$12.2 million verdict for Dr. Doe’ sends wake-up call for medical teaching
Needle-safety push gains momentum following huge jury award
A recent $12.2 million verdict in favor of a health care worker infected with HIV following a needlestick may speed the national transition to safer needle devices and spur re-examination of medical teaching methods, experts advise Hospital Infection Control.
"This award this verdict is a huge wake-up call," says Janine Jagger, PhD, director of the International Health Care Worker Safety Center at the University of Virginia in Charlottesville. "Health care institutions will really for the first time see themselves as extraordinarily vulnerable."
On Dec. 17, 1997, a jury in New Haven, CT, ruled that Yale University must pay $12.2 million to a physician who was infected with HIV after sticking herself with a needle while inserting an arterial catheter into an AIDS patient at Yale-New Haven Hospital in 1988.1 The doctor, who has been identified only as Jane Doe during the case, was a first-year medical intern at the time of the exposure. Her lawyers argued that Yale University did not train her properly, she had only performed the procedure once prior to the accident, and she was not supervised during the insertion. Doe claimed she was stuck when blood began spurting from the device and she attempted to stop it with her thumb. Yale’s lawyers, who are appealing the verdict, argued that the medical school had provided excellent training and that the doctor was responsible for the injury. Indeed, the jury reduced its total damage award from $15.8 million to $12.2 million to reflect that the doctor bore partial responsibility for the exposure.
Jagger and colleagues published an article in 1996 warning that medical schools could be particularly vulnerable to such rulings because infected trainees often do not qualify for workers’ compensation provisions that can insulate hospitals from liability claims.2 They also noted that traditional training methods may no longer be adequate for procedures that place students at risk for occupational infection.
Students should be required to demonstrate proficiency by using mannequins or other devices, or by serving as volunteers under supervision, before they perform procedures on patients, the authors concluded. In general, workers’ compensation benefits are provided to health care workers for occupational infections and injuries, the authors noted. In turn, under the exclusive-remedy provisions of workers’ compensation laws, an employee with an occupational injury usually cannot bring a private suit to recover damages when the employer has been negligent, they reminded.
"Medical schools are very vulnerable to liability because students trainees are not covered by workers’ compensation provisions," Jagger says. "This is a landmark case from that perspective. It shows that what we said was theoretically a hazard to medical schools is a reality."
While the verdict is most relevant to medical schools and training institutions, the case also suggests that health care settings in general may be vulnerable to increased liability should similar circumstances arise, notes Larry Gostin, JD, LLD, professor of law at Georgetown University Law Center in Washington, DC, and director of the Law and Public Health program at Georgetown and Johns Hopkins University in Baltimore.
"It’s true that hospitals that are engaged in teaching are more vulnerable because they have those direct responsibilities for teaching and because workers’ comp does not apply to them," he says. "But I think that virtually all hospitals do some teaching have some residents there and have some teaching responsibilities. So it seems to me that the [verdict] goes further, and I think that this will increase the push for using needles safety devices. I also think it will increase the push for more training and additional focus on universal precautions."
The jury-verdict case does not necessarily establish any legal precedent for future cases, but it does suggest juries may be highly sympathetic toward occupationally infected workers, he notes.
"It is a salutary lesson," Gostin says. "If you don’t follow the most rigorous training precautions and use the most up-to-date devices to protect staff from these kinds of needlestick accidents, you lay yourself open to liability. Anytime a health care worker becomes [occupationally] infected with HIV or another pathogen, juries are likely to be quite sympathetic."
The incident occurred in 1988 before there was widespread availability of safety devices, but protective IV catheter stylet designs are now available that can prevent such injuries, Jagger adds. One study showed that the safety IV catheters reduced needlestick injuries by 83% compared to conventional IV catheters, she notes.3
To reduce liability, reduce risk
"The picture now is not only that medical schools need to provide adequate training, but they also need to provide the safest equipment," she says. "We’re hoping that awareness will be drawn to the issue and we can fill the vacuum of information as people seek to address their liability. The best and most complete way to reduce liability is to reduce the risk of these incidents, with safety devices being No. 1 on the list."
An emphasis on needle-safety devices would be a more appropriate legacy for the case than a condemnation of medical education, adds Rita McCormick, RN, infection control practitioner at the University of Wisconsin Hospital and Clinics in Madison.
"Accidents can happen irrespective of the degree of education or the amount of carefulness," she says. "This is really a terrible tragedy. I would like to put the emphasis on the need to move to safer devices. The manufacturers have certainly met the call to produce them. There are some good [devices] coming on to the market. Hopefully that is where the emphasis [resulting from the verdict] will go, rather than to lay any sort of blame on curriculums and failure to teach."
The jury award also could speed the transition to safer designs because product manufacturers may be sued by infected workers who are blocked from suing their health care settings due to workers’ comp provisions, adds Tom Sutton, MBA, vice president for marketing and sales at Bio-Plexus Inc., which manufactures needle safety devices in Tolland, CT. "I think, over time, regulations are going to come out to make everybody use safety devices, or maybe the manufacturers will decide there is too much liability to still make non-safety needles," he says. "[The verdict] is having an effect. Simply based on the inquiries we have gotten in the last two or three weeks, I have noticed a pronounced increased interest. [Manufacturers] are starting to call around to people who have safety technology to find out how to incorporate it."
While the primary focus for change may be on more widespread implementation of needle-safety devices, the verdict also has opened up debate about whether the traditional mode of medical education is still appropriate for today’s clinical setting.
"As far as medical student house staff education, it is a see one, do one, teach one’ system in most facilities," says Marguerite Jackson, RN, PhD, CIC, FAAN, administrative director of the medical center epidemiology unit at the University of California in San Diego. "The responsibility for training rests with a senior physician, and the skill of that person in teaching technique is highly variable."
An unwritten rule in many teaching institutions has been that clinicians in training be given relatively low-risk cases as they improve their skill levels, she notes.
"That is not something anyone is going to write into policy, but implicitly we as educators do that all the time," she says. "You don’t give a brand-new nurse who has never started an IV except on a dummy arm’ an IV on an 85-year-old who has very fragile veins. "
Ancient and traditional’ methods still used
The educational approach at many medical schools has remained relatively unchanged even as an increasing array of technological and invasive devices have become common in the clinical setting, adds William Schaffner, MD, chairman of the department of preventive medicine at Vanderbilt University School of Medicine in Nashville.
"It is too early to say whether this particular case will have immediate ramifications, but I think it is fair to say that even though we are over 10 years into the AIDS era with vastly greater attention directed to health care worker safety, one of the areas that has yet to receive sufficient attention is this matter of training the medical neophyte in invasive procedures," he says. "We have been very content with the ancient and traditional case-by-case teaching learning in the context of doing."
Under such a system, there appears to be no national consensus on either the level of competence expected, or how a trainee’s ability is to be measured and documented before procedures are performed independently. For some surgical procedures and endoscopies, a log book may be kept to document procedures and training, but that does not necessarily extend to starting the variety of catheter lines and other relatively minor invasive procedures, Schaffner says. Complicating the picture is a medical teaching climate that may make clinicians in training particularly physicians reluctant to express doubt about their ability or request additional instruction, he says.
"There is still an enormous reluctance on the part of trainees to acknowledge to their immediate supervisors that they are not yet secure in doing the procedure," he says. "That’s part of the whole ethos that is built into the system. This is now occurring in an environment where patients are sicker, house officers are seeing more patients, and time is of the essence. In many areas of the country, there is a pressure to reduce the number of residents. Where there is found to be a need for more supervision, the question is: Where do the supervisors come from?"
References
1. New York Times. Yale must pay $12.2 million to doctor infected with AIDS. Dec. 18, 1997, p. A18.
2. Tereskerz PM, Pearson RD, Jagger J. Occupational exposure to blood among medical students. N Engl J Med 1996; 335:1,150-1,152.
3. Jagger J. Reducing occupational exposures to bloodborne pathogens; where do we stand a decade later? Infect Control Hosp Epidemiol 1996; 17:573-575.
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