CT scan of pregnant woman after ID error

The string of wrong-site errors at Rhode Island hospital may be attention-getting, but the hospital is not the only one experiencing this never event. An identification error led to a pregnant woman undergoing a CT scan intended for another patient at Banner Thunderbird Medical Center in Glendale, AZ, which is now prompting litigation.

Kerry Higuera of Peoria, AZ, was three months pregnant when she experienced bleeding and sought care at the hospital's emergency department in February 2008, according to her attorney, David Patton, JD, of Scottsdale, AZ. Higuera says she was told to wait in a room until a nurse came for her, and then a nurse came and told her the doctor wanted a CT scan. The woman questioned whether that was correct, but the nurse repeated that the doctor wanted a CT scan of the abdomen and pelvis, Patton says. She underwent the CT scan.

An hour later, she was visited by the emergency physician, two radiologists, and a hospital administrator who told her, "We made a mistake. We did something we shouldn't have done," according to Patton. The clinicians and administrator explained to Higuera that the CT scan was intended for another patient of the same age and also named Kerry, Patton says. The hospital staff did not confirm the patient's identity with other identifiers such as birth date or case number, he says.

The emergency physician, who happened also to be pregnant, cried as she explained that the baby could suffer mental retardation, growth problems, or a low IQ because of the radiation exposure in the first trimester, Patton says.

"The hospital offered her coupons for the cafeteria and asked what kind of flowers she liked so they could send flowers to her home," Patton says. "Other than that, there has been no effort to correct this. We offered to settle very early after the incident, but the hospital declined."

The child is being watched closely by pediatricians, and Patton says he is showing some signs of the damage that can come from radiation exposure, including a small head circumference.

"We are monitoring all the potential ways that radiation exposure in the first trimester can manifest itself, and based on what we're seeing, we expect to pursue litigation in early 2010, possibly as early as January," he says.

Bill Byron, senior director of public relations and online services for Banner Health, the parent company of the hospital, tells Healthcare Risk Management that because Higuera is represented by legal counsel and appears to be moving toward litigation, Banner Health is unable to provide any comment.


For more information on the Higuera case, contact:

• David Patton, JD, Patton Law Practice, Scottsdale, AZ. Telephone: (888) 905-9208. E-mail: david@medmal.com.