Malpractice

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This week’s topic is malpractice. I chose to write about this issue and also give my first podcast, as it is an issue which I am passionate about and it seems to be becoming ever more prevalent, sadly. I frequently witness firsthand the costly and life-altering consequences that can result from medical errors.

Medical malpractice can be defined as care that is subpar and below the same level of care that another clinician with the same credentials and in the same position would provide, resulting in injury to the patient (1). According to the American Medical Association (AMA), “one in three clinicians will be sued at least once throughout their career, with some surgical specialties having an even greater chance of being sued” (1). It is likely that these statistics, along with the fact that 8/10 cases typically go to trial for medical malpractice, necessitate clinicians having to have professional liability insurance as the time, money, and resources spent on preparing for and going through the case in court often ends up quite expensive and potentially financially destructive. But what about patients…how do they prepare for a potentially avoidable medical procedure that ends up injuring them and causing years or even a lifetime of pain, disability, and financial burden?

Healthcare providers have a duty to provide care as they were trained and licensed to perform. They are expected to acquire the knowledge and experience necessary to maintain a certain standard of care. Many of the standards physicians uphold stem from the Hippocratic Oath, which as you may know is a medical text originating in Greece in the 5th century BCE from the first physician, Hippocrates, who was a leader in medical research and thought (2). Although the Oath does not explicitly state “do no harm” and is not required by the majority of modern medical schools as is commonly thought, it does pave the way for the implied responsibility physicians and healthcare professionals assume when providing care for individuals and the community (2).

The breach in upholding the standard of care can be a result of lack of knowledge, nefarious actions, or human error. Whatever the reason, the effects can be disastrous. Here are some facts from 2022 and prior years:

• 1 in 3 providers is sued for medical malpractice

• Avoidable errors constitute 3-15% of all medical interventions

• The most common type of malpractice is misdiagnosis with cancer, infections, and vascular events such as stroke most commonly misdiagnosed

• Medication errors are a major problem with insulin and morphine being the most error-prone medications (this can be correlated with another major problem in the U.S. also known as “polypharmacy,” which I’ll go into later)

• Negligence on the part of providers is the third major cause of deaths in America (after heart disease and cancer), causing more deaths than chronic respiratory disease

• Medical errors account for 251,000 deaths per year

• Medical malpractice is considered a leading cause of death, accounting for 9.5% of all U.S. fatalities

(3).

The number of medical malpractice claims vary by state, which can be due to other factors such as state regulations and laws, access to attorneys, and transparency among providers. California had the highest number – 4,638 – of malpractice claims in 2022, while New York and Florida malpractice payouts were highest, totaling $551 million and $382 million respectively (3). The lowest cases were in the states of Vermont, Hawaii, Rhode Island, South Dakota, and Idaho (3). Some patients are more vulnerable to malpractice with patients over 65 years of age being the most likely victims (3). The last troubling fact I will leave you with is that the highest number of medical practice settlements occur because of unnecessary procedures (3).

Mistakes happen, health care workers are human and humans are prone to error. However, being a provider caring for the health of others makes one ever more responsible to practice with care and attention so as not to bring about harm or make a troublesome condition even worse, causing morbidity, disability, and possibly even death. Throughout my time as a nurse, I have heard many of my patients describe horrifying situations. One lady with a torn knee meniscus went in for surgery after continuing to experience pain despite months of physical therapy and three failed cortisone shots; after the procedure, she suffered through two years of post-surgical complications that necessitated two additional surgeries to correct. Her gait was permanently affected, needing a cane to get around for the rest of her life. Another patient had bilateral shoulder surgery that was done months apart allowing time for each shoulder to heal, but she ended up developing scar tissue on her right, dominant side preventing her from being able to raise her arm enough to drive or even put on her undergarments and clothes. She required daily assistance from her husband simply getting dressed in the morning.

More recently, I came across another patient who was elderly and suffered a fall, which led to a fracture and subsequent hospitalization. As he was nearly 90 years old, his appetite was affected and the providers in the hospital elected to insert a feeding tube, which unfortunately punctured his lung, leading to a pneumothorax and subsequent pneumonia due to aspiration of food particles from the feeding tube. He is left with permanent complications that have affected his quality of life, such that it left me wondering, is it really in the patient’s best interest at age 90 to be placed on a feeding tube when mobility is limited, energy expenditure is at a minimum, and the likelihood of feeding tube complications such as bleeding, bloating, aspiration, and a feeling of “drowning” is high, especially in the elderly? I read about one similar case in which a 50-year-old patient with oral carcinoma was transferred to the Intensive Care Unit (ICU) from the radiation therapy ward with sudden respiratory distress; the patient developed severe coughing, choking, and difficulty breathing after nasogastric or NG tube placement (4). His blood pressure was elevated and his pulse was at a rapid 130 beats per minute; patient had to be intubated at which point the laryngoscope showed his nasogastric tube had entered his vocal cords with 16 cm of the tube being caught within the trachea, impeding his breathing (4). It was later discovered that the feeding tube had been inserted by an inexperienced resident who only confirmed placement by auscultating with a stethoscope. Knowledge and experience of the standard of care, which is to confirm correct NG tube placement with an x-ray immediately after insertion and prior to initiating feeding through the tube, might have avoided this medical error. As with all mistakes, reporting them is essential, not to blame any one person, but to learn from them and to ensure that providers have proper checks and balance in place so as to prevent any similar future mistakes being made.

One recent class I taught on medication errors highlighted the importance of pausing to allow for a chance to think critically. The strategy devised by an experienced nurse was called “cause to pause” and was developed in response to a high number of – nearly 9,000 – annual deaths related to medication errors (5). Errors in healthcare can be due to a number of reasons, including healthcare workers being stressed or overworked, having constant distractions, and increasing responsibilities. The “cause to pause” strategy encourages clinicians that when something does not seem or feel right or when one is rushed and in a high stress situation, the best thing to do to avoid error is to stop what you are doing, step away from any distractions, allow yourself time to think critically and in a quiet space, consult with other providers and professional resources to ensure compliance with the standard of care, and then finally to “proceed with caution” (5). I found this strategy to be applicable to most healthcare situations, not just for nurses in preventing medication errors, but for all providers. One person pausing to think could be a patient’s last line of defense before a major medical error. As I mentioned in the beginning, patients do not have the luxury of being insured for medical accidents which could cause permanent morbidity or mortality – they are reliant on healthcare professionals to abide by the standards of care. Providers have every responsibility of ensuring that their actions do not cause any harm or injury.

All this to say that some medical errors are preventable. But another major issue is the amount of treatments prescribed. A topic of concern for me as a nurse is the issue of polypharmacy and overprescribing of medications, which I have seen cause numerous long-term side effects and an increased risk for falls with injury especially in my elderly patients. Polypharmacy typically involves taking five or more medications. Since older adults have more chronic health conditions including arthritis, chronic obstructive pulmonary disease, heart disease, diabetes, and hypertension, they are more likely to be a victim of polypharmacy; according to the Center for Disease Control and Prevention (CDC), 83% of adults over 60 years of age had used at least one prescription drug in the last 30 days and more than a third use five or more prescription drugs daily in the U.S. (6). This report was as of 2019, but I am certain the number has gone up. Sadly, this age group is also more affected by limited funds and some prescriptions can be quite expensive.

While some medications are truly necessary, such as antibiotics for infection, almost all medications carry risks of adverse effects. One patient of mine had never taken any antibiotics in his life, but was prescribed a course of antibiotics, not for an active infection, but as a preventative measure as he just had a finger amputation due to a work injury. He took the antibiotics as prescribed and immediately began having symptoms of anaphylactic shock within 30 minutes of taking his first pill. After reaching out to me, I advised him to call 911 immediately and he was rushed to the hospital, where he spent 3 days in the ICU. Medications often can have worse outcomes than the conditions that they are intended to prevent or treat (6). This has led to a new area of research funded by the National Institute of Aging (NIA), which looks at deprescribing as a new field involving physicians, pharmacists, nurses, and older adults and their caregivers to help improve the quality of care and health outcomes for older adults (6).

Working in hospice for nearly a decade, deprescribing was an integral part of my job. I routinely collaborated with medical directors and patients and families by educating and informing them of potential benefits to quality of life that they could potentially experience by discontinuing many of their daily medications. We reviewed benefits versus risks together and, with the added knowledge, most patients felt empowered to decide to discontinue their routine medications; often times, they reported feeling better afterwards with less side effects and the feeling of a burden or weight being lifted.

Each person is different, as is each condition and situation. The benefits must be weighed against the risks and each patient-provider interaction should be approached with care and collaboration. Providers often feel compelled to prescribe as it can be seen by others as “doing something for the patient” (6). However, that is not always the case. More importantly, all patients deserve 1:1 time with their providers that is not rushed or hurried, during which time they can be heard and understood as well as informed of all of their options. This can be more meaningful and valuable than any prescription or procedure, especially one that is unnecessary. Even patients have the power to question interventions that do not seem right – there should not be a fear of going against a provider – questioning treatments or medications is in fact the perfect time to identify possible risks and potential harm for the patient. This reinforces the importance of collaboration with providers in a supportive, comfortable environment. Perhaps such interventions can bring about change in our healthcare system and help reduce the incidents of malpractice and medication errors. It is our duty as providers to put forth the effort.  

References

1. Bono MJ, Wermuth HR, Hipskind JE. Medical Malpractice. [Updated 2022 Oct 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470573/

2. National Library of Medicine. (March-June 2008). Ancient Greek Medicine. “I swear by Apollo physician…”: Greek Medicine from the Gods to Galen. Retrieved on February 1, 2024 from https://www.nlm.nih.gov/hmd/topics/greek-medicine/index.html#case1

3. Bieber, C. (January 25, 2024). Medical Malpractice Statistics of 2024. Forbes Advisor. Retrieved on February 2, 2024 from https://www.forbes.com/advisor/legal/personal-injury/medical-malpractice-statistics/

4. Sweta, Srivastava U, Agarwal A. Inadvertent insertion of nasogastric tube into the trachea of a conscious patient. Indian J Crit Care Med. 2012 Apr;16(2):116-7. doi: 10.4103/0972-5229.99142. PMID: 22988372; PMCID: PMC3439777. Retrieved on February 1, 2024 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3439777/

5. Sassatelli, Elizabeth H. PhD, RN. Cause to Pause: Preventing medication errors with high-risk opioids. Nursing 52(6):p 26-30, June 2022. | DOI: 10.1097/01.NURSE.0000829888.93146.5d. Retrieved on February 1, 2024 from https://journals.lww.com/nursing/fulltext/2022/06000/cause_to_pause__preventing_medication_errors_with.9.aspx

6. National Institute on Aging. (August 24, 2021). The dangers of polypharmacy and the case for deprescribing in older adults. Retrieved on February 2, 2024 from https://www.nia.nih.gov/news/dangers-polypharmacy-and-case-deprescribing-older-adults