Commissioners approve $20 million settlement for boy's brain damage suit against county hospital
By Jonathan D. Rubin, Esq.
Kaufman Borgeest & Ryan New York, NY
Christopher U. Warren, Esq.
Kaufman Borgeest & Ryan Parsippany, NJ
Leanora Di Uglio, CPHRM,
Corporate Director, Risk Management Health Quest Systems Lagrangeville, NY
Financial Disclosure: Executive Editor Joy Daughtery Dickinson and Nurse Planner Maureen Archambault report no consultant, stockholder, speaker's bureau, research, or other financial relationships with companies having ties to this field of study. Christopher U. Warren, Allison Angel, Leanora Di Uglio, and Jonathan D. Rubin, co-authors, have no relevant relationships to disclose.
News: County taxpayers will pay $20 million to the family of a 3-year-old boy who suffered serious brain damage after undergoing outpatient surgery at the county's hospital. While the county did not admit liability, its commissioners voted to pay $20 million to settle the medical malpractice suit that the boy's family brought against the hospital. The settlement monies will be used to provide for the boy's care and medical support for the remainder of his life.
Background: The 3-year-old boy underwent elective outpatient surgery for an undescended left testicle at the county's hospital. While in the recovery room, the boy fell into cardiac arrest and stopped breathing. It is alleged that the boy went without oxygen for about five to seven minutes before hospital staff initiated cardiopulmonary resuscitation (CPR). Also, it was alleged that he received no assisted ventilation from the medical staff until after he suffered cardiac arrest.
The county's hospital was able to revive the boy; however, he was without a pulse for a period not less than 15 minutes. As a result of the heart attack and oxygen deprivation, the boy suffered permanent brain damage.
In a statement to the press, the family's attorney claimed that the county hospital should not have left the boy in the recovery room alone while he was in an overly sedated state. He claimed that the county hospital failed to monitor or tend to the boy until he went into cardiac and respiratory arrest. He said that there was a video of the boy running along the beach and yelling to his parents. And he highlighted that now, the boy cannot walk, cannot talk, and is incontinent. He also noted that the boy is tube-fed and that he requires care and treatment for every aspect of his life.
The county's board president told reporters that the hospital's CEO has taken steps to prevent a repeat of the mistake. She also noted that disciplinary actions were taken against several individuals who were involved. She is quoted as saying, "I think in any human enterprise, bad things happen. This was a particularly bad thing that happened."
The commissioners approved the settlement without discussion or opposition. The money will come out of the county's self-insurance fund. Despite this vote, and the president's statements above, the settlement will also stipulate the county does not admit liability for the boy's injuries.
The boy's family would not talk publically about the settlement. Their attorney said, however, that the money will be used for around-the-clock long-term care, occupational and speech therapy, and future surgeries.
What this means to you: The day probably started as a typical day in the postanesthesia care unit (PACU.) The operating room was full with adult and pediatric inpatient and ambulatory patients who were scheduled throughout the day. The PACU staff had the knowledge and skills necessary to promote positive outcomes in perianesthesia care for adult and pediatric patients, including the uniqueness of age-related pathophysiologic and anatomical differences found in the pediatric patient. Hospital PACU policies and procedures were established that complied with state, regulatory, and accreditation requirements. So what went so wrong that resulted in severe brain damage in a 3-year-old patient who underwent elective outpatient surgery?
Based on the summary of the case presented above, it is hard to identify the one process point in the delivery of post anesthesia care that failed. As I am sure when the county hospital performed its root cause analysis after this event, there were a number of process failure points that could have been involved. The root cause for this unfortunate outcome could stem from one or more of them. However, based on current patient safety literature, there are a few areas that risk managers should keep in mind when reviewing patient safety processes and policies. The Joint Commission's most recent Sentinel Event Alert No. 50, released in April 2013, is probably number one on every risk manager's list: alarm fatigue. (For more information about the Sentinel Event Alert, see "TJC warns about alarm fatigue putting patients at risk," Healthcare Risk Management, June 2013. To access the Sentinel Event Alert, go to http://www.jointcommission.org. Under "Topics," select "Sentinel Event Sentinel Event Alert." The alerts are listed on the left side of the page.)
In any hospital, there are multiple alarm sounds on every unit: heart monitor alarms, bed or chair alarms, IV infusion pump alarms, call bells. The PACU is no exception. All patients in the PACU are subject to various patient safety monitoring devices; however, members of the PACU staff might have determined that they do not need to rely on the alarms, because a PACU nurse is never very far away from a patient. Thus, it might not have been unusual for staff to mute or lower the alarms, reset the alarms at the lowest setting, or not respond to an alarm because of the competing alarm sounds or the false positive alarm signals they hear throughout the day. The Joint Commission is now recommending that a healthcare entity establish an alarm management program that will, among other tasks, establish guidelines for alarm settings on alarm-equipped medical devices used in high-risk areas; establish guidelines for the tailoring alarm settings based on individual patient needs; and inspect, check and maintain alarm-equipped devices.
Another critical area to review in the PACU is the ability of the staff to keep all patients in their direct line of sight throughout the patient's entire stay in the PACU. Patient privacy does not trump the need for staff to be able to visually observe a patient in the immediate postoperative period at all times, and some facilities have banned the use of privacy curtains during the immediate postoperative period. Although it would be surprising if the PACU staff used a privacy curtain for a pediatric patient, it might have been possible that the PACU staff member was using the privacy curtain to tend to an adult patient in the adjacent cubicle, which would have prevented other staff members from having this pediatric patient in their direct view at all times. Each facility should review their use of privacy curtains in the PACU and ensure that if they are used, they are used cautiously and infrequently.
It is unclear from the case described to know whether the patient was monitored appropriately during his stay in the PACU. Professional associations, such as the American Society of Anesthesiologists and American Society of PeriAnesthesia Nurses have established guidelines for post-anesthesia monitoring. It would be surprising if the county hospital did not adhere to these national guidelines. Postanesthesia monitoring guidelines include, among other elements: re-evaluation of the patient by the anesthesia care team upon admission to the PACU with a verbal report to the PACU nurse; initial assessment of the patient upon PACU arrival; and continual monitoring of oxygenation (quantitative method such as pulse oximetry), ventilation, circulation, level of consciousness, and temperature. According to the ASPAN, the pediatric population requires special consideration for the assessment of the pediatric respiratory system and subsequent airway management, pain management, pediatric-specific surgical procedures, and illnesses. This assessment would require consultation with the anesthesia provider to determine if the standard post-anesthesia monitoring guidelines were appropriate for this 3-year-old patient, given his medical history, age, and surgical procedure. Another unknown element that might change the manner in which this patient was monitored was whether the patient received any pain medications during his stay in the PACU. Certainly, due to the potential for respiratory depression after pain medication, closer monitoring, including a 1:1 staff-patient ratio, might have been in order.
The PACU is a fast-paced, high-risk specialty area. Patients flow in steadily and are discharged in stable condition within a few of hours after arrival. At times, patient care in the PACU can seem to be almost routine, which is when staff might become complacent with policies and practices. This is the time when errors, either human or situational, can occur. It is important to recognize the need for ongoing surveillance and monitoring of patient care processes, not only in the PACU, but throughout the healthcare facility. Routine risk assessments will assist staff with keeping patient safety at the forefront of their everyday practice and prevent an adverse event that will forever impact the life of a patient and his family.
12L-013-761. Circuit Court of Cook County (IL).