Measure and Analyze

When Cynthia Davis’s father had open-heart surgery, his cardiac surgeon asked him what medications he was on, and whether he had any allergies. When he went to the hospital’s outpatient center for pre-admission testing, they asked what medications he was on and whether he had any allergies. The anesthesiologist who visited him right before the surgery asked what medications he was on and whether he had any allergies. At that point, he turned to his daughter in exasperation and said, “Don’t you people ever talk to each other?”

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Comments (1)
3 days after his surgery, Mr. Davis died after a sudden, lethal episode of heparin-induced platelet aggregation (HIPA). He had never been exposed to heparin or any chemically related substances before, so there was no way to foresee this rare complication. Since there was a death, however, someone had to pay.

Although his surgeon, the pre-anesthesia clinic and his anesthesiologist all asked the repetitive allergy questions, the cardiologist who met him only briefly prior to surgery so that she would be recognized when she picked up his care after the case, dd not.

His estate's attorney asked the cardiologist why she had not asked about his allergies. She replied that the data was available to her in the EHR and that she was aware of it, so she didn't find it necessary. But the attorney proceeded to paint her as an uncaring, negligent physician who was so interested in making fast money that she was unwilling to take the time to confirm the data, and that she was so driven by greed as to ignore the proper care of her patients. Displaying large, high quality images of the decedent's swollen, black, purple and bloody arms and legs resulting from the HIPA, as the decedant's daughter sobbed nearby, the attorney succeeded in gaining the sympathy of the jury and the cardiologist was found guilty of negligence. The $20 million judgement far exceeded her malpractice coverage of $3 million dollars, she lost her practice privileges at the hospital, and the state medical board stripped her of her license to practice medicine a year later. 18 months later, the evening after she was forcibly removed from her home due to a sheriff's sale following asset seizures to enforce the judgement, she committed suicide.

It doesn't really matter whether those people talk to each other or not, and medical care has absolutely nothing to do with it. In our current malpractice environment, it's simply every man or woman for himself.
Posted by A D | Friday, March 01 2013 at 11:52PM ET
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