By Damian D. Capozzola, Esq.
The Law Offices of Damian D. Capozzola
Jamie Terrence, RN
President and Founder, Healthcare Risk Services
Former Director of Risk Management Services
California Hospital Medical Center
Rebeka Rioth, 2017 JD Candidate
Pepperdine University School of Law
News: In 2011, a 57-year-old woman was transferred to a hospital to treat a benign brain tumor. The hospital removed the tumor and prescribed heparin, an anticoagulant medication. However, staff failed to follow proper procedures in the administration of heparin over nine days. The hospital also stopped monitoring the woman’s blood despite prior blood tests indicating that her blood was thinning at an increasing rate and becoming unsafe. After nine days of receiving heparin, the woman was found in a deep coma. The woman had a massive brain bleed, which resulted in brain damage with severe and permanent neurological and physical deficits. The woman and her husband sued the hospital and the attending doctor for malpractice. They argued that the nurses failed to properly follow one or more orders for administering heparin and also failed to recognize or report that the drug had been improperly administered. They also argued that the hospital failed to recognize the changes in the woman’s blood that indicated the woman was at high risk of bleeding. Finally, they argued that hospital should not have stopped performing daily testing on the woman’s blood because the hospital knew the woman was at risk of developing a brain bleed. The jury returned a verdict in favor of the woman for $44.1 million and found that the hospital and attending physician violated the standard of care.
Background: A woman drove herself to a hospital to receive treatment for a benign brain tumor. After the hospital removed the brain tumor, the hospital prescribed heparin, often used to prevent deep vein thrombosis (DVT), or blood clots that can occur in the legs of bedbound postoperative patients, or for prevention of pulmonary emboli, or blood clots in the lungs, of patients.
However, the hospital failed to follow proper procedures in the dosing and administration of heparin. For example, on one or more occasions, hospital staff administered heparin through an improper route in the woman’s body, including her right arm at one point and a peripheral vein at another point. The hospital continued to administer heparin every eight hours over nine days. During the first six days, the hospital conducted partial thromboplastin time testing to determine how long it took for the woman’s blood to clot. The test results showed that the woman’s blood was moving from the low to high end of what is considered safe. On the sixth day, the hospital stopped testing the woman’s coagulation.
On the ninth day, the woman was found in severe and deep unconsciousness. Additionally, the external drain that had been placed in the woman’s brain showed bloody drainage. The same day, the hospital performed a d-dimer test to determine if there were blood clots in the woman’s brain. After the test returned abnormal and the hospital detected a brain bleed, the hospital discontinued heparin.
The hospital then ordered a hematology consult, which determined that the woman’s abnormal blood tests were caused by the “heparin effect,” which is when patients’ blood thins to the point at which they are at risk of bleeding and other complications. As a result of the woman’s brain bleed, she experienced brain damage and severe, permanent neurological and physical deficits. The woman and her husband sued the hospital and the attending physician for medical malpractice.
The woman’s attorneys argued that the woman’s blood began to thin to the point at which she was at risk of a brain bleed because this site recently had been surgically repaired, and they said healing of the blood vessels cut during the procedure had not completely taken place. The woman’s attorneys said that the hospital should have recognized this risk and adjusted or stopped the use of heparin. They also argued that daily partial thromboplastin time testing and patient monitoring would have indicated that the cause of the woman’s blood thinning was due to improper dosage and administration of heparin.
Lawyers for the hospital argued that the woman’s brain bleed was caused by numerous complications from the initial surgery to remove her brain tumor. They also contended that the hospital staff followed proper dosing procedures in administering heparin and properly monitored the woman’s blood. Following a 13-day jury trial, a verdict of $44.1 million was returned in favor of the woman. The jury found that the hospital and the attending physician were responsible for the woman’s extensive injuries due to a failure to follow established patterns of care in the medical community.
What this means for you: This case is significant because it represents the largest medical malpractice verdict issued in Pennsylvania since 2014. This case also demonstrates that while it is routine within the medical community for doctors not to test a patient’s coagulation levels after neurosurgery, such testing may be required if the patient is believed to be at a high risk for developing a brain bleed. Here, one of the attending doctors testified that the hospital performed partial thromboplastin time testing daily for the first six days after the surgery precisely because doctors believed she was at risk of developing a bleed. Although heparin is a widely used anti-coagulation medication, use of this drug also requires close monitoring to prevent the heparin effect. Therefore, it is imperative that healthcare practitioners avail themselves of the standard of care to which they will be held to then determine which protocols and testing are necessary. Despite the fact that the patient’s clotting times initially were being maintained within the normal range, as long as the patient continued on heparin, the potential remained for the values to deviate from normal at some point.
This case also highlights the importance of proper standards in the postoperative care of a patient. Here, numerous nurses were responsible for overseeing the administration of heparin and recording these dosages in the woman’s medical files. Heparin should be given subcutaneously in the soft tissue under the skin of the abdomen so that the rate of absorption into the bloodstream is controlled. However, these records indicate that nurses failed to recognize that other nurses improperly administered heparin and that they also failed to inform attending physicians of these occurrences.
It is equally important for attending physicians to supervise, review, and oversee all nursing and medical care, as well as the medications that are administered to patients in their care. In this case, attending physicians failed to review the nursing notes in the medical record, which revealed that heparin was administered contrary to their orders on at least two occasions. However, this practice is not unusual or a standard expectation for physicians. Physicians assume, perhaps incorrectly, that their orders are followed by nursing staff. Any deviation from those orders can be construed, especially in a courtroom, as nurses functioning outside of their scope of practice and in violation of their licenses. Also, postoperatively, the patient was at high risk for many complications, including cerebral hemorrhage, infection, cerebral edema, etc. There are other measures available to physicians to prevent DVTs, such as compression hose or sequential compression devices, neither of which compromises a patient’s clotting factor.
This case illustrates the vital role expert witnesses play in establishing the proper standard of care in malpractice cases. In a “battle of experts,” the expert who is more credible can shift the case. The hospital’s expert testified that it was well within the standard of care for the hospital to stop testing the woman’s blood daily because her blood tests were within the normal range. The expert testified that well before the brain bleed occurred, the woman suffered from post-surgery complications, including infection and swelling. Nevertheless, the woman’s experts were successful in proving that the cause of the brain bleed was due to the failure to administer heparin properly and monitor its effects on a woman who was at an increased risk of developing a brain bleed.
Philadelphia County Court of Common Pleas, Pennsylvania, Case No. 130901595 (April 27, 2016).