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News: The patient, an adult man, was scheduled for a standard cataract surgery in 2008 on his left eye. During the procedure, the ophthalmologist ordered a dye named VisionBlue that is used to stain the cataract in the eye so that it can be more easily visualized and removed during the surgery. However, although the ophthalmologist ordered the correct dye, the nurse who fulfilled the request instead brought methylene blue rather than the correct VisionBlue.
The nurse told the surgical technician that she was handing him methylene blue, and the surgical technician then relayed this same information to the ophthalmologist. The ophthalmologist claimed that he did not hear this and, believing the solution to be the correct VisionBlue, he applied it to the patient’s eye during the surgery, which caused serious permanent damage, including blindness in the eye. The patient brought suit against the ophthalmologist and hospital, and he claimed that their negligence brought about his injuries. The defendants denied any wrongdoing. The jury found the ophthalmologist and the hospital liable and awarded the patient $1.5 million in damages.
Background: The patient was an adult man who suffered from a cataract on his left eye and scheduled surgery to fix the problem in 2008. During the procedure, which is routine and uncomplicated, the ophthalmologist ordered a dye named VisionBlue that is used to stain the cataract in the eye so that it can be more easily visualized and removed during the procedure. The nurse who received the order from the ophthalmologist, however, fulfilled the request as methylene blue rather than VisionBlue.
Methylene blue, a completely different chemical compound, is extremely toxic to human eyes and can cause severe damage. The nurse who filled the order then passed the methylene blue to the surgical technician and announced that it was methylene blue. After this step, the surgical technician handed the methylene blue to the ophthalmologist, again stating that the solution was methylene blue. Neither the nurse nor surgical technician stated that the solution was VisionBlue. The ophthalmologist claimed that he did not hear the nurse or the surgical technician state the solution was methylene blue, and thus he believed it to be the correct VisionBlue dye.
After applying the methylene blue to the patient’s eye, the ophthalmologist became aware that it was the incorrect solution, and the patient’s eye became severely damaged. Corrective surgery was attempted at the same hospital, but the damage from the methylene blue was too serious. A full corneal transplant also was attempted, but the patient’s body rejected it. As a result, the patient became blind in his left eye and suffers from glaucoma due to the multiple corrective surgeries.
The patient subsequently brought suit against the ophthalmologist and hospital, and he alleged that both were negligent during the procedure that resulted in the patient’s injuries. According to the plaintiff, the ophthalmologist’s use of the incorrect solution constituted negligence because the ophthalmologist had a duty to the patient, and by administering the incorrect drug to the patient, he breached that duty. Similarly, the hospital was liable on the basis of respondeat superior, which is a legal theory where an employer is legally responsible for the actions of its employees. It was unclear whether the ophthalmologist was considered an employee, but the nurse and surgical technician were employees for which the hospital was responsible. Ultimately, the jury found the defendant ophthalmologist and defendant hospital jointly and severally liable, and it awarded $1.5 million in damages.
What this means to you: In this case, the primary issue was to what degree, if any, the ophthalmologist was negligent for administering the incorrect drug to the patient, and whether the hospital was liable for the ophthalmologist, nurse, and/or technician, who all played a role in the incident.
As the primary physician in charge of the procedure, the ophthalmologist owed the patient a duty to perform in accordance with the appropriate standard of care. There are many different ways medication errors can occur, as there are many steps between the initial prescription or order and the administration of the drug. A physician who prescribes the wrong medication to a patient can be liable for medical malpractice, but there are many other situations that might give rise to a medical malpractice claim as related to a medication error.
For example, look-alike, sound-alike (LASA) medication errors are common. The hospital pharmacy has the responsibility to put caution labels on LASA drugs such as methylene blue and VisionBlue. In addition, the pharmacy stocks medications in the operating suites and should take steps to separate LASA medications from each other to prevent staff from inadvertently choosing the wrong one. All regulatory and accreditation organizations require hospital staff and physicians to read medication labels before administration of any drug, even in the operating room. If medication is removed from the original container and not used immediately, a new label must be made and placed on the syringe or other delivery device. Physicians and hospitals must exercise caution throughout the entire process to ensure that there are no mistakes. In this case, the ophthalmologist ordered the correct drug to be used, so the error originated after this initial involvement. Because the physician holds ultimate responsibility for the patient’s medical care, the physician should be cautious when other individuals act as intermediaries or are required to perform duties delegated by the physician.
It is important to note that this situation could have been prevented by having additional measures relating to communication. Oral communications can inherently be unreliable. If the communication is one-way, it is impossible to know whether the other party actually has heard the message. This situation is exactly what happened here more than once. The nurse and surgical technician claimed to have announced that the solution was methylene blue, but the ophthalmologist never heard those words.
The situation potentially could have been prevented if the hospital had a policy requiring confirmation in this context. (Editor’s note: Confirmation bias leads people to see or hear what they expect to see or hear, regardless of the actual information. For more information on confirmation bias and solutions to this problem, see package of stories in Healthcare Risk Management, November 2014.)
Note also that the surgical technician should not have been involved in the confirmation process, as the technician is not trained to administer medication. Certainly the technician can pass medication from the hand of the nurse into the hand of the physician, but that involvement is the only one that the technician should have. Communications involving medications must be between physicians and staff trained in medication administration unless the physician is directly supervising the untrained individual and not involved in another activity such as performing surgery.
To prevent oral communication errors in emergency departments, operating rooms, and even over the phone, "read-backs" or "repeat-backs" are used in most hospitals. When a physician orders a medication verbally, the receiver repeats the name of the drug and the dose to the physician and the physician confirms it. Had this practice been carried out, the physician would have said, "VisionBlue" and the nurse would have said "methylene blue," which would have given the physician the opportunity to correct the error. Requiring this important oral communication process is a simple solution that provides extra defense for physicians and hospitals, and in this case, could have prevented injury and litigation. Written communications are inherently even clearer than oral communications; however, the realities of an operating room don’t allow for everything to be done in writing, so it is not the case that oral communication is forbidden.