Legal Review & Commentary: Improper blood transfusion leads to $35.3M settlement
Legal Review & Commentary
Improper blood transfusion leads to $35.3M settlement
News: A pre-eclamptic pregnant woman developed HELLP syndrome. Treatment for the syndrome was unsuccessful, and an emergency cesarean was conducted when the baby was at 27 weeks gestation. At birth, the child was diagnosed as intrauterine growth-retarded and was placed in the neonatal ICU. The child was later diagnosed with anemia and, in light of multiple blood draws, required a blood transfusion. Several days after the transfusion, white spots were noted in the brain, identified as air emboli. When the child was 1 month old, ultrasounds and CT scans showed a loss of brain tissue in the form of cysts or lesions. The child's mother claimed that the child's later retardation was a result of the negligent blood transfusion that allowed air emboli to enter the child's brain. A jury returned a verdict, but the parties ultimately reached settlement of that verdict in the amount of $35.3 million.
Background: A woman who was approximately six months pregnant was diagnosed as being pre-eclamptic. Later the woman developed HELLP syndrome, a disorder unique to pregnant women manifested by high blood pressure with decreasing amounts of platelets in the blood, placing its victims at high risk for bleeding. The only "cure" for HELLP syndrome is delivery of the child. As treatment for the syndrome was not successful, the woman was sent in for a cesarean at 27 weeks gestation. At the time of the delivery, the child was diagnosed as intrauterine growth-retarded and was placed in the neonatal ICU for observation and treatment. Intrauterine growth retardation is caused when the baby is growing slowly and does not weigh as much as is typically expected for that particular stage of the pregnancy. While the infant did not require a respirator at the time, he was diagnosed with some apnea, bradycardia, and anemia, all of which are not uncommon for premature babies. Ultrasounds of the baby's head were conducted and returned normal results. At 2 weeks of age, the infant required a blood transfusion due to anemia and blood loss through draws. A hospital nurse transfused the blood using an intravenous line and an automatic pump. At the end of the transfusion, a small amount of blood remained in the line. The nurse filled the syringe with air to push the remaining blood into the infant's line. Within minutes of the nurse's actions, the infant coded but was successfully resuscitated. Days after the transfusion, ultrasounds and CT scans displayed white spots in the infant's brain. These were identified as air emboli introduced during the transfusion. At 1 month of age, additional ultrasounds were taken that showed a loss of brain tissue in the form of cysts or lesions. Ultimately, the child was diagnosed with mental retardation, left-side hemiplegia, spastic quadriplegia, and a lack of speech capacity due to a lack of muscle control.
The child, through his parents and guardian ad litem, filed suit against the hospital and the hospital's insurer, seeking compensatory damages for the child's past and future medical expenses, lost ability to earn wages, pain and suffering, and the parents' loss of his society and companionship. The plaintiff claimed that negligence during the blood transfusion caused the air emboli to form in the child's brain and led further to the child's ultimate retardation. While the hospital admitted negligence with regard to the nurse's performance of the transfusion, it denied the correlation between such negligence and the child's eventual retardation. Rather, the defendants claimed that events prior to birth caused the brain damage, focusing squarely on small and abnormal placenta and early ultrasounds showing abnormalities where the cysts later developed.
The parties reached a final settlement in the amount of $35.3 million.
What this means to you: The anticipation of and actual birth of a child is most often a happy time for family and staff. Any time there is an untoward outcome, it is a sad scenario. In this case, the development of HELLP was one of those complications of pregnancy that can occur and was diagnosed and attempts to promptly treat undertaken. According to this scenario, the treatment of the syndrome never was in question, and the only "cure," delivery by cesarean, was undertaken in a timely manner.
The process of administration of blood and blood products to anyone is a recognized critical process that begins with the collection of the blood product, processing at the blood bank, collection of the sample from the patient who is to receive the blood for the type and cross-match, validating the correct blood is hung for administration to the correct patient, and continually monitoring for reaction or incompatibility and other potential complications. In the case of administration of blood or blood products to premature infants, in particular, close monitoring is very important as fluid overload and allergic/incompatibility reactions are areas of concern, among others.
The situation that led to this unfortunate situation was clearly avoidable and preventable. The administration of blood to this infant, as described, went without incident until the last remaining small amount of blood in the tubing. While the nurse may have had the best of intentions to be sure the infant got all the blood to be transfused, as anemia was the basis for the need for the transfusion, to have undertaken the flush with the air was outside the established and accepted practice and procedure. To take it one step further, for any nurse to flush any line with air, is not acceptable in any circumstance. As a student nurse, we are taught to "squirt out" any air bubbles from a syringe or from any intravenous (IV) line before injecting or attaching a line to prevent the introduction of any air, preventing an air embolus.
Immediately, the risk manager should undertake to convene a root-cause analysis to determine the root cause of this untoward outcome and apparent deviation from acceptable practice and process. In addition, the policy and procedure in place should be reviewed and consideration given to whether a failure mode and effects analysis should be undertaken as well. While it might appear that this nurse made this error based on lack of knowledge of the hazard of an air embolus and prohibition of injecting air to flush air through an IV line, until the actual, objective investigation is concluded, that remains a hypothesis. In addition, it should be emphasized to all nursing staff throughout the facility that in no circumstances will air be used as a flush in any intravenous line.
Disclosure of this untoward event to the parents of this infant is another task the risk manager should coordinate as soon as possible. The initial disclosure meeting with the parents only is the beginning of the support and ongoing communication with the infant's parents. As the investigation of the event and progress of the infant continues, subsequent meetings should be convened and information shared.
In addition to support of the family of the infant, we cannot forget the emotional and psychological toll such an untoward event has on the direct caregiver and the other staff in the unit. Oftentimes, in devastating events, a "crisis team" is brought in to work with staff, especially the direct caregiver. Sometimes the direct caregiver is put on paid leave until the investigation of the event is complete. This assists in facilitating the involvement and cooperation of the direct caregiver in the actual investigation and root-cause analysis. Depending on the state where this event occurred, there are requirements to report to a state agency. Sometimes those circumstances lead to disciplinary actions by the respective licensing board, and this can lead to the need for additional support of the direct caregiver.
Should the root cause and other investigation show that it was a faulty process that led to the untoward outcome, the organization can determine how to handle the disciplinary action that may be appropriate. However, even in this era of "just culture," some organizations terminate the direct caregiver, and sometimes that is the proper thing to do. With guidance from legal counsel, the statement of the direct caregiver should be taken before the actual termination to preserve that information.
All of these activities should have been and were, hopefully, carried out before the mediation and trial that is discussed in this scenario.
The hospital admitted liability for the actions of the nurse, but not for the resultant brain injury and retardation of the child. This is a legal tactic that should be discussed in detail with the CEO and the board, with full discussion of the pros and cons of such a tactic. One would wonder what were the limits of this organization's liability insurance, and if an offer were made to settle before the mentioned mediation. Risk managers are well aware that untoward outcomes involving infants and children induce jury sympathy and frequently lead to high jury verdicts; oftentimes, attempts are made to settle before trial, if possible, for that reason. With more than one normal MRI and otherwise normal progress of the infant before the injection of the air embolus, proving causation could not have been difficult.
This is an unfortunate outcome that could have been prevented.
Reference
Circuit Court of Wisconsin, Second Judicial Circuit, Walworth County.
A pre-eclamptic pregnant woman developed HELLP syndrome. Treatment for the syndrome was unsuccessful, and an emergency cesarean was conducted when the baby was at 27 weeks gestation. At birth, the child was diagnosed as intrauterine growth-retarded and was placed in the neonatal ICU. The child was later diagnosed with anemia and, in light of multiple blood draws, required a blood transfusionSubscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.