Assignment Overview

Researchers at Johns Hopkins University (Makary & Daniel, 2016) found that at the time of their study, medical errors accounted for the third leading cause of death in the United States. Medication errors are included in this. In Module 2 we explored individual liability. In Module 4 we examine organizational liability.

Makary, M., & Daniel, M. (2016). Medical error—the third leading cause of death in the US. BMJ, 353. 

Case Assignment

Capazzola, D. D. (2016). Medication mix-up leaves 51-year-old patient with permanent brain damage after heart surgery. Healthcare Risk Management, 38(1). Retrieved from the Trident Online Library.

Read the article above by Capazzola. After reviewing this and other background readings, and doing independent research, address the following:

1. What are the details of the case described by Capazzola?

2. What was the decision of liability made by the court?

3. While the article does not state the specific legal grounds for decision, why do you think that the hospital was found partially liable? Be sure to specifically discuss forms of organizational liability reviewed in the textbook.

4. What safeguards could be put in place to reduce the risk of future error, and thus hospital liability? 

Assignment Expectations

1. Conduct additional research to gather sufficient information to justify/support your analysis.

2. Limit your response to a maximum of 4 pages (title and reference page is not included in page number count).

3. Support your paper with peer-reviewed articles, with at least 3 references. Use the following link for additional information on how to recognize peer-reviewed journals:
Angelo State University Library. (n.d.). Library guides: How to recognize peer-reviewed (refereed) journals. Retrieved from https://www.angelo.edu/services/library/handouts/peerrev.php

4. You may use the following source to assist in formatting your assignment:
Purdue Online Writing Lab. (n.d.). General APA guidelines. Retrieved from https://owl.english.purdue.edu/owl/resource/560/01/

5. For additional information on reliability of sources, review the following source:
Georgetown University Library. (n.d.). Evaluating internet resources. Retrieved from https://www.library.georgetown.edu/tutorials/research-guides/evaluating-internet-content

6. This assignment will be graded based on the content in the rubric. 

Medication mix-up leaves 51-year-old patient with permanent brain damage after heart surgery

Hospital and physicians liable for $12.2 million jury award

Hospital and physicians liable for $12.2 million jury award

By Damian D. Capozzola, Esq.
The Law Offices of Damian D. Capozzola
Los Angeles
Jamie Terrence, RN
President and Founder, Healthcare Risk Services
Former Director of Risk Management Services (2004-2013)
California Hospital Medical Center
Los Angeles
David Vassalli, 2016 JD Candidate
Pepperdine University School of Law
Malibu, CA

News: In 2011, a 51-year-old man was undergoing heart surgery when complications requiring resuscitation arose. The man required cardioversion and was resuscitated after being shocked five or six times. The surgeon then ordered 150 mg of amiodarone, which is a medication used to normalize abnormal heart rhythms. The anesthesiologist retrieved three vials of what he believed to be 50 mg of amiodarone to intravenously administer to the man. However, and unbeknownst to the surgeon and anesthesiologist, each of the three vials that the anesthesiologist did administer to the man contained 900 mg each. The man’s heart stabilized, and the surgeon completed the surgery successfully. The man soon after had a second episode of ventricular fibrillation, which caused the lower chambers of his heart to quiver and prevented it from pumping blood and oxygen to his brain. This situation allegedly was caused by an amiodarone overdose and led to the man being permanently brain damaged, being unable to function on his own, and requiring medical services for the rest of his life. The man brought a medical malpractice suit against the hospital where the medication mix-up occurred, the anesthesiologist who administered the incorrect dosage, and the healthcare provider for whom the anesthesiologist worked. The anesthesiologist acknowledged he administered an incorrect dosage. The hospital denied liability but admitted there was breakdown in communication at the hospital. In a two-week trial, the jury awarded the man $12.2 million, which consisted of $6.4 million for past and future medical costs, and $5.8 million for pain and suffering. The jury further determined that the hospital was 60% responsible, the anesthesiologist was 25% responsible, and the healthcare provider for whom the anesthesiologist worked was 15% responsible for the jury award.

Background: In March 2011, a 51-year-old-man underwent cardiac bypass surgery to replace a heart valve. When the man was taken off of the bypass machines, he developed a ventricular fibrillation and required resuscitation through cardioversion. As a result, the surgeon ordered lidocaine and 150 mg of amiodarone be administered to the man. The bottles that were in the OR room contained 900 mg each of amiodarone, which was an error committed by the hospital’s pharmacy. The pharmacy is to release medication in their minimal dosages so the physicians do not need to measure out their dosages. Nevertheless, the anesthesiologist administered 2,700 mg of amiodarone to the man, which temporarily stabilized his heart and allowed the surgeon to successfully complete the surgery. Soon after the surgery concluded, the man allegedly overdosed from the amiodarone and suffered a second ventricular fibrillation. This situation caused a restriction of blood and oxygen to his brain and left him with a permanent brain injury, loss of ability to function, and in need of around-the-clock medical care for the rest of his life.

The man filed a medical malpractice suit against the hospital for mixing up the dosage of the medication in the pharmacy, the anesthesiologist for administering the incorrect dosage of the medication, and the healthcare provider for whom the anesthesiologist worked for the conduct of its employee. The man alleged these mistakes fell below the standard of care and caused his permanent injuries. The hospital admitted at trial that the medication mix-up was due to a hospital system failure, and the anesthesiologist admitted to administering the wrong dosage, but all parties denied liability and asserted the overdose of amiodarone did not cause the man’s brain damage.

The jury agreed with the man and awarded him $12.2 million in damages. The man was awarded $6.4 million in economic damages for medical expenses, lost wages, and earning capacity, as well as an additional $5.8 million for pain and suffering. The jury also found all three parties responsible and allocated 60% of the liability to the hospital, 25% of the liability to the anesthesiologist, and 15% to the healthcare provider for whom the anesthesiologist worked. In Oregon, where this case took place, all defendants are jointly liable for the entire amount of damages to plaintiffs. As such, the hospital, anesthesiologist, and the healthcare provider for whom the anesthesiologist works are liable for the entire $12.2 million if the other parties cannot pay.

What this means to you: This case shows the physician’s need to confirm what he or she is administering to a patient. In this case, an anesthesiologist, who didn’t work for the hospital where he was assisting, simply followed the direction of the hospital’s surgeon by administering three doses of amiodarone, which each presumably contained 50 mg of the medication. However, each dose actually contained 900 mg of amiodarone, which led the man to receive 2,700 mg of the medication. As was seen in this case, the fact that the anesthesiologist was following direction and the medication doses being mixed-up was not his doing did not shelter him or his employer from liability.

Medication administration requires checking and double checking for the many “rights:” the right patient, the right drug, the right dose, the right time, the right route, etc. It is not just for nurses. All providers must follow these steps. Amiodarone is considered a high-risk medication and should be labeled with that statement along with the dosage. Simply reading the label on the vials should have alerted the anesthesiologist that he was not holding a vial of 50 mg, but in fact 18 times that dose. The pharmacy did not send the dose expected, and that issue is one with preparing and dispensing the medication. However, the duty of the person administering the medication to double check the label is a built-in step to catch these types of errors. Eliminating even one step in the medication administration process can have serious consequences or even be deadly.

Checking the medication he might be administering prior to the surgery or during the surgery, and documenting such actions, likely would have diminished or entirely avoided liability for the anesthesiologist and his employer. As such, medical practitioners seeking to avoid liability should check the label to ensure his or her assumptions are correct when possible before the medication is administered to a patient.

Additionally, during an urgent situation, such as heart surgery, staff might easily become stressed. During periods of high stress, more errors are likely to occur. It is critical that caregivers step back, become composed, communicate with each other, and follow each step of every procedure. Simply asking another person to read the label on the vial to confirm the dose would have favorably altered the outcome.

The other lesson from this case is directed toward hospitals and calls for increased attention to automated systems that deal with sensitive medical materials. The technological mishap in this case occurred with an alleged mistake reading the computer screen when receiving the medication from the pharmacy that caused the 900 mg doses of amiodarone to leave the pharmacy and end up in the surgery room instead of the standard 50 mg. Technology undoubtedly streamlines hospital processes, but heavy reliance upon it can cause a false sense of security for staff. When, as was the case here, hospital protocol is for the physician to expect the minimum dosages of medication to be available, there should be a system in place to ensure the medications are being disseminated in the lowest dosage rates. This relatively easy error to commit resulted in nearly $8 million worth of liability to the hospital and permanently injured a man. Considering the high cost of such an error, it is cost-efficient and in the best interest of physicians and patients for hospitals to implement a safeguard against solely relying on the accuracy of emerging technologies, to monitor such systems regularly to ensure they are functioning properly, and to constantly educate hospital staff on how to operate all the technology associated with patient care.

REFERENCE

Circuit Court of Oregon, Lane County, Case Number 1161413229 (Sept. 29, 2015).