Saturday, September 01, 2012

Two recent interesting settlements at Massachusetts General Hospital (MGH), both involving technology

Two recent interesting settlements at Massachusetts General Hospital (MGH), both involving technology.

The first case involved a medication error (from a 'miscommunication between doctors and nurses', an infusion pump snafu, and failure to perform obvious follow up labs;  if health IT was involved it would not surprise me).  The second case involved alarm fatigue.

These amounts are interesting considering the age and condition of the patients.


1.  http://www.lubinandmeyer.com/cases/medication-error.html


Medication Error Lawsuit against MGH Settles for $1.25 Million

The plaintiff’s decedent was a 76-year-old woman who died on 11/24/10 from a hemorrhage. Her death occurred following a preventable medication error involving the drug Lepirudin. The patient was given over 30 times too much medication which resulted in uncontrollable internal bleeding and her subsequent death.

Her past medical history included cirrhosis with well preserved hepatocellular synthetic function. She also had Type 2 diabetes, hypertension and hypercholesterolemia, and a history of splenectomy for treatment of severe thrombocytopenia.


and


2.  http://www.masslive.com/news/index.ssf/2011/11/mass_general_hospital_alarm_fa.html


Mass. General Hospital 'alarm fatigue' lawsuit settled for $850,000

BOSTON (AP) — The family of an 89-year-old man who died at Massachusetts General Hospital when nurses did not respond to alarms on his cardiac monitor has settled its case against the hospital for $850,000.

I see potential lessons for at least two healthcare stakeholders in these cases:

Hospital executives:  bad technology is not your friend.  get it right before rolling it out, with robust, validated safeguards, to save lives - and to save your organizations from costly litigation and reputational damage.

Clinicians:  bad technology is your enemy.  While hyper-vigilance is mentally exhausting, that's what's required to avoid the fate of the patients - and the clinicians - in the above cases.

Reporting bad technology and making sure the problems are remediated promptly, not glossed over, is equally essential.

Note: my interpretation is that both technology and people issues probably played a role in both these accidents, based on my own knowledge and experience, but that is of course a personal opinion. 

-- SS

4 comments:

Anonymous said...

The alarm fatigue case is fascinating. That guy laid there for a long duration in extremis. What were the doctors and nurses doing to have neglected and ignored this patient at prime time?

There was a case of such egregious negelect at UPMC in which a patient with dementia walked from her room to the roof of the Montefiore Hospital in December, 2008, and froze to death. None of the staff knew she was missing, for hours.

I query the readers of this blog to offer opinions as to what exactly could preoccupy the minds and sight of the health care professionals to cause neglect of this magnitude.

For $800k, MGH escaped with ease.

Anonymous said...

In response to the query, I am beginning to wonder if the nurses and doctors have had their workflows disrupted by user unfriendly mind numbing EHRs without search functions and CPOEs requiring multiple clicks to order an aspirin, as an example.

Such workflow disruption is the genesis of distraction, intense focus on the EHR terminal, and other psychological phenomena that cause neglect of the person lying in bed.

The pressure is on to use the EHR and document, order, read the gibberish of decision support, and solve simple problems with elaborate workarounds.

quasimodo said...

What's interesting is how MGH handles complaint. How many times don't healthcare workers get caught because victims don't realize their suffering is due to malpractice or negligence.

Mass General's orthopedic surgeon operated on my shoulder without ever taking any image (e.g., MRI, Xray), and ended up cutting off the end of my clavicle (the wrong shoulder joint) unnecessarily leaving me disfigured, deformed and continuing pain, with an arm that continues to dislocate and sublux since the surgery.

He diagnosed a shoulder separation, but failed to diagnose a torn labrum, torn rotator cuff, Hill Sachs fracture. He falsified medical records, failed to show up for our scheduled pre-op appointment (never rescheduling), took out stitches without gloves or washing his hands.

Their surgeon agreed to do arthroscopic surgery, and after I was out, did open because he later told me "it was faster." When I complained that my hand was numb 2 days after surgery, his comment "I didn't operate on your hand."

Incidentally, the surgeon is 70 years old.

MGH response was to send it to their insurance claims adjuster who in December told me it would take 3 - 4 months to review my claim. In July, he wrote to say, he'd give me a "firm date" by the end of August, but, never did. He claimed he didn't receive image disks until I provided the Post Office certified delivery number. And it goes on.

You can make conclusions for yourself about MGH errors and how they handle them. Or, if you're conscious, you can choose to go elsewhere.

Anonymous said...

Many times nurses are not staffed with telemetry technician monitors whose job is strictly to oversee the patient alarms in the unit. Because nurse are busy running around taking care of multiple patients (and at times their families) with multiple issues and cannot physically respond to each alarm. Nurses should know to check the patient when an alarm goes off and not rely on the monitor. As any human would, over time, nurses become desensitized to these alarms and the ever increasing noise distractions on any shift. No, this is not okay. There are some solutions, but those cost money and we all know the bottom line is money. Google and watch "a nursing minute", it gives a great idea of the distractions that happen in one minute of a nurses shift.