Two recent interesting settlements at Massachusetts General Hospital (MGH), both involving technology

Two recent interesting settlements at Massachusetts General Hospital (MGH), both involving technology.

The first case involved a medication error (from a 'miscommunication between doctors and nurses', an infusion pump snafu, and failure to perform obvious follow up labs;  if health IT was involved it would not surprise me).  The second case involved alarm fatigue.

These amounts are interesting considering the age and condition of the patients.


1.  http://www.lubinandmeyer.com/cases/medication-error.html

Medication Error Lawsuit against MGH Settles for $1.25 Million

The plaintiff’s decedent was a 76-year-old woman who died on 11/24/10 from a hemorrhage. Her death occurred following a preventable medication error involving the drug Lepirudin. The patient was given over 30 times too much medication which resulted in uncontrollable internal bleeding and her subsequent death.

Her past medical history included cirrhosis with well preserved hepatocellular synthetic function. She also had Type 2 diabetes, hypertension and hypercholesterolemia, and a history of splenectomy for treatment of severe thrombocytopenia.

and


2.  http://www.masslive.com/news/index.ssf/2011/11/mass_general_hospital_alarm_fa.html

Mass. General Hospital 'alarm fatigue' lawsuit settled for $850,000

BOSTON (AP) — The family of an 89-year-old man who died at Massachusetts General Hospital when nurses did not respond to alarms on his cardiac monitor has settled its case against the hospital for $850,000.

I see potential lessons for at least two healthcare stakeholders in these cases:

Hospital executives:  bad technology is not your friend.  get it right before rolling it out, with robust, validated safeguards, to save lives - and to save your organizations from costly litigation and reputational damage.

Clinicians:  bad technology is your enemy.  While hyper-vigilance is mentally exhausting, that's what's required to avoid the fate of the patients - and the clinicians - in the above cases.

Reporting bad technology and making sure the problems are remediated promptly, not glossed over, is equally essential.

Note: my interpretation is that both technology and people issues probably played a role in both these accidents, based on my own knowledge and experience, but that is of course a personal opinion. 

-- SS

8:46 AM

Hospital Malpractice Defense: No Justice For "Shylock"

At Healthcare Renewal we write about leadership and governance in health care that threaten the core values of medicine.

How about governance that doesn't just threaten, but nukes those values?

What would you think of a hospital that:

(1)  Commits an error in the medical care of a doctor's mother, not giving her a critical heart medication, that leads to her severe injury and death, to the point where even Medicare reports the care did not meet accepted professional standards due to medication reconciliation failure and caused the harms, and then:

(2)  Tells the Court that the resulting lawsuit is a  "vendetta" by the doctor who "didn't tell the hospital about the heart medicine" to get even with the hospital (implying he was attempting matricide) for not hiring him a few years prior into an EMR role?

It's quite an offensive tactic, one that invokes the offensive, vindictive stereotype from Shakespeare's "Merchant of Venice."

I would put a number (3) in:  that the hospital had the medicine (started by the hospital's own heart specialist) in their electronic and paper records over the course of multiple ED visits and admissions dating back from two weeks prior to as far back as a decade, and that the doctor and the mother herself, not being a dog being taken to the veterinarian, told the emergency room staff about the medicine, but it's really not relevant to the issue at hand.

Shylock, an offensive caricature

Like I wrote, not just threatening medicine's core values, but nuking them.  The people making this claim are sick, poster examples of the worst of healthcare we write about at this blog.  

Who needs core values?

They're also not very smart. The judge overseeing the case deals with a lot of cases involving petty criminals, and I suspect can pretty well figure out when people, including doctors being sued for malpractice and their lawyers, are trying to bamboozle him with tall tales.  I suspect he's pretty disgusted about now.

-- SS

2:17 PM