Alleged Negligence Causes Oxygen to Ignite: $1.2M Verdict
Legal Review & Commentary
Alleged Negligence Causes Oxygen to Ignite: $1.2M Verdict
NEWS: A woman was admitted to the hospital after suffering a heart attack. The woman was a high fall risk and eventually fell and fractured her nose and cut her forehead. The woman was fitted with an oxygen mask. Shortly thereafter, the electrocautery combined with oxygen from the mask, sparking a fire and leaving the woman with first and second degree burns. A jury returned a verdict of $1,215,000 in Michigan.
BACKGROUND: A 75-year-old woman suffering from deafness and blindness and unable to speak English was admitted to the hospital suffering from heart attack. She was immediately placed in the ICU, and although her condition was improving, she was medicated, agitated, and pulling at her breathing tubes and IV lines. Once the woman's condition improved, she was to be scheduled for cardiac bypass surgery. Due to the woman's high fall risk, she was fitted with restraints. Five days after being admitted, the restraints were removed by a nurse, causing the woman to fall and suffer a fractured nose and a cut on her forehead. While a resident was being called to care for the woman, she was placed back into a bed and fitted with an oxygen mask. The resident utilized a cauterization tool on the woman which emitted thermal energy. The electrocautery in the device mixed with the oxygen, a highly flammable element, from the mask, causing a spark and igniting a fire. The fire department was called to the scene, but the fire had been extinguished by the time they arrived. The woman lost consciousness during the ordeal and was resuscitated by hospital staff and was later placed into a medically induced coma for several weeks. The fire caused the woman to suffer first and second degree burns on her face and shoulders. Due to the injuries sustained during her hospital stay, the woman was forced to move out of her family home and into a nursing home.
The plaintiff alleged that the hospital's resident was negligent in failing to remove the oxygen mask. The resident, who had been on the job for only a few months, admitted he was fatigued when he committed the mistake. The case triggered a renewed discussion in Michigan regarding the number of resident per-shift hours worked and increased supervision of first-year residents. However, the defendant denied liability. The parties disagreed on what injuries triggered the need for the woman's move to the nursing home. The defendant alleged that it was the underlying heart attack and the woman's pre-existing conditions, including deafness and blindness.
The plaintiff filed two suits one for negligence and one for medical malpractice. The jury verdict of $1.2 million was returned only on the medical malpractice claim.
Reference
Circuit Court of Michigan, Case No.: 2008-004622-NM
WHAT THIS MEANS TO YOU: This case presents multiple areas of concern: the decision to remove the vest restraint in the presence of ongoing fall risk factors, impaired judgment on the part of the resident due to fatigue, and lack of supervision of this relatively new resident.
This patient was injured shortly after use of a vest restraint was discontinued. This raises the question of whether an adequate fall risk assessment was done prior to deciding to discontinue restraint use. It is also unknown whether staff considered alternative means of addressing fall risk. The patient was described as being blind, deaf, and unable to speak English. In an unfamiliar environment and without the ability to comprehend instructions or make her needs known, this patient should have been assessed as being at high risk for falling. Despite this, the vest restraint was removed, and it is unclear that any alternative means of protecting the patient were implemented in its place.
Resident fatigue is a significant threat to patient safety that has been well documented in the literature. It has been shown that 17 hours of sustained wakefulness impairs performance to the same degree as a blood level alcohol of 0.05%, the legal definition of intoxication in many industrialized countries. Thus, in this case, if the resident had been awake for 17 hours or more at the time of the incident, it was as if he had been intoxicated while caring for this patient. Given this, it is not hard to understand why he failed to discontinue the oxygen while using the cautery.
In 2003, the Accreditation Council of Graduate Medical Education (ACGME) introduced duty limits that restricted resident work weeks to 80 hours averaged over a 4-week period. However, interns and residents routinely worked more than the specified 80-hour limit. But even if residents' work hours adhered to the ACGME guidelines but included extended shifts, they were eight times more likely to commit a preventable medical error and four times more likely to commit a fatal medical error.
In 2008, the Institute of Medicine (IOM) recommended that further measures be taken to safeguard patients from fatigue-related errors on the part of medical trainees. These measures included alleviating fatigue and loss of sleep among trainees by further reducing work schedules and providing five-hour periods of uninterrupted sleep during shifts of 16 hours or more, increasing resident supervision, and improving handoffs among trainees. In June of 2010, the ACGME released for comment new duty limit standards, with special focus on PGY-1 trainees. Under these new standards, PGY-1 work weeks cannot exceed 80 hours per week or 16 hours per shift, averaged over 4 weeks. More senior residents are also limited to 80 hours per week, averaged over four weeks, but may be scheduled for 24-hour shifts, with an additional four hours for patient handoffs. Although the ACGME rejected the IOM's recommendation of a period of five hours of uninterrupted sleep for residents working shifts longer than 16 hours, it did recommend "strategic napping" for such residents. The new standards are to take effect in July 2011.
Lack of adequate resident supervision is another well-documented threat to patient safety. Lack of technical competence and errors in judgment are common among trainees and can be easily counteracted with adequate supervision from more senior physicians. In addition, better supervision of medical trainees has also been shown to counteract the effects of fatigue in medical trainees.
This case highlights important lessons about the effects of fatigue on medical trainees and the ultimate impact on patients. In light of research evidence showing the effects of fatigue on medical trainees and the resulting injuries to patients, it is no longer acceptable to deploy fatigued medical trainees to care for patients. Even though the revised ACGME guidelines will not take effect until July 2011, organizations with residency programs would be well-advised to begin making the proposed changes now.
In addition, organizations must address resident supervision, particularly for PGY-1 residents. In addition to counteracting the deficiencies in judgment and technical skill among inexperienced residents, increased supervision is also a recognized countermeasure for fatigue among those residents. With increased national attention being focused on the role of fatigued and unsupervised medical trainees in medical errors, organizations that do not address these issues proactively do so at their own peril and that of their patients.
A woman was admitted to the hospital after suffering a heart attack. The woman was a high fall risk and eventually fell and fractured her nose and cut her forehead. The woman was fitted with an oxygen mask. Shortly thereafter, the electrocautery combined with oxygen from the mask, sparking a fire and leaving the woman with first and second degree burns. A jury returned a verdict of $1,215,000 in Michigan.Subscribe Now for Access
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