Case Study

The Hospital of Death

The young parents-to-be had hoped for a baby since they were married several years ago. They had undergone several rounds of IVF therapy with the hopes of conceiving. They were thrilled when their obstetrician informed them that they were expecting.

When the pregnancy was at twenty-four weeks, the mother had been awakened in the night while sleeping with a sharp pang in her abdomen and the onset of labor. They were very surprised at the onset of labor pain as the pregnancy was only at twenty-four weeks'gestation. They had been instructed by their OB/GYN to wait until the labor pain was approximately five minutes apart or if the mother could no longer tolerate the discomfort.

Suddenly, they realized that the labor pain was becoming increasingly intense and rushed to the labor and delivery department at their local hospital, Northshore Hospital. They had been receiving prenatal care from their Obstetrician who had referred them to Northshore for the labor and delivery. The Obstetrician was not employed by Northshore but practiced with a group of Obstetricians in the community.

Four months prior to that fateful night, the Joint Commission had visited Northshore Hospital and alarms were raised in the final report because of the quality of the care being delivered to patients. The labor and delivery service was singled out as especially deficient in their care of new mothers and newborns. The Joint Commission identified serious quality issues such as lack of training among nurses for emergencies, sterility of equipment, and the use of obsolete equipment and technology at Northshore. The Joint Commission specially identified the lack of security for pharmaceutical drugs that were used in the Neonatal Intensive Care Unit (NICU) and in the labor and delivery unit.

The Joint Commission observed and documented that the drugs were stored in an unsecured location that was unlocked and lacked facial or speech recognition, password technology or physical security. The refrigerated storage facility lacked a security camera and its lock was broken so that the password security pad was not functioning. The hospital had no way of tracing the drugs stored in the refrigerated locker and there was no barcoding technology in place for the drugs.

The CEO of Northshore Hospital, Alan Groves, received the final report from the Joint Commission three months before the parents-to-be arrived at the labor and delivery for the birth. Due to financial pressures, lack of time, and other crises at the hospital, the executive team and the Director of Nursing had not addressed any of the issues identified by the Joint Commission in the report. The executive team was under intense pressure from their Board of Trustees to increase patient volume, profits, and donations from foundations. Northshore had always had a strong reputation in the community for delivering primary care and being dedicated to the health and wellbeing of the local population. However, they were facing increasing competition and decreasing revenue and were under intense pressure to be profitable.

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The Board of Trustees of Northshore were also made aware of the patient safety and quality concerns raised by The Joint Commission. They were briefed on the matter by the CEO and the Chief Medical Officer. However, the Board assumed that the CEO would take care of the situation and address the concerns raised by The Joint Commission. They chose not to pursue the issue further in the two board meetingsbetween the Commission's visit and the incident.

The baby was successfully delivered by Cesarean section at 3:45 am on June 1, 2010. Almost immediately the baby suffered from breathing and circulation complications. It was rushed to the NICU and was under the care of the neonatologist, an employee of Northshore. That night the baby was also under the direct care of a NICU nurse who had a reputation for theft and abusing methamphetamines. None of the allegations had been proven and the nurse had never been cited for harming a patient. However, Northshore did not have a process whereby such suspicions could be reported to the charge nurse and investigations could take place. There were no means whereby other nurses could report such suspicions anonymously. The NICU nurses feared that if they reported a colleague based on suspicions, that same nurse or management would target them for retribution in the future.

Unbeknownst to the hospital administration and the other nurses, the NICU nurse had been battling chronic back pain, severe depression, and insomnia for the last year. He had not slept more than several hours in the last week and was taking two prescription strength Vicodin medications per night. These issues were unknown because Northshore did not conduct regular drug testing among clinical personnel who had access to medications or who was responsible for patient care.

At approximately, 8:30 am on June 1 the NICU nurse administered a massive overdose of pancuronium bromide, Pavulon, a neuromuscular blocking agent. The package insert for the drug stated that excessive exposure can cause kernicterus, especially in pre-term infants. The drug had been stored in the refrigerated locker located near the NICU. The drug immediately caused the twenty-four-week premature baby to be paralyzed for 24 hours.

The parents and their family were shocked and horrified that this had happened to their newborn. They were horrified that such a drug could be administered at such high dosages and there were no processes in place to identify such a medication error. The parents despaired of learning that the nurse sincerely believed there was a prescription from the Neonatologist for the drug and at the dosage that was given. The newborn recovered from the paralysis and other complications and was discharged with the mother after four months.

The hospital investigated and determined that the NICU nurse was unauthorized to administer the drug. The NICU nurse was terminated and referred to the Board of Registration of Nursing. No drug testing was ever performed on the nurse. No security measures were put into place for the drugs stored at the NICU.

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The hospital wrote a letter to the infant's parents assuring them that the boy would suffer no adverse consequences due to the overdose. The infant was in the NICU for four months.

At age two it was apparent that the child had symptoms of kernicterus, which prevented physical development and caused cerebral palsy, hearing loss and decreased oral motor function. He was fed through a G-tube and required continuous oxygen therapy through a tracheotomy. The child required 24-hour care by a trained nurse.

The baby's family claimed that the overdose of the drug caused the patient to develop kernicterus and claimed that the package insert stated that excessive exposure can cause kernicterus, especially in pre-term infants.

The baby's family also claimed that the drug should have been secured and that theNICU nurse who administered the overdose was impaired and should not have beenentrusted with patient care. The baby's family maintained that the nurse had previously demonstrated severe behavioral issues and was widely known in the NICU as a thief.

Questions:

1. Identify the issue (e.g., negligence, battery, invasion of privacy, defamation, sexual harassment, breach of warranty, etc.).

2. In one sentence identify the most important fact of the case that determines whether the Plaintiff or Defendant prevails in the case.

3. The arguments that the plaintiff and the defendant would use to win their case at the trial level. How would the plaintiff argue? How would the defendant argue?

4. Likely outcome of the case and your rationale. If applicable, include what your recommended for damages would be for each lawsuit. If there are cases or legislation mentioned in the scenario, make sure to apply these in your analysis. For instance, when there is a case mentioned, make sure to document the holding in the case and then show how it informs your decision regarding how the court will likely hold in the mini-scenario under consideration.