Before going to law school, I was a hospital administrator. In that role, I spent a substantial amount of time on various hospital committees reviewing the quality of care and how to improve it. One of the most interesting dilemmas for hospital leaders in such roles is dealing with system errors. System errors are to hospitals as building catastrophic failures are to structural engineers.
Now as a long-time plaintiffs’ medical malpractice attorney, I have some additional observations about health care system errors. In most medical negligence cases, there are multiple errors that contributed to the patient’s injuries. Due to the multidisciplinary way that health care is now provided, it’s less likely in many situations for a mistake by one doctor or nurse to lead to a bad outcome.
Then there are some exceptional cases where there is a massive, inexplicable system failure. These are cases where almost everyone involved with the patient’s care made serious mistakes. I am currently working on a case like that. The challenge in this type of case is making an up-front determination of whose mistakes made a difference in the patient’s injuries and outcome.
In this current case, our client is a trauma patient who was brought to a hospital emergency room by ambulance after a high-speed car accident. He had some serious abdominal injuries from the wreck and also fell and head planted when he got out of the crashed car.
The first of the long list of system errors was in the emergency room. Two minutes after his arrival, a registered nurse documented that a physician assistant (PA) from the trauma service cleared the patient’s cervical spine. This meant that the PA thought it was safe for the patient to be treated without c-collar that would immobilize and stabilize his neck and cervical spine.
The problem with this line of thinking is the peer-reviewed standard of care requires diagnostic radiographic imaging, such as a CT scan, to rule out an unstable cervical spine in trauma patients like this. It’s simply impossible to clear the cervical spine without imaging, but the PA did it anyway. The registered nurse didn’t advocate for proper cervical spine clearance, despite the PA’s decision, which an emergency room physician and trauma surgeon went along with.
The second system error was on the part of the anesthesia providers, and anesthesiologist and certified registered nurse anesthetist (CRNA). The standard of care requires them to do a pre-anesthesia evaluation of the patient to ensure that general anesthesia can be administered safely. They didn’t question the lack of a c-collar or any precautions to stabilize and protect the patient’s neck and cervical spine.
The third system error was on the part of the operating room (OR) team, including the anesthesia providers, the trauma surgery team, and the operating room nurses. He was taken to surgery, by the way, to explore his abdominal injuries from the car crash. Part of the universal protocol requires the entire OR team to pause and verify the correct patient, procedure, and site before proceeding with the surgery. Our experts believe that part of this discussion should have included the consideration of whether the patient’s cervical spine had been properly cleared.
The fourth system error was again on the part of the anesthesia providers, who used conventional endotracheal intubation (insertion of a breathing tube through the patient’s mouth into the airway) rather than alternatives that would have protected an unstable cervical spine.
Shockingly, the errors continued after the patient was taken to the post-anesthesia care unit (PACU or recovery room) and later to the intensive care unit (ICU). In both the PACU and ICU, registered nurses assess the patient and documented a progression of neurologic changes that they failed to communicate to any doctor or PA on the night shift following the patient’s abdominal surgery. As a result, the patient’s neurologic status deteriorated over a period of about 12 hours.
In the morning, the dayshift nursed realize that something was wrong after doing a neuro check on the patient and notified a resident physician with the surgery service. A resident is a junior physician who is still receiving clinical training in a hospital setting. The resident ordered placement of a C-collar and a MRI of the neck and cervical spine.
The fifth system error was the resident’s choice to order the MRI as a routine scan, rather than stat (as soon as possible). The sixth system error is that it took five hours for the scan to be performed and a radiologist to interpret the images and report back to a doctor. The report showed that the patient’s neck had been injured and that his cervical spine was unstable.
The sixth system error was the sluggish response by the resident and the supervising attending trauma surgeon in ordering a consultation with a spine surgeon. This should have been done as soon as they had learned of the patient’s change in neurologic status first thing that morning. Instead, they waited over five hours for the MRI results to order a spine surgery consult, and even then, only ordered it routine, rather than stat.
The seventh system error was the snail’s pace response of the spine surgery service. Once the spine surgeon and PA were notified of the patient’s rapidly deteriorating neurologic status and the abnormal MRI result, they responded by ordering a CT scan. You guessed it—the order was routine, not stat.
The eighth system error was taking two and half hours for the CT scan to be performed and interpreted. It revealed further emergency abnormalities in the patient’s cervical spine, including a space-occupying lesion that was felt to be a hematoma. Hematomas are notorious for causing spinal cord compression.
Despite the patient’s poor neurologic status and amount of evidence showing that he needed emergency surgical intervention, the ninth system error was the spine surgery services decision to wait until the next day to perform surgery. By then, though, it was too late to save his neurologic function. The patient was permanently quadriplegic.
The medical experts hired by Painter Law Firm are surprised and, frankly, confused at how so many physicians, nurses, and other health care provider shown no urgency. No one called to follow up on orders or questioned why scans were taking so long. No one advocated for urgent surgical attention. They just let their patient decline right in front of their eyes.
If you’ve been seriously injured because of poor hospital or surgical care in Texas, then contact a skilled, top-rated Houston, Texas medical malpractice lawyer to discuss your potential case.
