Legal nurse consultants work within the high stakes arena of medical malpractice errors litigation. We are often asked to screen medical malpractice cases for merit – does the case meet the criteria for a winnable case – for the plaintiff or the defendant?
Other industries, such as aviation, manufacturing, and energy developed safety interventions needed to reach a zero-defect level. Health care has not been as successful.
We have an incredibly complex system with multiple opportunities for error. I envision patient safety as resting above a safety net. The holes in the safety net range from small to wide.
We had an expression in my legal nurse consulting business: “It is a dangerous world.”
Swiss Cheese Model
The Swiss Cheese Model is another way to view patient safety. In James Reason’s model, the holes line up in the system. A patient passes through and is injured. A series of errors occur. If anyone along the chain of events had done something different, the patient would not have been injured.
Those of us who work in the medical malpractice errors arena can think of cases where this unfortunate cascade of errors has occurred.
For example, I worked on a nursing malpractice case involving a man who received the wrong type of blood. Another patient and he had the same name; a mix up of identity occurred. The admissions clerk, laboratory technician, unit secretary, hematologist and several registered nurses were part of the chain. The nurses did not check the blood bag at the bedside with the patient’s identification band. He died as a result of receiving the incorrect blood type.
A surgeon told a patient there was a 1 in 100 risk of a certain complication occurring in the operating room. The patient asked, “What number am I in your total of 100?”
How often are we hiding medical malpractice errors?
I sat in a hospital Pharmacy and Therapeutics Committee meeting while the director of nursing had to explain each of the 6 medication error incident reports that had occurred that month in a 600 bed hospital.
The physician leader said, “I want there to be zero errors!” After the meeting, I pulled the vice president of nursing aside and said, “We’re not getting accurate reporting. Statistically, there should be a much larger number of incident reports.” She disagreed.
However, the nursing department disciplined nurses who made errors. The nursing department terminated a nurse after three errors. Not surprisingly, nurses were reluctant to report errors. They functioned within a culture of fear.
Culture of Fear
That culture of fear still exists, and prevents staff from making a full disclosure after an error has occurred. Plaintiffs still come to attorneys to get answers about what occurred, and legal nurse consultants help to provide the answers when they screen medical malpractice errors cases.
Learn more about how you can contribute to the screening of cases for merit by investing in a new webinar by Pat Iyer and Barbara Levin. They collaborated in creating a program specific to screening medical malpractice cases: Medical Malpractice LNC Case Screening. Get details about this program at this link.