Mistakes by health-care practitioners happen every day, despite the best of intentions. But does a mistake always rise to the level of medical malpractice? This month’s case examines that question.
Ms. P, aged 35 years, was a nurse practitioner employed in the emergency department of a hospital. She had been working there for the past two years and she enjoyed the fast-paced atmosphere. Ms. P’s first job had been in a small family practice, but after about a decade, she found the work to be a bit too repetitive and tedious.
She certainly never had that issue in the emergency department. As a rule, Ms. P liked the varied cases and found the work interesting and challenging. Some days, however, were more challenging than others. This particular day was one of them.
Ms. P and her husband, a paramedic, had three children, all younger than age 7 years. On one particular day, two of them were sick with a stomach virus and home from school, and Ms. P was dealing with the logistics of arranging child care until her shift was over.She would have taken the day off, but with three young children, she had already used the bulk of her leave, and her husband had to work as well.
Ms. P was tempted to feel sorry for herself, but there was never any time for that. Instead, she straightened her spine, asked her mother to watch the children for the rest of the day, and began looking at the charts of the new patients flowing steadily into the emergency department.
One of the patients was 58-year-old Mrs. Z. She had come in suffering from an allergic reaction to acetaminophen with codeine, which had been prescribed by her dentist for pain following a dental procedure.
Mrs. Z had already been seen by the emergency department physician, Dr. L. The physician ordered that three medications be administered to the patient—two to be given intravenously, and the third, epinephrine (Adrenaclick, Adrenalin Chloride Solution, EpiPen, Twinject), to be given subcutaneously. Ms. P prepared the medications, but accidently put the epinephrine in the IV as well.
The patient sat up immediately, put her hands on her chest, and said her heart was palpitating. She became pale, nauseated, and anxious. Recognizing that the patient was experiencing the side effects of epinephrine much faster than expected, Ms. P felt her heart sink as she realized her mistake. She immediately notified the physician.
“I’m so sorry Dr. L,” said Ms. P. “I made a mistake and put the epinephrine in the patient’s IV rather than administering it subcutaneously. Mrs. Z is having anxiety and palpitations and is nauseous.”
The physician examined the patient and had her transferred to the intensive care unit (ICU). The rest of the day passed as a miserable blur to Ms. P. She spoke candidly to the hospital administrators and risk management team, and filled out all the necessary reports before her shift ended and she went home.
Dr. L spoke to the patient about the erroneous administration of the epinephrine and explained to her that she’d have to stay at the hospital for observation. Hospital administrators and risk managers met with Mrs. Z and her family during her stay and also acknowledged that an error had been made.
The administrators reassured Mrs. Z that everything would be taken care of, that she would be seen by the best physicians they had, and that they were very sorry for her discomfort.
Mrs. Z was discharged from the hospital within a week, but she continued to complain about ongoing symptoms and serious medical conditions allegedly caused by the IV administration of epinephrine. She returned to the hospital’s emergency department six times post-discharge.
On the first visit, the attending physician conducted a full assessment but found no physical abnormalities. On the second visit, Mrs. Z underwent a variety of cardiac and neurologic tests, all of which came back negative.
After four additional visits to the emergency department, Mrs. Z’s physicians still could not discover any physical problems other than an unrelated kidney infection.
Despite this, Mrs. Z sued the hospital for $5.7 million, alleging anoxic brain damage, cardiac damage, thoracic outlet syndrome, headaches, depression, anxiety, cognitive defects, and pain in the neck, shoulder, and back, all supposedly caused by the intravenous administration of epinephrine by Ms. P.
Ms. P was notified of the lawsuit and felt terrible that her error had caused such problems, but the hospital administrators were kind about it and pointed out that until then, her record had been impeccable. The hospital’s lawyers began gearing up for a trial.
The discovery process was long and slow, with numerous medical records being subpoenaed and medical experts being retained.
From the beginning, the hospital’s lawyers and administrators agreed that they should admit that the error took place and that Ms. P’s actions had fallen below the standard of care. The attorneys filed a formal stipulation in court, admitting the error, but clearly stating that the patient had not sustained actual damages.
Since liability had already been admitted, the only issue to go to the jury was whether Mrs. Z had injuries, and whether those injuries had been caused by Ms. P’s error.
On the issue of causation, the hospital introduced a parade of experts, including but not limited to a neurologist, a neuropsychologist, and a cardiologist, to testify that the patient had suffered no permanent harm from the administration of the epinephrine.
Other evidence introduced by the hospital’s attorneys showed that Mrs. Z had seen physicians for anxiety, chest pain, headaches, and neck and shoulder pain for years before Ms. P’s error occurred. The plaintiff introduced her own experts to try to prove that she had sustained injury.
The judge asked the jury to decide the answer to one simple question before it reached the question of amount of damages: Did the hospital’s breach of the standard of care cause the plaintiff’s injuries? The jury’s response to that question was, “No,” and the jury awarded no damages to Mrs. Z.
Four essential elements need to be proven for a medical malpractice case to be successful:
- Existence of a legal duty of care on the part of the health-care provider
- Breach of this duty
- Causal relationship between the breach of the duty and injury to the patient
- Existence of damages from the injury. Without these four elements, a malpractice case will fail
In this case, Ms. P had a legal duty to her patient, and she did breach that duty by executing an action that fell below the standard of care required by the profession. However, the plaintiff was unable to prove causation—that is, that Ms. P’s breach caused the injuries in question. The case therefore failed.
Mistakes happen, but how one responds to them is very important. Ms. P took responsibility, sought help immediately, and cooperated fully with the risk management team and the hospital’s administrators.
One word of caution: Before making any statements to a patient, find out whether your state has an “apology law,” which allows clinicians to apologize or express sympathy to a patient without fear that such actions will be used as evidence in court.
Ann W. Latner, JD, a former criminal defense attorney, is a freelance medical writer in Port Washington, N.Y .