LEGAL AND ETHICAL ISSUES OF A MEDICAL ERROR CASE

CASE STUDY: LEGAL AND ETHICAL ISSUES OF A MEDICAL ERROR

By Matt Stone QHCusa 2010

Legal aspects of our case surround medication and safety errors, which led to the death of a day-old infant born to a mother with a prior history of syphilis. Facts of our case surround, misuse of Medication- processes of safety and quality, misdiagnoses of infant disease and treatment, and incomplete information about mother’s past treatment for syphilis related to current status both mother and child. Among these factors, communication was difficult due to both parents speaking only Spanish. As a result, a decision to mistreat our infant for congenital syphilis was due to misleading and verification processes (Quality Chasm Series, 2007).

In order to identify laws that were, or may have been broken, who was, or may have been liable, elements of negligence must exist. According to Pozgar (2010), four elements must be present for negligence, duty to care, breach of duty, injury, and causation. Negligence is a civil personal wrong of unintentional commission or omission of an act a reasonable prudent person would or would not do under similar circumstances (Pozgar, 2010). Our case suggests, nurses did not apply knowledge ordinarily exercised in care or treatment of a patient.

Pozgar (2010) describes our four elements of negligence as; Duty to care, must not deviate from practice of competent members of his or her profession, and thus, requires health professional to conform to a specific standard of care to protect others (Pozgar, 2010).

Breach of duty must show a deviation from recognized standard of care, which means there must be a failure to adhere to an obligation. Injury is actual damages established, if there are no injuries, no damages are due. Causation is an act or behavior departing from recognized standard of care and must be a cause of injury, for example, Injury was subject to cause by breach of duty, and an injury was foreseeable, in our case, death of a patient (Pozgar, 2010).

Because of a tragic death in our case, and reasons why, facts clearly demonstrates a disregard of protocols conducted by the entire staff, therefore, laws were broken, Malpractice and Criminal Negligence coexist. Pozgar (2010) defines Malpractice is carelessness of healthcare professionals, nurses, pharmacist, and physicians. Criminal Negligence is reckless disregard for safety of another, in other words, willful indifference to an injury that could follow an act (Pozgar, 2010). In our case, each person within our care team is accountable for his or her actions when caring for a patient with fiduciary responsibilities to ensure quality, and safety.

This brings us to forms of Negligence, Misfeasance, and Nonfeasance. Pozgar (2010) defines Misfeasance as improper performance of an act resulting to an injury, in our situation, death of an infant as our patient received wrong treatment due to misdiagnoses of a disease. Further, says, Pozgar (2010) Nonfeasance is failure to act when there is duty to act as a reasonable prudent person should do in similar circumstances, for instance, failure to bring in an interpreter as both parents spoke no English to ensure appropriate diagnosis which led to wrong treatment, as assumed, our infant did not have syphilis.

As assumed, our infant did not have syphilis and our cause of death is due to medication error, because of misdiagnosis of a disease, a final ruling of an autopsy report. Facts show our cascade of event began at the point of access. Accurate information was lacking due to cultural differences. Accurate information guides our path to quality care fostering a culture of safety. When providers treat a patient, communication is how providers move to the next level of treatment. Providers cannot assume treatment without gathering credible information as needed.

A root cause analysis is a tool to realize steps needed to ensure quality of care, and hence, fosters a culture of safety. In our case, we should begin a root cause analysis by compiling information from various forms of documentation. For instance, an Incident Report offers a hand written description of current events of care and shows any events not consistent with routine operating procedures and patient care activities (Abdelhak, et al. 2007).

Provider did fail to adhere to at least three ethical standards, Pozgar (2010) states; Health Care Professionals have a fiduciary responsibility to their patient and should act as patient advocates. The American Nurses Association (2005) Code of Ethics adheres to promoting patient advocacy, not limited to but striving to protect health quality of our patient fostering a culture of quality care and safety (Nurses Association, 2005). Patient Advocacy is an action taken on behalf of an individual that goes beyond facilitating communication, says, NCIHC (2004) with sole intention of health outcomes.

Understanding our National Code of Ethics for Interpreters in Health Care should have been a foci point at the point of access at first episode of interpretation or lack thereof. NCIHC (2004) further cites Ethical interpretation protocols as “When patient’s health, well-being, or dignity is at risk, an interpreter may be justified in acting as an advocate, and thus, Advocacy must exhibit careful and thoughtful analysis of situations, and only if other less intrusive actions have not resolved the problem” (NCIHC, 2004).

At times, this is not as easy as it sounds, especially when barriers exist, such as a cascade of events, most of which, poor syringe labeling, pharmacist’s mistake, and confusing drug information, benzathine penicillin. To top it off, communication at the point of access with both parents only speaking Spanish, in support, our hospital physicians, nurses, and pharmacists, were unfamiliar with treatment of congenital syphilis, and had limited knowledge about benzathine penicillin (Quality Chasm Series, 2007).

As administrators, a Root Cause Analysis is a foci point identifying policies, practices and ability to prescribing authority to nurse practitioners where they did not clearly define such authority in terms of the ability. For instance, change prescription orders, poor syringe labeling, pharmacist’s mistakes, and confusing drug information, and hence, weaknesses in the structure of an organization, such as faulty information management, and ineffective personnel training or faulty drug labeling (Quality Chasm Series, 2007).

Our scenario did not identify how providers interacted with our patient or family after the error was exposed. In terms of pros and cons, having provider disclose and apologize for errors soon after an error occurrence, is a delicate matter but is ethically expected. For instance, how might this approach influence an apology of a medical error, often posits misinterpretation as admission to fault before facts present themselves, and add to Legal implications. An arrogant person or lacking interpersonal skills can come across insincere and add fuel to the situation. The purpose of the ACHE code of ethics is to serve as a standard of conduct; standards of ethical behavior for healthcare providers in their professional relationships (ACHE, 2007).

In what ways can health care administrators help prevent this kind of error from happening in the first place is to foster a culture of accountability, is best approach to assist providers and organization after such an error occurs. Perhaps revising HCO mission Statement reflecting, Safety Systems in Health Care Organizations. To Error is Human (200) “Safety Systems in Health Care Organizations seek to prevent harm to patients, families, health care professionals, contract-service workers, and volunteers, and thus, whose activities bring them into a health care setting.”
In summary, Safety issues we face within our health delivery system in terms of death related to errors must focus on Treatment, Diagnostic, and Preventive Measures. For instance, To Error is Human (2000) defines three domains fostering a culture of safety.

Treatment, Errors in performance of an operation, procedure, or test, Errors in administering treatment, Error in dosage or method of using a drug, and avoidable delays in treatment or in response to an abnormal test. Diagnostic, Errors or delays in diagnosis, Failure to employ indicated tests, Use of outmoded tests or therapy, and failure to act to results of monitoring or testing, and Finally, Preventive Measures, Failure to communicate, Equipment Failure, and ability to foster prophylactic treatment and expose areas of inadequate monitoring or follow-up of treatment (To Error is Human, 2000).