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Failure to Confine Pregnant Woman: $24.1M Verdict
News: A pregnant woman exhibiting bleeding caused by placenta previa was hospitalized. Twelve days later, while walking to the bathroom, the woman experienced a massive hemorrhage, resulting in the premature birth of her twins. The hospital staff allegedly failed to adequately monitor the mother and confine her to bed, a necessity for women suffering from placenta previa. The resulting injuries to one of the infants have required multiple surgeries and rehabilitative sessions throughout her life, and she suffers from a continual debilitating condition.
Background: In July 1994, a pregnant woman suffering from bleeding caused by placenta previa was hospitalized. Prior to the birth of the twins, the mother had become severely constipated and was administered a laxative. Twelve days after the mother's hospitalization, while walking to the bathroom unattended, the placenta detached, resulting in a massive hemorrhage.
Because of the premature delivery caused by the hemorrhage, the female infant suffered from periventricular leukomalacia, a type of brain injury affecting infants, characterized by the death of small areas of the brain around the ventricles. This brain damage caused the infant to suffer from spastic triparesis, a partial paralysis of her legs and one arm. The resulting hospitalization of the infant lasted 12 weeks and included treatment for respiratory distress syndrome.
At the age of seven, the child underwent a rhizotomy, a procedure where nerve roots are selectively severed to release tension caused by neuromuscular conditions like spastic triparesis. The following year, the child again required surgery to remedy the chronic dislocation of one of her hips. These surgeries each required approximately 12 weeks of rehabilitative therapy.
With the assistance of a physical therapist, crutches, and a brace that covers most of her torso, the child is able to walk. The remainder of the time, however, the child is confined to a wheelchair. The child suffers atrophy of the leg muscles, and doctors doubt she will ever be able to walk independently.
The mother of the infant sued the hospital and several of its employees, alleging that the staff's failure to render proper care constituted medical malpractice. The hospital accepted responsibility for the actions of its staff, and the matter proceeded to trial. At trial, the plaintiff's counsel contended that the hospital staff was aware of uterine bleeding prior to, and during, the hospitalization. Because the hospital staff was cognizant of the bleeding, the plaintiff claims that every measure should have been taken to prolong the infant's gestation by restricting her movements. The plaintiff claimed that, while the bed was fitted with railings, the rails were not deployed at the time.
The plaintiff's counsel asserted that the hospital staff should never have allowed the pregnant woman to become severely constipated, and further, should not have administered a laxative to a woman who was confined to bed rest.
The defendant claimed that the hemorrhage occurred during an unapproved trip to the bathroom while the rails were properly deployed, and that the likely cause of the hemorrhage was engaging in sexual activity prior to hospitalization. The defense further claimed that the mother was not severely constipated and that administration of the laxative was an appropriate treatment. The defendant also contended that the child's current limitations on mobility were caused by unwillingness to rigorously follow the rehabilitative therapy.
A $24.1 million verdict was returned against the defendant-hospital.
What This Means To You: It appears there are many unanswered questions in this scenario. Even so, there are many risk management issues raised here.
A pregnancy with twins is a high-risk pregnancy. A pregnancy with a placenta previa is a high- risk pregnancy. Having both those high-risk issues present in the same pregnancy emphasizes the high level of risk. A high-risk pregnancy is usually referred to a neonatologist and an obstetrician who specializes in such cases for prenatal care. In the facts given here, we have no reference to the physician's involvement. It is of interest that only the hospital was a defendant in this action.
This is a significant untoward outcome that should have been immediately reported to the risk manager. As a part of the investigation into the event, a root-cause analysis (RCA) should be initiated. Depending on the state, reports to the state may be required, and it may meet The Joint Commission definition of a reportable sentinel event. In addition, by the very nature of the event, it would be reportable to the hospital's liability insurance carrier (depending on whether the hospital is self-insured or commercially insured).
We have information that the patient was bleeding prior to admission and after. We don't know how long after admission the patient became constipated, when the laxative was administered, or what the laxative was. We do know that no medication may be administered to a patient without a doctor's order. The root-cause analysis of this sequence of events may peel back the layers of this onion to answer many of the questions this scenario raises.
Patient care is an all-encompassing process that involves the entire patient and his or her family. We work as a team to take care of patients and monitor all their systems. In this particular case, the patient's intake, nutrition, and fluids were as important as the elimination. While it is nursing staff who usually monitor and document the intake and output, it is also up to the physician to monitor and consider that information and act accordingly depending on that information. The medical record contains documentation of information and data that is to be reviewed and considered by all members of the patient care team, including the physician. One important piece of information we do not have is what documentation was in the record regarding the patient's output; was there documentation, or was it blank? Again, the root-cause analysis would address these questions. Another question this raises is why the physician didn't question the patient's output before the patient became severely constipated. We don't know the laxative ordered. Some laxatives are gentler than others. Was the choice of laxative ordered a factor in the hemorrhage? Was the laxative administered based on a standing order for all hospitalized prenatal patients, or specifically for this patient? This should be revisited with the obstetrical medical staff and as a part of the root-cause analysis.
Pregnancy is not an illness. In this case, the placenta previa and twins were a condition of the pregnancy. That means the staff was dealing with a healthy person who was on bed rest with the goal to control bleeding, prevent abruption of the placenta, and delay delivery as long as possible to provide the fetuses the opportunity to develop as long as possible before being brought into this world. That being said, a healthy pregnant woman would not have had the side rails up, as there was no need to restrain the patient, as having both side rails up would be considered a restraint. Again we don't have enough information here to know why the patient was walking to the bathroom. The root-cause analysis would identify whether the patient called for assistance that never arrived or never asked for assistance as she disregarded the instructions not to get out of bed. One might argue that even if the patient was being assisted to the bathroom whether that would have prevented the hemorrhage. Had the side rails been raised, that may have increased the danger if the patient climbed over the raised side rails or crawled out of the foot of the bed. Again, we don't have information to know if a bedside commode was ordered and at the patient's bedside, or if the patient was on strict bed rest, requiring the use of a bedpan, or if the order was for bed rest with assistance to the bathroom. Education is a part of the admission process of a patient ordered to be on bed rest. The physician is the first line of that education when the placenta previa is identified as a part of the patient care to inform of the potential complications and treatment. Nursing reinforces that education on admission, based on the admitting physician's orders. A part of that education is the reason and importance of the need for bed rest. A patient who disregards that bed rest order is a party to the untoward outcome. The patient could not be physically restrained in her bed. The root-cause analysis would identify the patient's compliance with the need for bed rest and the education and information provided the patient and her family in this regard by both nursing and the physician(s). Disclosure of the investigation into this unfortunate untoward outcome cannot be forgotten. This is an important step in the handling of this event and the support of the patient and her family. Risk management should facilitate the disclosure process.
Re-emphasis of the requirements of thorough documentation is imperative.
1. Supreme Court, Second Judicial Circuit, Kings County, New York, No. 12356/04.