Medical Malpractice?

[mikester]

http://www.latimes.com/news/local/la-me-kingdrew29jul29,1,1220002.story?coll=la-headlines-california

Text:

CALIFORNIA
King/Drew Ignored Surgical Safety Checks
* County health director says staff neglected in hundreds of cases to count instruments after operations. Clamp was found inside a patient.


By Charles Ornstein, Times Staff Writer

In hundreds of surgeries, operating room staff at Martin Luther King Jr./Drew Medical Center sewed up patients without checking whether instruments were left inside them, contrary to basic hospital safety standards.

The widespread failure, which was disclosed by Los Angeles County's health director Wednesday, was uncovered by King/Drew officials after a metal clamp had been left inside a patient for 10 days last month.

The clamp error was the latest in a series of patient-care lapses identified in the last year at the county-owned hospital in Willowbrook, just south of Watts. It occurred six months after the health department brought in a crisis team and outside consultants to oversee changes at the hospital.

Dr. Thomas Garthwaite, director of the county Department of Health Services, said he could not explain why staff members had violated hospital policies and industry standards that call for them to count instruments before and after all surgeries.

"Somewhere along the line, we stopped doing instrument counts," Garthwaite said. "This wasn't just random."

A hospital audit of several hundred cases from the last four to five months found no documentation that instruments had been counted, Garthwaite said. He said he did not know how far back the policy had gone unheeded.

But nurses and staff members consistently had been counting needles and sponges used during surgeries, he said.

Garthwaite said King/Drew staff were not aware of other cases in which instruments had been left inside patients.

The patient who had the clamp left inside him told The Times that when it was discovered, he feared for his life.

Jeffery Baber, a 42-year-old Compton mechanic, underwent emergency trauma surgery on June 22 for multiple gunshot wounds.

The 5-inch clamp, a scissors-like instrument used to cut off blood flow to certain areas, was discovered accidentally when Baber was being prepared for a separate surgery on his leg, officials said.

When the X-ray technician looked bewildered, Baber said, "I asked the guy, 'What's wrong, man?', and he said there's something shiny inside of me.

"They did another X-ray and another X-ray," Baber said. "It showed plain as day, they had one of the clamps just sitting there. They had to go back in me."

Though county officials said Baber was not injured, Baber blamed the clamp for intestinal cramps, severe back pain and a persistent fever during his first days in the hospital.

He said he was thankful that the error didn't kill him.

"It could have been worse," he said. "I could have been a lost cause."

Leaving tools inside a surgical patient is rare, occurring in as few as one in 1,500 abdominal surgeries, studies show.

Baber, whose mother works at the hospital, said the surgeon who first operated on him, Dr. Anthony McCloud, told him that he had nothing to do with the mistake. McCloud also performed the operation to remove the clamp.

No one has apologized to him, Baber said.

Garthwaite said surgeons ultimately shoulder the blame for what goes on in their operating rooms.

"The attending surgeon is responsible for the conduct of the operation, in my mind," he said.

"And the attending shouldn't be delegating responsibilities to someone unless he feels they are able to handle them," Garthwaite said.

McCloud declined to comment Wednesday through King/Drew Medical Director Roger Peeks. McCloud did not blame anyone else for the error, Peeks said.

Dr. Kenneth W. Kizer, president of the National Quality Forum, a patient safety group in Washington, D.C., said King/Drew may never know how many instruments were left in patients because surgical staff members weren't following basic rules.

"It's what you do when you're taking care of patients the way you're supposed to be taking care of them," said Kizer, a former California health director. "And they're not doing it. What can you say?"

County Supervisor Yvonne Brathwaite Burke, whose district includes King/Drew, said she called the hospital's interim nursing director, Larry Kidd, on Wednesday for an explanation of the lapses.

He had "assumed all of the routine kind of things that were normally being done were being followed," Burke said.

Kidd's consulting firm, Camden Group, plans to bring in an operating room expert to go through every surgical policy and ensure that it was being followed, Burke said.

But she said she was still concerned over why the consultants, who were hired in December to address systemic concerns about King/Drew's nursing care, didn't find the problem sooner.

"You wonder," she said, "you bring in the top consultants and experts, you think that all these things are going to be solved."

She said that even she knows how important it is to count instruments.

"What I see on television, with very little experience in the operating room myself, there's a routine counting of sponges and of instruments," she said. "I'm very surprised that this is not followed there."

[Moses]

As I began reading this, two things popped into my head. No sponge count? Not counting is different than not documenting that you counted. Both are errors. Only one is dangerous.

Second, when I hear about missing instruments I immediately think of a trauma case in an obese patient. When you have a trauma like multiple gunshot wounds there is no time to count instruments before surgery. Hell, there's no time to wash your hands properly. The guy is trying to bleed to death while two or three surgeons are up to their elbows in blood clamping vessels and throwing stitches. It is easy to lose instruments in a big trauma case.

The question for the "victim" is; "Would you rather we take our time and carefully count all our instruments (twice) while you bleed to death?"

[Moses]

Originally posted by mikester

... Baber blamed the clamp for intestinal cramps, severe back pain and a persistent fever during his first days in the hospital.

Of course! It couldn't have been all those damn bullets, right?

[mikester]

I agree, trauma cases are special and have an immediate need to attention. I think it was poor journalism (LA TIMES!) for them to use a trauma case to elaborate their point.

22 Gunshot wounds? Wow, someone wanted that guy dead.

[84porsche]

I don't want to start a health care debate but why is it you get better care in certain hospitals and with better insurance. My sister's friend's mother was put under anesthesia for too long or the wrong mixture was done and she ended up with severe brain damage. Who is responsible for this? I understand doctors and nurses have a lot of responsibilty. What can be done to make service uniform throughout all hospitals?

[Moses]

Originally posted by 84porsche
I don't want to start a health care debate but why is it you get better care in certain hospitals and with better insurance. My sister's friend's mother was put under anesthesia for too long or the wrong mixture was done and she ended up with severe brain damage. Who is responsible for this? I understand doctors and nurses have a lot of responsibilty. What can be done to make service uniform throughout all hospitals?

Why was your sister's friend's mother under anesthesia?


why is it you get better care in certain hospitals

Because uniform quality in humans is impossible.

What can be done to make service uniform throughout all hospitals?

For starters, get the HMO's and the lawyers off the doctors butts and you will once again attract the "best and brightest" to the field.

[nostatic]

I like to think of the clamp as a "door prize". The patient should have been thanking them and shouting "now I'm going to Disneyland!"

King/Drew has had a long history of "issues". In fact they have been almost shut down on a number of occasions.

As for the field, I had a choice back in '87 and chose grad school. Even way back then it was obvious how the medical profession was heading...

[84porsche]

Originally posted by Moses
Why was your sister's friend's mother under anesthesia?

She went for some kind of cosmetic surgery.

By the way, do HMOs require cheap medical care or what is their primary responsibilty and or purpose? All I have heard are bad things. I was offered one here at work and chose to up it to a PPO.

[Moses]

Originally posted by 84porsche
She went for some kind of cosmetic surgery.

By the way, do HMOs require cheap medical care or what is their primary responsibilty and or purpose? All I have heard are bad things. I was offered one here at work and chose to up it to a PPO.

A healthy woman undergoing cosmetic surgery should not have that type of complication. Either the surgical stress uncovered an unknown medical condition or someone fell asleep at the switch. I've seen both. Awful.

HMO's exist to make money. They make money by rationing care. Less access. Less options. More profit.

Think about applying the HMO model to Starbucks. You pay a yearly fee and Starbucks agrees to take care of all your coffee needs. Next thing is the local Starbucks is not part of your plan. When you find a participating Starbucks, the lines are long and there is only one sluggish "barista" working. They won't give you a latte. Your plan only covers a small black coffee. That's the HMO thing.

[304065]

For starters, get the HMO's and the lawyers off the doctors butts and you will once again attract the "best and brightest" to the field.

Whhooooa there! Just a durned minute saw-bones!

While I certainly admire your PROFESSIONAL LOYALTY you are WAY over the line pinning what is a CLEAR CUT case of medical malpractice on lawyers and HMOS.

This wasn't a COMBAT situation with bullets flying over the heads of the trauma docs. . .it has long been established as STANDARD OF CARE that you count instruments and sponges.

And don't give me the, "This is a county hospital, the doctors that work there aren't "bright" enough." If we have people being certified to practice medicine who don't get the basic idea that you don't leave surgical instruments in the patient then maybe we better go back to letting BARBERS do medicine!

We can debate Med-Mal, Tort Reform, Capitation, HMOs, Medicare reform and the virtues of traditional indemnity insurance all day long, but that doesn't change for a SECOND the fact that the standard of care was seriously violated. And no amount of making excuses for the situation is going to change that, either in the eyes of the patient, the law or the public.

In the law, we call it "Res Ipsa Loquitur" - The thing speaks for itself. Leaving a 5 inch clamp inside the PT is an act so egregious that you don't even have to prove the first couple elements of a traditional negligence claim (which are, that the Defendant owed the Plaintiff a legal duty, and breached that duty, which breach was a proximate cause of the Plaintiff's injuries). The mere fact of a clamp left in this guy's body is enough to have the Med-Mal carrier settle faster than you can say, "there are no bad risks, only bad premiums."

What's next, the "code of silence?"

[Moses]

Originally posted by john_cramer
Whhooooa there! Just a durned minute saw-bones!

I knew I'd draw you out with that one!

Yes, Drew/MLK has had issues for years. Not documenting a surgical count is indefensible for non-emergency cases.

In trauma cases there is rarely an instrument count. There is simply no time. The count is performed by two nurses and takes a good deal of time. If the patient is not stable no count is attempted. Years ago I proposed a sealed "pre-counted" tray of emergency instruments. The hospitals lawyers said it did not meet the HICFA standards. Oh, well.

If you had ever seen an emergency surgery like this you might have a different opinion. It is a complete flail. Blood everywhere. Scrambling to stop bleeding from crushed organs and areas you can't even see. It is not unusual to have half a dozen hemostats in the abdomen clamping off bleeders while you search for the "big bleeder". Intestine fills the cavity, burying your clamps. It's rare, but a wayward, unaccounted for clamp is not hard to imagine.

Here's my point. The fellow came in full of bullets. Do nothing and he dies. The clamp that was left behind caused no permanent damage, but required a second surgery to remove. If I pull your ass out of a burning building, don't sue me because I sprained your elbow getting you out.

When the ambulance drops your bullet-ridden body off at the hospital, what are reasonable expectations? The "victim" is alive and apparently well enough to lawyer up and sue the people who saved him. Beautiful.

[mikester]

Originally posted by Moses
I knew I'd draw you out with that one!

Yes, Drew/MLK has had issues for years. Not documenting a surgical count is indefensible for non-emergency cases.

In trauma cases there is rarely an instrument count. There is simply no time. The count is performed by two nurses and takes a good deal of time. If the patient is not stable no count is attempted. Years ago I proposed a sealed "pre-counted" tray of emergency instruments. The hospitals lawyers said it did not meet the HICFA standards. Oh, well.

If you had ever seen an emergency surgery like this you might have a different opinion. It is a complete flail. Blood everywhere. Scrambling to stop bleeding from crushed organs and areas you can't even see. It is not unusual to have half a dozen hemostats in the abdomen clamping off bleeders while you search for the "big bleeder". Intestine fills the cavity, burying your clamps. It's rare, but a wayward, unaccounted for clamp is not hard to imagine.

Here's my point. The fellow came in full of bullets. Do nothing and he dies. The clamp that was left behind caused no permanent damage, but required a second surgery to remove. If I pull your ass out of a burning building, don't sue me because I sprained your elbow getting you out.

When the ambulance drops your bullet-ridden body off at the hospital, what are reasonable expectations? The "victim" is alive and apparently well enough to lawyer up and sue the people who saved him. Beautiful.

I would much rather he say "thank you" and go on his way.

But I'm not a Dr. or a Lawyer.

[304065]

When the ambulance drops your bullet-ridden body off at the hospital, what are reasonable expectations?

Man, that is a pretty SPECIOUS argument from somebody who ought to know better!

Yeah, you better waive your expectations that you won't be treated NEGLIGENTLY when you show up at the hospital!

Diabetics, when you need an amputation, you better be prepared to have the WRONG LIMB sawn off, and then the correct limb once they figure out what happened, making you a DOUBLE AMPUTEE!

Back pain got you down? Goin' in for that SPINAL FUSION? Better know where to put those pedicle screws yourself!

How about some medication? Allergic? We don't know!

http://www.yerridlaw.com/verdict35.cfm

Yep, you take your life in your hands when you show up at the hospital! Overworked residents, having been up 24 hours, under the direction of a grumpy attending!

My REASONABLE EXPECTATIONS are that I'm in the hands of a competent professional who will fulfil the highest standards of the profession to save my sorry butt. And in so doing, protect his own.

I don't understand why a pre-counted tray of surgical instruments for the trauma center would be a violation of the HCFA rules. Maybe they were concerned that billing Medicare (the Health Care Financing Administration = CMS = payor for Medicare) for an entire bag of tools would be considered "overbilling?"

Just WAIT for my HCFA/Capitation/Fraud and Abuse thread, it's coming.

[Moses]

Originally posted by john_cramer
Diabetics, when you need an amputation, you better be prepared to have the WRONG LIMB sawn off, and then the correct limb once they figure out what happened, making you a DOUBLE AMPUTEE!

Back pain got you down? Goin' in for that SPINAL FUSION? Better know where to put those pedicle screws yourself!

How about some medication? Allergic? We don't know!

C'mon John! Aren't those a bit different? I have established that I believe the Med Mal industry is an important tool to help keep us on our toes, but the bullet-ridden trauma victim is a little different, don't you think?

I believe the reason we can't pre-count our instrument trays is because the "chain of accountability" has to be immediate and unbroken. Without that it would likely be more difficult to figure out who to sue.

[dhoward]

Just keep in mind that 50 percent of the doctors out there finished in the bottom half of their class...

[Moses]

John, I read your link about the spinal fusion gone bad. I agree. Definite malpractice.

Let me run this one by you:

Experienced obstetrician performs what he thinks is an uncomplicated forceps delivery. Problem: Newborn has complete left facial paralysis. This is a rare but known complication of forceps delivery.

Family hires the services of well known charismatic malpractice lawyer. When the infant is 6 months old, a neurologist performs a MRI scan that shows complete absense of the left facial nerve! There was no injury. The poor kid was born with no facial nerve. The planned expert witness declined to testify for obvious reasons. Undaunted, the lawyer found another "expert" who would refute the MRI findings.

Amazingly, the lawyer won the case! It was reversed on appeal.
Now here is where you and I part ways, John. For intentionally misleading a jury, I believe the lawyer should be disbarred.

What's the problem with leaving clamps in? Get um out and they work great for roach clips.