between 39 and 40 weeks’ gestation.

Meconium was present when the membranes were broken. When fetal heart-rate monitors showed nonreassuring heart tones, an emergency cesarean delivery was performed.

The baby required resuscitation due to a low heart rate. She experienced a seizure at 4 hours of life. Head imaging was consistent with a herpes infection or an hypoxic ischemic event. The child has cerebral palsy with speech and motor deficits.

PATIENT’S CLAIM The resident failed to respond to signs of fetal distress and call in the attending physician. Cesarean delivery should have been performed earlier.

DEFENDANTS’ DEFENSE The baby recovered well after being slightly depressed at birth; umbilical cord blood gases were in the normal range. There was no hypoxic ischemic event during labor. The baby’s injuries were due to infection.

VERDICT A New York defense verdict was returned.

Diaphragmatic hernia missed on fetal US
At 19 weeks’ gestation, a 25-year-old woman underwent fetal ultrasonography at a radiology clinic. The radiologist’s report indicated that the standard fetal structural survey was “unremarkable.” When the child was born, catastrophic impairment and deformity were present due to a diaphragmatic hernia.

PARENTS’ CLAIM The parents claimed wrongful birth. The radiologist missed a diaphragmatic hernia that was evident on the ultrasound.

DEFENDANTS’ DEFENSE The case was settled before trial.

VERDICT A $333,664 net Florida settlement was reached after deduction of attorney’s fees.

Was breast cancer missed on screening mammogram?
Screening mammography conducted in July 2009 was reported by a radiologist as being unchanged when compared to studies from the previous 2 years. Several months later, the patient discovered a lump in her right breast that was diagnosed as cancer. She underwent a lumpectomy in July 2010, followed by chemotherapy. The patient’s cancer metastasized and she developed lymphedema.

PATIENT’S CLAIM The 2009 mammography showed an abnormality in the right breast that was not present on earlier films. Further testing and treatment in 2009 would have prevented metastasis.

PHYSICIAN’S DEFENSE There was no negligence; the 2009 mammogram was properly read. Treatment and outcome would have been the same regardless of the timing of diagnosis.

VERDICT A $140,919 Michigan verdict was returned.

Premature twin has CP
Born at 26 weeks’ gestation, one twin was in critical condition. She was taken to the pediatric intensive care unit, where she remained for 46 days, and was then transferred to a long-term care center. She suffers from cerebral palsy.

PARENTS’ CLAIM Prompt treatment would have reduced or eliminated some of the effects of cerebral palsy. The birth hospital did not have pulmonary surfactant or nitric oxide with high-frequency jet-ventilation therapy that would have improved the newborn’s respiration. The baby should have been immediately transferred to a facility where this treatment was available. The parents requested a transfer, but it was denied.

DEFENDANTS’ DEFENSE The child was given every appropriate method of treatment; she was adequately oxygenated. Nitric oxide was not FDA-approved for use in this case. The child’s disabilities were a result of her prematurity.

VERDICT A New York defense verdict was returned.

Benign findings after radiation had started
After a 45-year-old woman found a lump in her right breast in October 2006, a pathologist interpreted biopsy results as ductal carcinoma in situ. A general surgeon and an oncologist both recommended partial mastectomy and lymphadenectomy with radiotherapy and possible tamoxifen treatment. Surgery was performed in November 2006, and radiation treatment began in early December.

The oncologist required that slides be reviewed by pathologists at her cancer center before determining if tamoxifen was appropriate. The pathology report indicated that the patient did not have breast cancer, but had atypical ductal hyperplasia. When the patient learned she did not have cancer, she immediately halted radiation therapy, but had already suffered radiation burns on her breast.

PATIENT’S CLAIM The oncologist was notified that the patient did not have cancer in mid-December, but did not tell the patient until January, when they met to discuss tamoxifen therapy. The patient is now at risk for sarcoma, changes in breast tissue, and rib fractures because of radiation therapy. Partial mastectomy and lymphadenectomy are proper treatment for atypical ductal hyperplasia, but radiation therapy is not. The patient is depressed and anxious.

DEFENDANTS’ DEFENSE The oncologist claimed the patient was not informed of the change in diagnosis because radiation treatment is acceptable treatment for atypical ductal hyperplasia; there was no reason for treatment to be stopped.

The pathologist stated that cell variation between ductal carcinoma and atypical ductal hyperplasia is so slight that two pathologists could reach different conclusions reading the same slide. His interpretation was appropriate. The patient was not clinically depressed; she never sought treatment.

VERDICT A $150,000 Pennsylvania verdict was returned against the oncologist. A defense verdict was returned for the pathologist.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

WE WANT TO HEAR FROM YOU. Tell us what you think.

Uterine rupture after unplanned VBAC
A 34-year-old woman went into labor 9 days before a scheduled repeat cesarean. She gave birth vaginally to a healthy baby.

After delivery, the mother complained of sharp abdominal pain that she rated 10/10 on the pain scale; pain was unrelieved by morphine. Moderate bleeding was noted. After the ObGyn performed a manual exploration and curette procedure, uterine scar rupture was ruled out and the patient was treated for uterine atony. For 90 minutes, the patient was hypotensive and tachycardic with moderate bleeding. Her hemoglobin and hematocrit levels dropped lower than before delivery, and she went into cardiac arrest. After resuscitation, she received a blood transfusion. A second ObGyn took over her care.

Although the patient received 7 U each of packed red blood cells (PRBC) and fresh frozen plasma (FFP) over the next 5 hours, she continued to have low hemoglobin and hematocrit values. Bleeding was noted as sporadic. Shortly after a decision was made to perform a hysterectomy, the patient experienced cardiac arrest and was successfully resuscitated. At surgery, a uterine rupture was noted. She received 14 U each of PRBC and FFP during surgery. Bleeding stopped after the hysterectomy, but the patient remained on a ventilator for 9 days, suffered renal failure and adrenal insufficiency, and went into cardiac arrest twice more.

The patient suffered brain damage and has poor memory function. She had to relearn to walk, talk, and perform normal life tasks. She underwent a kidney transplant because of permanent kidney damage and will require additional kidney transplants during her lifetime.

PATIENT’S CLAIM The ObGyn failed to recognize uterine scar rupture and perform an immediate hysterectomy. The operative report from the hysterectomy used the words uterine scar “rupture” and “dehiscence” interchangeably as the source of bleeding and hemorrhagic shock.

DEFENDANTS’ DEFENSE The patient’s injury was a prior uterine scar “dehiscence” and not a complete rupture; conservative measures were appropriate.

VERDICT A $4 million Virginia verdict was returned that was reduced to $2 million under the state cap.

Woman in vegetative state after cystectomy
Two days after ovarian cystectomy, a 55-year-old woman was returned to the operating room for primary repair of a colon injury. Postoperatively, a colovesical fistula developed. During a third operation, the patient suffered cardiac arrest and sustained brain damage due to lack of oxygen. She remains in a vegetative state.

PATIENT’S CLAIM The colon injury was not detected or treated in a timely manner. A temporary colostomy should have been performed. Metoprolol tartrate, given after the third operation, caused cardiac arrest.

DEFENDANTS’ DEFENSE A settlement was reached during trial.

VERDICT A $2.725 million New Jersey settlement was reached with two physicians, a nurse, and the hospital. A third physician was released from liability.

Breast surgery leaves triangular areola
Cosmetic breast surgery on a 37-year-old woman included insertion of implants, a mastopexy, and reduction of the areolae. After surgery, one areola appeared triangularly shaped. After several months, the patient saw another plastic surgeon who surgically removed the undesirable tissue to reshape the areola.

PATIENT’S CLAIM Postoperatively, the plastic surgeon explained that the patient’s nipples were surrounded by hyperpigmented tissue that had to be removed during a second operation. The patient signed a consent to surgery, but the document did not explain that additional procedures could be necessary.

PHYSICIAN’S DEFENSE The signed consent form included language that additional procedures could be necessary. The plastic surgeon would have performed a free correction of the areola, but the procedure could not occur until the patient’s breasts had healed. In the meantime, the patient went to another surgeon.

VERDICT A New York defense verdict was returned.

Operative report contested
A gynecologist performed a hysterectomy on a 43-year-old woman. Two days after surgery, she was found to have an obstruction of the left ureter and a bladder injury. Extensive treatment was required to treat the injury.

PATIENT’S CLAIM Surgery was performed in a negligent manner. The surgical report states that the arteries were clamped and sutured before the ureters had been identified. The ureter injury was caused by the improper use of a clamp.

DEFENDANTS’ DEFENSE The gynecologist claimed that the proper sequence was used during surgery; an assisting physician may have erroneously documented the sequence of events. Surgery was complicated by fibroids that distorted the patient’s anatomy. The injury was a known risk of the procedure. Damage to the ureter could have been caused by a kink in the ureter or by treatment given later by a urologist.

VERDICT A $526,088 verdict was returned.

Was CP a result of poor communication?
The on-call ObGyn was notified that a woman was about to deliver at the hospital. The attending resident monitored labor and delivery until the ObGyn arrived. A cesarean delivery was performed. The child suffered hypoxic ischemic encephalopathy with brain damage and cerebral palsy.

PARENTS’ CLAIM A delay in performing cesarean delivery caused the child’s injuries. The ObGyn, who was not present during labor, failed to properly instruct the resident.

DEFENDANTS’ DEFENSE The ObGyn claimed the resident’s interpretation of the fetal monitoring strips misled her to believe that there was no emergency. Cesarean delivery was immediately performed upon the ObGyn’s arrival.

VERDICT The hospital and resident settled for an undisclosed amount before trial. An Ohio defense verdict was returned for the ObGyn.

Was excessive electrocautery used?
A 52-year-old woman underwent supracervical hysterectomy with bilateral salpingo-oophorectomy. She developed a vaginal-peritoneal fistula and a chronic abscess with pain; additional operations were required.

PATIENT’S CLAIM The ObGyn used excessive electrocauterization during the first operation, leading to fistula development. An adhesive barrier prevented fistula healing. The patient would not have had her ovaries removed had she known the consequences, including hot flashes and painful sexual intercourse.

PHYSICIAN’S DEFENSE Surgery was properly performed; excessive electrocautery was not used. The adhesive barrier was correctly applied and did not cause injury. Fistula development is a known complication of the procedure. Appropriate consent was obtained.

VERDICT An Illinois defense verdict was returned.

Why did child have brain damage?
At 25 weeks’ gestation, a mother was found to have genital herpes and received medication. Gestational diabetes was diagnosed at 29 weeks’ gestation and treated with diet. At 38 weeks’ gestation, the patient came to her prenatal visit with scabies on her abdomen, hands, and feet; a scabicide was prescribed. The resident in charge of her care planned to induce labor between 39 and 40 weeks’ gestation.

Meconium was present when the membranes were broken. When fetal heart-rate monitors showed nonreassuring heart tones, an emergency cesarean delivery was performed.

The baby required resuscitation due to a low heart rate. She experienced a seizure at 4 hours of life. Head imaging was consistent with a herpes infection or an hypoxic ischemic event. The child has cerebral palsy with speech and motor deficits.

PATIENT’S CLAIM The resident failed to respond to signs of fetal distress and call in the attending physician. Cesarean delivery should have been performed earlier.

DEFENDANTS’ DEFENSE The baby recovered well after being slightly depressed at birth; umbilical cord blood gases were in the normal range. There was no hypoxic ischemic event during labor. The baby’s injuries were due to infection.

VERDICT A New York defense verdict was returned.

Diaphragmatic hernia missed on fetal US
At 19 weeks’ gestation, a 25-year-old woman underwent fetal ultrasonography at a radiology clinic. The radiologist’s report indicated that the standard fetal structural survey was “unremarkable.” When the child was born, catastrophic impairment and deformity were present due to a diaphragmatic hernia.

PARENTS’ CLAIM The parents claimed wrongful birth. The radiologist missed a diaphragmatic hernia that was evident on the ultrasound.

DEFENDANTS’ DEFENSE The case was settled before trial.

VERDICT A $333,664 net Florida settlement was reached after deduction of attorney’s fees.

Was breast cancer missed on screening mammogram?
Screening mammography conducted in July 2009 was reported by a radiologist as being unchanged when compared to studies from the previous 2 years. Several months later, the patient discovered a lump in her right breast that was diagnosed as cancer. She underwent a lumpectomy in July 2010, followed by chemotherapy. The patient’s cancer metastasized and she developed lymphedema.

PATIENT’S CLAIM The 2009 mammography showed an abnormality in the right breast that was not present on earlier films. Further testing and treatment in 2009 would have prevented metastasis.

PHYSICIAN’S DEFENSE There was no negligence; the 2009 mammogram was properly read. Treatment and outcome would have been the same regardless of the timing of diagnosis.

VERDICT A $140,919 Michigan verdict was returned.

Premature twin has CP
Born at 26 weeks’ gestation, one twin was in critical condition. She was taken to the pediatric intensive care unit, where she remained for 46 days, and was then transferred to a long-term care center. She suffers from cerebral palsy.

PARENTS’ CLAIM Prompt treatment would have reduced or eliminated some of the effects of cerebral palsy. The birth hospital did not have pulmonary surfactant or nitric oxide with high-frequency jet-ventilation therapy that would have improved the newborn’s respiration. The baby should have been immediately transferred to a facility where this treatment was available. The parents requested a transfer, but it was denied.

DEFENDANTS’ DEFENSE The child was given every appropriate method of treatment; she was adequately oxygenated. Nitric oxide was not FDA-approved for use in this case. The child’s disabilities were a result of her prematurity.

VERDICT A New York defense verdict was returned.

Benign findings after radiation had started
After a 45-year-old woman found a lump in her right breast in October 2006, a pathologist interpreted biopsy results as ductal carcinoma in situ. A general surgeon and an oncologist both recommended partial mastectomy and lymphadenectomy with radiotherapy and possible tamoxifen treatment. Surgery was performed in November 2006, and radiation treatment began in early December.

The oncologist required that slides be reviewed by pathologists at her cancer center before determining if tamoxifen was appropriate. The pathology report indicated that the patient did not have breast cancer, but had atypical ductal hyperplasia. When the patient learned she did not have cancer, she immediately halted radiation therapy, but had already suffered radiation burns on her breast.

PATIENT’S CLAIM The oncologist was notified that the patient did not have cancer in mid-December, but did not tell the patient until January, when they met to discuss tamoxifen therapy. The patient is now at risk for sarcoma, changes in breast tissue, and rib fractures because of radiation therapy. Partial mastectomy and lymphadenectomy are proper treatment for atypical ductal hyperplasia, but radiation therapy is not. The patient is depressed and anxious.

DEFENDANTS’ DEFENSE The oncologist claimed the patient was not informed of the change in diagnosis because radiation treatment is acceptable treatment for atypical ductal hyperplasia; there was no reason for treatment to be stopped.

The pathologist stated that cell variation between ductal carcinoma and atypical ductal hyperplasia is so slight that two pathologists could reach different conclusions reading the same slide. His interpretation was appropriate. The patient was not clinically depressed; she never sought treatment.

VERDICT A $150,000 Pennsylvania verdict was returned against the oncologist. A defense verdict was returned for the pathologist.

These cases were selected by the editors of OBG Management from Medical Malpractice Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information available to the editors about the cases presented here is sometimes incomplete. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation and are meant to illustrate nationwide variation in jury verdicts and awards.

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