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News: In 2011, a man was driving to an airport to board a flight for his work as an aerospace configuration manager. It was still dark as he looked at the traffic around him and pulled out from an intersection. As he made a turn, the man’s car was struck broadside by another car, requiring he be extracted from the vehicle. Emergency medical technicians reported “an obvious loss of lower extremity sensation and limited use of his arm.” The man was taken to a hospital, where he underwent emergency cervical decompression and anterior spinal fusion surgery to repair a burst cervical fracture. The neurosurgeon installed an Atlantis Vision Elite Anterior Cervical Plating System to stabilize his spine.
Three days later, while recovering from the surgery, the nursing staff attempted to transfer the man from a chair to his bed. While he was being lifted by a Hoyer lift, the patient slipped out of the sling, back into the chair and his head collided with the rear of the chair. This collision resulted in irreversible damage to his spine. The man’s wife witnessed the incident, but the nursing staff failed to include it in their charting. The man and his wife brought suit, eventually resulting in an award of $6.8 million to the patient and $1.25 million to his wife for loss of consortium.
Background: On Sept. 8, 2011, a 72-year-old configuration manager presented to a hospital for emergency cervical spinal surgery. Three days later, while recovering at the same hospital, the patient claimed he suffered various permanent injuries, including paraplegia, when his nurses were attempting to move him from a reclining chair to his bed.
According to the patient, the nurses attempted to move him from a heavy reclining chair to his bed, using a Hoyer lift with an attached sling. While he was being raised and moved with the Hoyer lift, the patient began to slide out of the sling, with his legs sliding toward the floor. The nurses allegedly reacted to this situation by pushing the Hoyer lift back toward the chair.
This pushing movement caused the sling to swing toward the back of the chair in which he had been sitting. He claimed his head then struck the back of the chair with sufficient momentum to force his head toward his chest, dislodging surgical screws that were inserted during the course of the initial surgery and causing him injury.
The patient subsequently filed suit against the hospital, alleging that it was vicariously liable for the negligence of its nurses. He claimed that the nurses breached the relevant standard of care by improperly attaching the sling to his body and causing him to strike the heavy chair. He also argued that the nurses failed to properly document the incident, which led to a delay in addressing the new injury caused by the nurses. The patient sought economic and noneconomic damages, and his spouse sought damages for loss of consortium.
At trial, the hospital contended that the surgeon who performed the surgery failed to stabilize the patient’s cervical spine, causing the partial paralysis. The hospital further asserted that the nurses conformed to the relevant standard of care and that the patient’s injuries were not caused by their actions. Because the nurses failed to document the incident, the defense argued that the plaintiff’s narrative was unsupported by the medical record. In support of its allegations, the hospital called two expert witnesses, one legal nurse consultant, and one neurosurgeon.
The patient claimed that he suffered an anterior dislocation of C7 over T1, resulting in partial paralysis. He asserted the dislocation occurred when the cervical screws were dislodged when his head contacted the chair and were aggravated by inadequate documentation of the incident, which led to a delay in treatment. The plaintiffs selected 15 experts to support their case, the specialties of which varied from standard of care to economics. Of particular importance to the plaintiff’s case was the testimony given by the patient’s wife, who witnessed the incident.
After the seven-day trial, the jury deliberated for 7.5 hours before delivering a verdict in favor of the plaintiff. The jury awarded $6.8 million to the patient and $1.25 million to his wife for loss of consortium. The jury did not apportion any liability to the physician who conducted the patient’s initial surgery. Based on post-trial juror interviews, the jury found the defense’s experts to lack credibility.
What this means to you: This case illustrates the importance of addressing new issues and symptoms as they present themselves throughout the course of caring for a patient. Physicians and supporting staff should be educated on the value of awareness as it relates to administering quality care. Negligence can arise quickly from a failure to diagnose based on overlooking new symptoms. There is little excuse for complacency and reckless ignorance in the medical industry. Hospitals should take it upon themselves to ensure employees have sufficiently high morale to maintain the motivation to stay aware for long periods of time. Potential options for boosting morale to improve employee awareness include ensuring employees are treated with respect, receive adequate feedback, are given goals and clear expectations, and providing hospital employee retreats.
Even assuming medical professionals experience increased morale, mistakes still happen — including in the operation of cumbersome equipment. Hoyer lifts have many moving parts, and it is imperative that professionals and staff who operate them receive sufficient training. Whenever hospitals implement new equipment, medical professionals should be trained on how to correctly and safely operate that equipment, as well as how, if at all, the operation of the new equipment differs from similar or previous equipment. For example, Hoyer lifts come with different sling attachments and can be electronic or hydraulic and the use of each varies, although the lifting sequences are similar.
The facts of this case suggest that the nurses may have attempted to swivel the patient while lifting him. It is important to note that Hoyer lifts do not swivel. The proper use of the lift requires the patient’s weight to remain directly over the base legs of the apparatus at all times. To avoid accidents due to miscommunication, medical professionals should take the time to explain the lifting procedure to the patient. A potential solution for operator error-related complications is to post visual instructions or written reminders on proper operation of lifts and other equipment.
Moreover, regardless of the cause of the Hoyer lift issue, the nurses’ first responsibility was to put hands on the patient. Simply moving the lift in any direction while the patient is sliding off is misguided; the patient’s body must first be positioned on the sling. Protecting his head and body during the scenario described can only be accomplished by physically holding on to the patient’s body until safe to release. Had the nurses done this, the outcome may have been different and injuries sustained may have been lessened or completely prevented.
On a related note, it is imperative that hospitals ensure their equipment is adequately maintained and serviced. Various organizations, such as the World Health Organization, publish best practices for the maintenance of medical equipment as well as best practices related to medical equipment generally. Procedures for documenting maintenance logs and ensuring manufacturer service schedules should be implemented and followed. This prevents or minimizes negligence liability for using unsafe equipment and keeps patients and medical professionals safe. This also can provide hospitals recourse in alleging that an injury may have been caused by a defect in the design or manufacture of a piece of equipment. All injuries occurring during the use of medical equipment, whether a product or user error, should be reported to the FDA via its Medical Device Reporting website. Reporting helps all involved, such as hospitals, patients, and manufacturing companies, prepare for problems and improve the quality of their products.
Another significant issue in this case was the fact that the nurses failed to properly document the incident, which ultimately led to a delay in treatment of the patient. More untoward events go undocumented than many people would expect; the rate of unreported events is close to 7:1. This continual problem has plagued the healthcare system for decades. A few institutions have found a way using the “just culture” method to empower staff to report events without fear of reprisal. Medical professionals should be encouraged to be proactive when facing unexpected circumstances and accidents. Patients who are particularly vulnerable, such as the elderly or those recovering from surgery, require elevated care and attention if accidents occur. Medical professionals should be reminded that dealing with problems as they arise is a better course of action than waiting for another person to discover them, or hoping those problems will remain undiscovered. The sooner an injured patient is treated, the less likely he or she will be to sue hospitals. If litigation does occur, prompt treatment serves to reduce the amount of damages.
In a similar vein, it is imperative that patients who are injured by medical professionals are treated with respect. Hospitals should be prepared for the inevitable mistake by a staff member and should communicate expectations to those staff members in such a case. Disclosure, documentation, treatment, and professionalism must be prioritized.
Decided on Nov. 21, 2017, in Fulton County State Court; Case Number 13EV017577C.
Financial Disclosure: Author Greg Freeman, Editor Jill Drachenberg, Editor Jesse Saffron, Editorial Group Manager Terrey L. Hatcher and Nurse Planner Maureen Archambault report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Consulting Editor Arnold Mackles, MD, MBA, LHRM, discloses that he is an author and advisory board member for The Sullivan Group and that he is owner, stockholder, presenter, author, and consultant for Innovative Healthcare Compliance Group.