Legal Review & Commentary-Patient loses lips to frostbite: $2.55 million settlement
By Mark K. Delegal, Esq., and Jan Gorrie, Esq.
Pennington, Moore, Wilkinson, Bell and Dunbar, PA
Tallahassee, FL
News: A $2.55 million settlement was reached with the manufacturers of the liquid oxygen delivery base unit and flow meter and supplier of the liquid oxygen that caused severe frostbite to a plaintiff's face and mouth. The flow meter was not designed to read the actual flow of oxygen from the base unit, which allowed the flow to be higher than the level the machine indicated.
Background: The 76-year-old patient had been discharged from a hospital and admitted to a nursing home for further recovery of pneumonia. To treat the condition, his physician prescribed supplemental liquid oxygen. Under the physician's orders, he was to receive the oxygen at a rate of 7 liters per minute through a face mask that covered his mouth. Sometime during the morning of the incident, the oxygen flow had been increased by the nursing home staff and exceeded 28 liters per minute. When the flow of liquid oxygen reaches or exceeds 28 liters per minute, it comes out of the machine at a temperature below freezing.
None of the nursing staff was aware that liquid oxygen was capable of freezing and able to cause harm to patients if it did freeze. The patient's exposure to the freezing oxygen caused frostbite to his face and mouth, which eventually necessitated the removal of his lips.
The flow meter, which had been designed for wall-unit, nonliquid oxygen, could flow at a rate of up to 50 liters per minute, but the meter dial only read up to 8 liters per minute. That could result in users operating the oxygen delivery unit at very high flow rate without realizing they had exceeded 8 liters per minute.
The plaintiff claimed the manufacture of the delivery unit was aware of the risk of excess flow and should have installed a restrictor into the base unit that would prevent the flow from exceeding dangerous levels. In addition, the plaintiff claimed the manufacturer of the flow meter should have properly metered the device so the actual flow of oxygen could be accurately read by users of the unit. And, finally, the plaintiff alleged that the supplier could have installed a more restrictive flow meter on the unit to reduce the potential flow of oxygen.
What this means to you: Though the settle-ment was with the manufacturers and the supplier, this case presents opportunities for enhancing risk management in health care, particularly in the areas of employee education, development of clinical policies and procedures, and corporate liability.
"With regard to employee education, staff should be trained regarding the differences between and particularly the risk associated with nonliquid and liquid oxygen. Further, oxygen needs to be considered as a medication in that it is only given under a physician's order at the specified flow level. The provision of oxygen and its amount is simply not a nursing judgment issue, and this is sometimes overlooked." says Georgene Saliba, RN, BSN, FASHRM, HRM, director of claims and risk management for Lehigh Hospital and Health Network in Allentown, PA.
"Policies and procedures should address and reinforce the continuing education and training of staff as to the risks of liquid oxygen, such as the fact that it can freeze and the point of which that happens; policies and procedures for the administration of oxygen, particularly liquid oxygen, should be tailored to include appropriate parameters for monitoring the patient," she says. "In this particular case, it is not known exactly how long the patient was exposed to freezing oxygen; however, one might assume that the exposure was long enough for the patient to have experienced some severe pain and discoloration before the situation was discovered. One might assume that the patient was not monitored during the period between the flow of oxygen being elevated and the frostbite occurring."
Finally, corporate liability must be examined. "The manufacturers of both the oxygen delivery system and flow meter as well as the liquid oxygen suppliers should have recognized the differences in risks between liquid and nonliquid oxy- gen and recognized that different systems, or at least precautionary devices, are probably needed for liquid vs. nonliquid oxygen. Given the different elemental properties of liquid and nonliquid gaseous oxygen, each potentially merits a different system or at least a system that can be adjusted or read for both types of oxygen," says Saliba.
It is not known in this instance whether the nursing home had been told the oxygen delivery system could handle both liquid and gaseous oxygen or if it had simply assumed such. "In either instance, risk management should be involved in such purchasing or lease decisions or, alternatively, once patient care devices are delivered, risk management should have the opportunity to review the operating instructions so that they might be incorporated into continuing education, staff communications, and/or policies and procedures," she says.
"Prior to a health care facility's use of equipment in the provision of patient care, appropriate review of the technology, staff's ability to operate the devices, and staff knowledge of the policies and procedures relating to the new devices, methods, and systems should be considered. Failure to do so may expose the health care facility to corporate liability claims," Saliba concludes.
Reference
John Doe, et al. v. XYZ Company, et al., Cuyahoga County (OH) Common Pleas Court.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content