Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
Undiluted Acetic Acid Used for Surgery on Vulvar Lesion
The patient, a 42-year-old Ohio woman, was scheduled for a
gynecologic surgical procedure. The surgery was to be performed in the hospital by a general practice obstetrician/gynecologist for treatment of low-grade squamous intraepithelial lesions (ie, vulvar intraepithelial neoplasm [VIN] with moderate dysplasia). The planned procedure was a wide local excision of the vulvar lesions, to be performed under general anesthesia.
The procedure typically includes application of a diluted acetic acid wash to the vulvar area to delineate the borders of the dysplastic areas. Instead of the diluted solution, however, a highly concentrated acetic acid, trichloroacetic acid (TCA), was used.
The patient sustained a severe chemical burn of the vulva, which took several months to heal. She was left with permanent scarring of the vulvar area and extreme tenderness at the vaginal opening, which is atrophic and severely reddened and discolored. The patient has a band of thick scar tissue at the posterior fourchette, and she also sustained burning and severe scarring of the perineum that extends to the anal area, including a 2-mm plaque layer.
The plaintiff claimed that her injuries limited her to extremely painful sexual intercourse (if any), as well as discomfort at all times. Only a complicated set of additional surgical procedures could be recommended to attempt to alleviate her condition and allow relatively pain-free intercourse.
OUTCOME
A $600,000 settlement was reached in direct negotiations with the risk management department of the hospital in question.
COMMENT
This case settled before trial after direct negotiations with the hospital’s risk management department, which is unusual; cases are typically turned over to trial counsel after a case is initiated.
Jurors take a harsh view of such mix-ups, expecting simple safety precautions, like clear labeling, to prevent devastating outcomes.
The negotiated settlement is rather low, given the patient’s pain and demonstrable losses. Ohio has a damages cap on noneconomic damages (eg, pain and suffering, vs economic damages, such as loss of income). Ohio also has a cap on punitive damages—which is double the cap on compensatory damages. In a different jurisdiction without these caps, the defendant hospital’s exposure to larger damages would have been greater.
Clinicians must take an active role to prevent such outcomes. Any substance used in a clinical setting should be clearly labeled. Items not suitable for direct patient use (eg, undiluted acetic acid) should never be brought into the examining room or the operating room. Clinicians should actively monitor support personnel to detect practices that could result in an accident.
Our role as clinicians is to protect the patient: That includes monitoring our practice environment for patterns that could result in accidents (eg, slip and fall), errors (medication administered to the incorrect patient), or unclear accountability (lab values not reviewed in a timely manner). Stay vigilant and work within your team practice environment to spot and correct problems before those problems ripen into errors that may injure patients and land clinicians in court. —DML
Excessive Epinephrine Injection Causes Cardiac Arrest
An Idaho woman, age 39, was to undergo an arthroscopic shoulder procedure in February 2007 at a specialty hospital. Prior to surgery, the patient was mistakenly given an injection of 9 cc epinephrine at a concentration of 1:1,000 instead of the ordered presurgical injection—a diluted concentration of epinephrine 1:200,000, combined with bupivacaine. The patient went into full cardiac arrest and was subsequently diagnosed with a mild brain injury resulting from the lengthy code conducted at the hospital.
The plaintiff claimed that the hospital’s use of 30-mL multidose vials of concentrated epinephrine 1:1,000 in the operating room heightened the risk for medication error. The plaintiff also claimed that the circulating nurse failed to properly label the syringe containing the medication and that the circulating nurse failed to properly run a time-out procedure prior to the medication error.
The defendant claimed that the presence of multidose vials of concentrated epinephrine in the operating room was proper and that the syringe used to inject the plaintiff was properly labeled. The defendant also claimed that a time-out had been properly conducted prior to the medication error.
OUTCOME
According to a published account, a $760,000 verdict was returned. The plaintiff had settled the claim against the orthopedic group prior to trial for a confidential amount and had entered into a high-low agreement with the hospital ($750,000/$500,000) minutes before the verdict was returned.
COMMENT
As in the previous case, this action involves the unintended use of a substance (epinephrine 1:1,000) that bears some similarity to the correct substance (bupivacaine with epinephrine 1:200,000). There was disagreement as to whether the syringe was properly labeled.