“Leaders must commit to creating and maintaining a culture of safety.” National Patient Safety Foundation. Free From Harm: Accelerating patient safety improvement for 15 years after To Err is Human.  2015 (accessed Dec. 8, 2016). This is just a part of the Sentinel Event Alert publication of The Joint Commission Issue 57, March 1, 2017.

The core of the publication is that leadership in hospitals and medicine generally have a priority to be “accountable for effective care while protecting the safety of patients, employees, and visitors. Competent and thoughtful leaders contribute to improvements in safety and organizational culture.”

This alert acknowledges that hospitals, doctors, nurses and health care professionals must do a better job of protecting their patients from harm. The article states that “The Joint Commission’s Sentinel Event Database reveals that leadership’s failure to create an effective safety culture is a contributing factor to many types of adverse events-from wrong site surgery to delays in treatment.” Smetzer, J, et al. Shaping systems for better behavioral choices: lessons learned from a fatal medication error. Joint Commission Journal on Quality and Patient Safety. 2010; 36: 152-164.
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In a case being reported with a confidentiality agreement, Doe, age 15, developed a mass on the bone of her left middle finger, for which orthopedic surgeon Dr. Ronald Hillock recommended surgery.

During the outpatient procedure, Dr. Hillock used a latex Penrose drain to place a tourniquet around Doe’s finger. While in the recovery room, a nurse noted that Doe’s finger looked discolored; however, Hillock discharged Doe.

Doe had several follow-up appointments with Dr. Hillock in the next few weeks but the finger remained discolored. Doe consulted a different doctor about 30 days after the surgery. That physician diagnosed ischemia and later performed a finger amputation.
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Kelly Wolfe was 56 years old when he was involved in a motorcycle crash. Paramedics from the city of Grand Prairie arrived at the crash location where they found him alert and breathing regularly. The paramedics attempted unsuccessfully to intubate Wolfe. The paramedics undertook the intubation even though Wolfe told the paramedics that he wanted to go home.

A helicopter service operated by PHI Air Medical Inc. came to the scene to transport Wolfe to a nearby hospital. Before the helicopter transport, the paramedics provided the PHI Air personnel with a paralyzing agent to facilitate Wolfe’s intubation.For some reason, the paramedics were determined that intubation was the thing to do.

Twenty minutes later, when Wolfe arrived at the hospital, he was deemed brain dead due to prolonged oxygen deprivation. Wolfe subsequently died. He had been working as a paramedic instructor, earning about $50,000 per year. He is survived by his three children, one of whom was a minor.

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This case concerned the first of over 500 cases regarding the Wright Medical Conserve “metal-on-metal” hip replacement device designed and manufactured by the defendant. The plaintiff filed a products liability suit alleging, among other things, that the defendant was liable for design defects based on strict liability and negligence.

On appeal, the defendant challenged the entry of a $2,100,000 judgment. The court rejected the defendant’s argument that the district court erred in ordering the jury to continue deliberations after the jury had already begun to deliver its verdict.

In this case, upon recognizing the inconsistency in the jury verdict, the district court immediately halted publication of the verdict and instructed the jury that an error had been made; the district court acted in a neutral and non-biased manner in acknowledging and addressing the inconsistent verdict; and the district court also recharged the jury.
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The Illinois Appellate Court has ruled that the guardians of a seriously injured student football player must include a supporting statement from a health care professional to proceed with the case. The guardians had claimed in a lawsuit that a physical and sports-injury therapist provided improper care that caused or exasperated the student’s injuries. Under Illinois’ Code of Civil Procedure, 735 ILCS 5/2-622, the Healing Art Malpractice section, “…a plaintiff shall file an affidavit, attached to the original and all copies of the complaint…”

In the court’s opinion, the three-judge panel found that Illinois law requires the “622” affidavit from a health care expert in a suit alleging medical malpractice and that failure to do so is grounds for dismissal. However, this case is murky because an Athletico Ltd. athletic trainer hired by the public school system is not a traditional medical professional, according to the ruling.

Jodine Williams and Christopher Williams, the guardians of Drew Williams, who suffered a concussion in a football game and then continued to play, filed the suit. Drew Williams became disabled following the injury. Their suit was dismissed. The court ruled that the Williams’ suit should not have been dismissed. The appeals court said in remanding the case that the guardians should have a reasonable chance to file the 622 affidavit along with an amended complaint.

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A  Springfield, Mo., jury signed a verdict for $28.9 million for a 24-year-old woman who sustained a devastating brain injury caused by a rare copper disorder. The lawsuit, brought in Greene County, Mo., claimed that a local hospital’s medical staff chose not to correctly diagnose and treat Emilee Williams’ symptoms. In fact, it was alleged that the hospital took the position that it did not need to do a full and complete neurological exam even though Williams presented to the hospital with symptoms. The hospital dismissed her symptoms as anxiety.

It was in December 2012 that Williams presented to the hospital. She was examined by Dr. Elene Pilapil with complaints of fatigue, tremors, balance issues, insomnia, difficulty concentrating, crying spells and anxiety. Dr. Pilapil diagnosed Williams with anxiety and did not consider ordering more diagnostic testing. A prescription for Prozac was written and Williams was sent home. Eight months later, not until August 2013, was an MRI finally ordered that showed that Williams was brain damaged, caused by the previously undiagnosed Wilson’s disease. This was done only after Emilee and her mother continued to complain to the doctor that Emilee had something much more significant happening to her than just anxiety.

As it was proved at trial, Williams had undiagnosed Wilson’s disease. This disease, although rare, causes too much copper to accumulate in the liver, brain and other vital organs, which was the cause of her devastating permanent injuries. Williams was a former high school student and athlete, but today is limited from paralysis, motor and speech impairment and must be fed through a tube in her stomach.
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Helen Manfredi, 85, underwent right colectomy surgery at Loyola University Hospital because of her colon cancer. She also had a large pre-existing hiatal hernia that was asymptomatic.

During the colectomy surgery, the surgeon decided to reduce the stomach organ, but the hernia was not repaired.

Four days after the colectomy surgery, April 29, 2011, Manfredi suddenly became unresponsive and required emergency surgery, which showed the stomach had become incarcerated with ischemia of portions of the stomach lining.
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Betty Collins appealed from a summary judgment that was entered in favor of the defendants Ricardo Herring D.C. and Herring Chiropractic Center LLC. She filed a lawsuit for damages alleging medical malpractice with respect to the treatment of her knee, shoulder and back pain.

Collins’s knee was treated with a cold pack. The evidence in the case viewed in a light most favorable to Collins showed that the cold pack had been in the refrigerator for seven days, that it had not been thawed when Collins arrived for her appointment and that it was frozen hard on the day of her treatment compared to the treatment on other visits.

Collins reported that she felt heat when the cold pack was removed from her knee. She developed blisters on her knee following the treatment and later scarring.
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This case involved a medical malpractice action for a lost chance. The parties jointly sought direct discretionary review under Washington law, RAP 2.3(b)(4), challenging two pretrial rulings:

(1) whether a court should use a “but for” or “substantial factor” standard of causation in loss of chance cases; and (2) whether evidence relating to a contributory negligence defense should be excluded based on the plaintiff’s failure to follow his doctor’s instructions.

The trial court decided that the “but for” standard applies and the contributory negligence defense was not appropriate in this case. “Traditional tort causation principles guide a loss of chance case.” Applying those established principles, under the circumstances here, the Supreme Court concluded a “but for” cause analysis was appropriate and affirmed the trial court’s ruling on that issue. The court reversed the trial court’s partial summary judgment dismissing the contributory negligence defense. The case was remanded for further proceedings.
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In the recent Illinois Appellate Court decision of McChristian v. Brink, it was held that the defendant’s attorney, representing a podiatrist and the podiatry clinic, was not prohibited from calling a controlled expert (Ill. S. Ct. Rule 213 (f)(3)) podiatrist to testify at trial when this expert was also one of the injured plaintiff’s treating podiatrists and a member of defendant’s podiatry clinic.

This court held that the Petrillo doctrine does not preclude ex parte communications with individuals who serve as the “corporate heads and are the decision makers of the defendant corporation.” Petrillo v. Syntex Laboratories, Inc., 148 Ill. App. 3d 581, 601 (1st Dist. 1986). The Petrillo decision and the many cases following that basic principle is that defense attorneys are not allowed to retain an expert who works for the same professional organization where the plaintiff received medical care.

In the McChristian case, the court ruled that the defendant medical group and doctor could utilize an expert witness at trial who worked for the same clinic as the defendant. Recent cases have expanded the Petrillo decision stating that a treating physician’s status can now be imputed to expert witnesses in the same professional association, even if they practice in different fields of medicine.
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