Medical Error: Permanent Brain Damage After Heart Surgery

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Medical Error: Permanent Brain Damage After Heart Surgery

Medical error is a substantial issue affecting thousands of patients and parties related to the healthcare system. According to approximate estimations, medical error is counted as the third leading cause of death in the United States (Makary & Daniel, 2016). In particular, between 210,00 to 400,00 patients die each year because of medical error, compared to about 600,000 annual deaths due to heart disease or cancer (Makary & Daniel, 2016). While certain lethal cases can be counted, the estimations of adverse effects on health appear rather challenging. The case of a 51-year-old man who suffered from a brain damage is one of those where the medical error was recognized due to the jurys decision in a related suit. All of the parties, including the hospital, the health provider, and the anesthesiologist, were found liable for conducting a medical error that caused a severe negative impact on the mans health and life.

The details regarding the mentioned case are critical to understanding the complex environment prone to errors. Initially, a team of medical professionals was performing heart surgery on a 51-year-old man (Capozzola, 2016). At a particular point, the patient suffered a ventricular fibrillation complication, which required resuscitating procedures (Capozzola, 2016). In addition to cardioversion, giving shocks to restore the mans heart rhythm, the surgeon ordered medication needed to stabilize heart rhythm so that the surgery could be finished. The medication ordered was amiodarone, in the dosage of 150 mg (Capozzola, 2016). The anesthesiologist followed the instruction and administered three vials of what he believed to be 50 mg of amiodarone (Capozzola, 2016). Although the heart surgery was finished, the patient had ventricular fibrillation for the second time, which affected the function of his heart and prevented blood and oxygen from being delivered to the mans brain. This situation led to permanent brain damage, meaning that the man would not be able to function adequately and would require medical services throughout his life (Capozzola, 2016). Consequently, the brain damage was alleged to occur due to an amiodarone overdose because the contents of the vials significantly exceeded the expected dosage, which was the result of the hospital pharmacys error.

In the suit against the hospital, the anesthesiologist, and the healthcare provider for whom the anesthesiologist worked, the court decided that all three parties were liable in the case. In particular, the man was awarded $12.2 million, and the hospital was determined 60% liable, the anesthesiologist 25% liable, and the healthcare provider 15% liable (Capozzola, 2016). The hospital was partially liable because the overdose of amiodarone happened as a result of the hospitals pharmacys misdeed. Instead of 50 mg in each of the three vials, there was 900 mg of medication, meaning the patient received an 18 times higher dose than needed (Capozzola, 2016). In this case, organizational liability assumes vicarious responsibility of the superior party (hospital) for their employer (pharmacy) (Edwards, 2022). Since there are various forms of liability, including disciplinary, administrative, civil, and criminal, the hospital took civil liability for its personnels mistake.

The jury decided that the patient should be awarded based on the cost of medical services and experienced pain. All three parties shared joint responsibility, meaning they have to pay satisfaction according to the proportion of their liability (Edwards, 2022). In addition, the healthcare provider for whom the anesthesiologist worked could be indicated as vicariously liable. Since the anesthesiologist failed to double-check the dose of medication, his employer could be considered liable for lack of training or instruction provided to their employees.

Hospitals should ensure proper personnel training and the safety of their internal medication-serving systems in order to reduce the risk of similar errors in the future. Foremost, the staff should follow the medication administration rules, checking if the right medication is given to the right patient in the right dose (Capozzola, 2016). Hence, such high-risk medications as amiodarone should be labeled appropriately. The error, in this case, occurred because both surgeon and the anesthesiologist assumed the minimal dosages in the vials (Capozzola, 2016). Although this is a common practice in hospitals, the pharmacys mistake occurred, and higher dosages were contented in the vials.

Accordingly, Makary & Daniels (2016) suggest three steps to reduce the risk of medical errors, such as making errors more visible, responding to them, and making them less frequent. Healthcare institutions need to recognize their responsibilities to foster a safety culture, develop error prevention algorithms, and facilitate the speak-up culture, among others proactive measures (Makary & Daniels, 2016). Accordingly, healthcare professionals should be educated regarding their role in reducing possible errors and contribute to transparency and safety measures to conquer the error issue. As a result, many risks could be prevented, and the hospitals could reduce liability risks in a range of complex cases.

Overall, medical errors affect patients lives and health and lead to severe consequences for hospitals and healthcare practitioners. Many errors can be prevented by such simple steps as double-checking or putting a proper label on the medication. Therefore, hospitals should consider implementing efficient measures to reduce the risk of medical errors, which would contribute to their success and the well-being of their patients.

References

Capozzola, D. D. (2016). Medication mix-up leaves 51-year-old patient with permanent brain damage after heart surgery. Healthcare Risk Management, 38(1). Retrieved from the Trident Online Library.

Edwards, J. S. (2022). Tort law. Cengage.

Makary, M., & Daniel, M. (2016). Medical error the third leading cause of death in the US. BMJ, 353.

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