Healthcare Risk Management 2003-04-01

Duke transplant error spurs hospitals, risk managers to reassess programs

Hospitals across the country are taking a hard look at their processes to spot weaknesses similar to those at Duke University Hospital, where a patient died because of a lack of redundancy in the system for matching donated organs.

Error occurred when confirming blood type

Sentinel events like the transplant error at Duke University Hospital in Durham, NC, often can be traced to a simple human failing by one individual, but risk managers look beyond that to ask how the system allowed the error to go undiscovered.

Asking permission when permission isn’t required

Physicians acted appropriately when they removed Jesica Santillan from life support without the consent of her parents, according to advice offered by an attorney who says such situations can be difficult for risk managers to handle.

When it comes to choosing counsel, give it some push

Choosing legal counsel for your organization is a big responsibility, whether youre entirely responsible for the decision or just one of several people with input. A great deal of money rides on the decision, along with the outcome of future malpractice suits and other legal matters.

Reader Questions: Falls are an RM’s business, not the custodial staff’s

Question: How much should our risk management department take responsibility for preventing slips and falls in the facility, as opposed to letting environmental services handle that issue? I know were responsible for any resulting litigation, but shouldnt prevention really be their job, not mine?

HHS: Litigation crisis worse, many lawsuits unfounded

Problems associated with medical litigation have significantly worsened in the past year, according to the Department of Health and Human Services (HHS), which says the spiraling cost of insurance for health care providers is impairing patients access to health care, as well as the cost and quality of care.

Twenty percent of hand surgeons admit to error

One-fifth of hand surgeons admit they have operated on the wrong site at least once in their careers, according to a new survey. But at the same time, they report that a campaign begun in 1998 by the American Academy of Orthopaedic Surgeons (AAOS) to prevent such errors may be showing good results.

Smallpox vaccination: Is your plan in place?

Physicians are practicing more defensive medicine

A new survey of physicians, nurses, and hospital administrators suggests that malpractice concerns are leading to the practice of more and more defensive medicine. Large numbers of medical doctors report that they order more tests, refer more patients, prescribe more medication, and suggest biopsies more often than is necessary because of concerns about malpractice.

Legal Review & Commentary: Resident performs negligent biopsy and $2.5 million is awarded

News: A woman died following a liver biopsy performed at an outpatient facility by a resident physician. The resident was inexperienced and punctured her lung. Unaware of the injury, the resident and supervising physician left the patients bedside, and shortly thereafter she aspirated on her own blood and died.

Legal Review & Commentary: Negligent hire, supervision: $850,000 verdict reached

News: After a hospital hired a patient care technician who had a rape conviction, suit was brought against the hospital by a patient alleging sexual assault by the hospital employee.

Healthcare Risk Management – April 1, 2003

April 1, 2003