Tag medicalmalpracticeattorney

In this blog, I’ll be introducing a maternal sepsis case study, followed by supportive content to enhance the readers understanding of the incidence of maternal sepsis in the U.S., causes, risk factors, and complications that can occur as a result of maternal sepsis. I’ll provide information on the recommended screening, diagnostic criteria, as well as assessment, and treatment  recommendations. 

Case Study: A 38-year-old woman, gravida 6 para 5, with an unremarkable past medical history presented to labor and delivery in active labor at 39 weeks of gestation and delivered vaginally shortly thereafter. Delivery was uneventful, without regional anesthesia and without perineal tears nor other complications. Twenty-four hours after delivery, the patient developed isolated left lower quadrant pain. Physical examination, abdominal ultrasound, and laboratory tests including complete blood count and basic metabolic panel were unremarkable, and the pain subsided after a bowel movement. On the following day, abdominal pain worsened, while the patient remained afebrile and was hemodynamically stable. Clinical assessment and physical examination of the pelvis and abdomen by the gynecological and surgical teams were unremarkable and revealed no acute distress; the abdomen was soft and non-tender on palpation, and bowel sounds were normal in all four quadrants. Notably, there was a significant discrepancy between the symptoms (referred abdominal pain) and the objective clinical findings. An abdominal and pelvic CT scan demonstrated normal post-partum uterus, endometrium and pelvic organs without signs of acute pathology. A large fecal burden throughout the colon was seen, suggesting possible constipation. Subsequently, 60 h after birth, her clinical condition deteriorated as the patient developed tachycardia with 130 beats per minute, tachypnea with 20 breaths per minute, and blood pressure of 103/65 mmHg. Laboratory values included a white blood cell count of 1.5 × 10⁹/L and C-Reactive Protein (CRP) of 27.1 mg/dl and Lactic acid of 4.05 mmol/L. Creatinine, liver-function tests, and electrolytes were within the normal range. Due to a high clinical suspicion of puerperal sepsis at this point, a wide-spectrum antibiotic regime of ampicillin, clindamycin and gentamicin was initiated, and the patient was transferred to the intensive care unit (ICU). Shortly afterward, the patient became hemodynamically and respiratorily unstable and required sedation, mechanical ventilation, and the use of inotropes to maintain adequate blood pressure. Laboratory results revealed worsening leukopenia, thrombocytopenia, and lactic acidosis. A post-contrast computed tomography scan showed an enlarged uterus with abundant periovarian and peritoneal fluid. Since the presence of pus in the abdomen was suspected and due to the severe clinical deterioration, an emergency exploratory laparotomy was executed, during which 600 ml of thick yellowish-white abdominal fluid was aspirated. The uterus and both ovaries were swollen, necrotic, and covered with fibrin, therefore a total abdominal hysterectomy and bilateral salpingo-oophorectomy were performed. Ovarian preservation was not possible because of severe necrosis. Gross findings of the post-operative pathological specimen showed an ischemic and partially necrotic uterus, while microscopic examination of the uterus revealed a severe acute inflammatory process with necrotic myometrium and bacterial colonies, confirmed later to be Streptococcus pyogenes on blood-agar medium culture. Post-operatively, the patient underwent a prolonged recovery period and was discharged without any further obstetrical or gynecological complications (Kabiri D, et al., 2022. Case report: An unusual presentation of puerperal sepsis. Front Med).

 

What is Maternal Sepsis:  Maternal sepsis is a life-threatening condition defined as organ dysfunction resulting from infection during pregnancy, childbirth, post-abortion, or postpartum period.

The most common pathogens that cause maternal sepsis include Streptococcus pyogenes, Escherichia coli, Staphylococcus aureus, Group B Streptococcus, Streptococcus pneumoniae, Methicillin-resistant Staphylococcus aureus (MRSA), Clostridium septicum, and Morganella morganii.

Clinical Presentation: The normal changes of pregnancy complicate identification, and treatment of maternal sepsis. Pregnant patients appear clinically well prior to rapid deterioration with the development of septic shock, multiple organ dysfunction syndrome, or death.  This is due to pregnancy-specific physiologic, mechanical, and immunological adaptations (JAMA, 2021). 

National Statistics: Maternal sepsis is the second leading cause of pregnancy-related death in the United States.  Among all pregnancy-related deaths in the U.S., 12.5% are attributed to sepsis (JAMA, 2021). It is estimated that 4 to 10 per 10,000 live births are complicated by maternal sepsis (ACNM, 2018). Rates of pregnancy-associated sepsis are increasing in the U.S., as are rates of sepsis-related maternal deaths.

*Approximately 40% of maternal sepsis cases are preventable with early recognition, early escalation of care, and appropriate antibiotic treatment (Kabiri D. et al. 2022).  

Risk Factors: Risk factors for maternal sepsis include advanced maternal age, preterm premature rupture of the membranes (PPROM) and preterm delivery, multiple gestation pregnancies, cesarean delivery, retained products of conception, post-partum hemorrhage, and maternal comorbidities.  It’s important to note that maternal sepsis occurs in patients without risk factors.

Screening & Diagnostic Criteria: The use of a maternal early warning system (MEWS) is recommended.  This is a set of specific vital sign, and physical exam findings that prompt a bedside evaluation and/or work-up (see ACOG’s MEWS example below)

Complications of Maternal Sepsis: Complications include, but are not limited to, maternal death, fetal death (pregnancy loss),  preterm premature rupture of membranes, preterm labor and birth, preterm delivery complications of the newborn, lower newborn weight, cerebral white matter damage, cerebral palsy, and neurodevelopmental delay.

Management Recommendations: Survivability requires early detection, prompt recognition of the source of infection, and targeted therapy.

*Delayed antibiotics > 1 hour = increased mortality

How The American College of Obstetricians and Gynecologists’ (ACOG) Safe Motherhood Initiative (SMI) Sepsis Bundle Reduces Maternal Morbidity: The SMI is a collaborative initiative between ACOG and NYSDOH to improve patient safety and raise awareness about risk factors that contribute towards maternal morbidity & mortality.  The SMI supports provider readiness, and recognition through the availability of education, standardized sepsis work-up criteria and diagnostic tools. The SMI supports timely provider response, and reporting by the availability of a standardized sepsis management algorithm, recommended criteria for consultation, and transfer to a higher level of care, and case debriefing tools.

Resources:

ACNM, 2018. Recognition and Treatment of Sepsis in Pregnancy

ACOG, 2020. Maternal Safety Bundle for Sepsis in Pregnancy

JAMA Network Open. 2021;4(9): Perinatal Outcomes Among Patients with Sepsis During Pregnancy

Kabiri D, Prus D, Alter R, Gordon G, Porat S, Ezra Y. 2022. Case report: An unusual presentation of puerperal sepsis. Front Med 15:9.

P.S. Comment and Share: What is your experience with maternal sepsis?

If you are in need of a medical legal expert specific to a maternal sepsis case, contact Barber Medical Legal Nurse Consulting, LLC. Email: Contact@barbermedicallegalnurse.com

In this blog, I’ll be reviewing the common allegations specific to obstetrical triage.  I’ll also review the incidence of obstetrical triage, the sources of recommendation specific to the use of standardized obstetrical triage acuity tools, and offer an introduction to the Maternal Fetal Triage Index (MFTI):

Common Allegations Specific to Obstetrical Triage:

• Failure to perform a medical screening exam
• Failure to perform a timely assessment of the fetus
• Delay in completing a medical screening exam
• Failure to have a policy delineating conditions that require a bedside evaluation by an obstetrical care provider prior to discharge following a medical screening exam by an obstetrical nurse
• Failure of the provider to perform a bedside evaluation for an obstetrical patient with a high risk medical or obstetrical condition
• Discharge of a patient without confirming fetal well-being
• Discharge of a pregnant woman who is unstable for discharge
• Failure to meet all aspects of the Emergency Medical Treatment and Labor Act (EMTALA) regulations in assessing, treating, and discharging a pregnant woman who presents for care

Incidence of Obstetrical Triage:

According to the American College of Obstetricians and Gynecologists, ACOG (2020), obstetrical triage exceeds the overall number of hospital births by 20–50%.  Up to one third of evaluated obstetrical patients will not deliver. These obstetrical patients will be discharged home, or transferred to another unit following initial obstetrical evaluation.   In addition to labor evaluations, obstetrical patients commonly present for (but not limited to) evaluation of preterm labor, preeclampsia, decreased fetal movement, preterm premature rupture of membranes, vaginal bleeding, and acute abdominal pain.  Critical conditions such as motor vehicle collision injury, large placental abruption, or seizure, are less common, but require immediate triage, assessment, and management (ACOG, 2020).

Recommendations for Standardized Obstetrical Triage Acuity Tools:

ACOG recommends that women should be cared for according to triage acuity rather than by time of arrival.  Historically, women have been evaluated on a first come, first serve basis when presenting to the labor and delivery unit (or, obstetrical triage unit).  This method didn’t support timely identification of urgent or emergent obstetrical events (AWHONN).

Several obstetrical triage acuity tools have been developed to classify patients based on the urgency of the patient’s condition, often using a five-level system. These tools have increased the proportion of high-acuity patients being seen urgently.  Several of these tools have been tested for content validity and interrater reliability and may be used to improve quality and efficiency of care and guide allocation of resources (JOGNN, 2015).

Many professional organizations recommend that hospital obstetrical units develop triage protocols based on local conditions, resources, but also informed by evidence-based decision making. ACOG recommends the validated algorithm, the Association of Women’s Health, Obstetric and Neonatal Nurses’ Maternal–Fetal Triage Index (MFTI).

The Maternal Fetal Triage Index (MFTI):    

The Association of Women’s Health, Obstetric and Neonatal Nurses’ (AWHONN) implemented a Maternal Fetal Triage Index (MFTI) which serves as the first obstetrical acuity tool developed by a professional society for use across the United States.

The MFTI serves as an acuity tool (scale) that standardizes obstetrical triage and assists providers and nursing staff to prioritize urgency for provider evaluation and promotes effective multidisciplinary communication. 

The MFTI evaluates maternal vital signs, fetal heart rate, presenting condition, status of labor, fetal movement, current obstetrical, medical and surgical history. 

The ultimate goal of utilizing this tool is to improve patient safety and care.  These improvements will assist in mitigating the common allegations associated with obstetrical triage medical malpractice cases.  The elements of the MFTI prompts timely medical screening exams, with the inclusion of fetal assessment and evaluation of current history that supports risk stratification of the patient and fetus.  Based on the risk assessment, the tool offers clinical guidance specific to follow up care.     

Resources:

American College of Obstetricians and Gynecologists (ACOG) 2020. Hospital Based Triage of Obstetrical Patients, Committee Opinion, #667.

Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN)

Ruhl C, Scheich B, Onokpise B, & Bingham D. 2015. Content Validity Testing of the Maternal Fetal Triage Index. J Obstet Gynecol Neonatal Nurs. 44(6):701-9. doi: 10.1111/1552-6909.12763.

P.S. Comment and Share:  What is your experience in representing an obstetrical triage case?  During case development, did you identify the use of an obstetrical triage acuity tool?

In this blog, I’ll be reviewing common allegations specific to the use of oxytocin for labor management, as well as current standards of care.  I’ll also identify some risk reduction strategies. 

Oxytocin management is a common area of professional perinatal liability claims.  Knowledge of this, and being armed with current evidence and standards of care from professional organizations can reduce a clinician’s liability risk.  

Common Allegations:

• Initiation of oxytocin in the absence of evidence of fetal well-being.  Failure to complete a non-stress test prior to initiation of oxytocin
• Failure to accurately assess maternal-fetal status during labor induction.  Continuous fetal monitoring not performed; failure to assess and document fetal heart rate and uterine activity per organizational policy and standard of care
• Excessive doses of oxytocin resulting in uterine tachysystole, with or without an indeterminate or abnormal fetal heart rate (FHR) pattern.
• Failure to discontinue or decrease oxytocin in the presence of a Category II and/or Category III fetal heart rate (FHR) tracing unresolved with intrauterine resuscitation

Standards of Care:

• Assess and document fetal well-being prior to the initiation of oxytocin
• Administer the lowest dose to achieve cervical change and labor progress (ACOG, 2017)
• Initiate oxytocin at 1-2mU/min and increase by 1-2mU/min no more frequently than every 30-40 minutes.  Approximately 90% of women at term will have labor successfully induced with 6mU/min or less (AWHONN, 2014).
• Titrate the dose of oxytocin to fetal response and uterine activity / labor progress (ACOG, 2017)
• Avoid uterine tachysystole (more than 5 contractions in 10 minutes averaged over 30 minutes) and treat (decrease or discontinue) in a timely manner if it occurs (ACOG, 2017; JOGNN, 2020)
• Avoid prolonged uterine contractions lasting greater than 2 minutes, avoid inadequate uterine resting tone (contractions occurring less than 1 minute of each other) (ACOG, 2017)
• If labor is progressing, there is no need to increase the dosage rate
• If utilizing a labor management and/or oxytocin policy, follow all policy elements
• Ensure adequate personnel are available to monitor maternal-fetal status (ACOG, 2017).  E.g. one nurse to one woman receiving oxytocin for labor induction or augmentation (AWHONN, 2014)

Risk Reduction Strategies:

• Ongoing education and periodic competence validation for health care professionals who engage in fetal heart monitoring (FHM) (JOGNN, 2015)
• Consider the requirement for electronic fetal monitoring (EFM) education for obstetrical provider re-credentialing   
• Implementation of a pre-oxytocin and in-use oxytocin checklist.  Such checklists offer a guideline for care and reinforces to the providers that if the checklists cannot be completed, Oxytocin should not be initiated and/or continued (HCA, 2009) 
• Utilize the organizational chain of command and conflict resolution policy in the event of disagreement in fetal monitor strip interpretation.  Document employment of the chain of command.
• Per JOGNN, 2020: Organizational implementation of a quality improvement initiative – Identify quality measures related to induction of labor and augmentation of labor that emphasizes
  • perinatal structure measures:
    • completed 39 weeks gestation prior to elective induction
    • criteria for prioritizing inductions based on medical necessity
    • standard policy for oxytocin administration
    • standard order set for oxytocin
    • agreed upon definitions of tachysystole base on NICHD/ACOG/AWHONN terminology
    • agreed upon and standardized treatment for tachysystole
  • perinatal process measures:
    • greater than or equal to 39 weeks gestation if elective induction
    • if <39 weeks, indication is consistent with ACOG and The Joint Commission (TJC) clinical indications
    • cervical readiness or ripening before induction
    • oxytocin protocol starting at 1-2mU/min; increase by 1-2mU/min; at least 30min. between oxytocin dosage increase
    • fetal status is normal
    • appropriate and timely interventions for tachysystole if it occurs (use of a tachysystole audit tool)
    • compliance with all aspects of care (clearly identified aspect of care)

References:

ACOG. (2017). Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles

AWHONN. (2014). Perinatal Nursing 4^th ed.

HCA. (2009). Perinatal Safety Initiative Recommended Pre-Oxytocin Checklist For Women with Term-Singleton Babies

JOGNN. (2015). Fetal Heart Monitoring

JOGNN. (2020). AWHONN Practice Monograph

P.S. Comment and Share: What has been your experience with a case involving oxytocin for labor induction or augmentation?

When reviewing content from the electronic health record (EHR), there are many elements to assess.  One of the elements is the use of the copy/paste functionality (CPF).  In this blog, I’ll be reviewing the use of CPF within the EHR.  I’ll also will be reviewing The American Health Information Management Association’s (AHIMA) position on the use of CPF, statistics, and risks associated with CPF.  I will conclude with reviewing the role of the medical legal consultant, as well as best practice recommendations to mitigate documentation risk. 

Use of the Copy/Paste Functionality (CPF) in EHR’s: The American Health Information Management Association (AHIMA) maintains the position that “the use of copy/paste functionality in EHRs should be permitted only in the presence of strong technical, and administrative controls, which include organizational policies, and procedures, requirements for participation in user training and education, and ongoing monitoring.  Users of the copy/paste functionality should weigh the efficiency and time savings benefits it provides against the potential for creating inaccurate, fraudulent or unwieldy documentation.”

CPF – A Common Occurrence in the EHR: The use of CPF continues to be a common occurrence which can lead to adverse outcomes. 

The Joint Commission published the results of the Partnership for Health IT Patient Safety work group.  Their literature review identified 51 publications:

• One study of diagnostic errors found that CPF led to 2.6% of errors in which a missed diagnosis required patients to seek additional unplanned care.

• Several case reports identified clinical harm related to CPF, including a patient who died from a heart attack after his primary care physician (PCP) failed to diagnose cardiac disease.

A. Two years prior, the patient was discharged from the ED after a new diagnosis of atrial fibrillation, and potential heart disease; he was instructed to follow up with his PCP for a stress test.

B.  The PCP copied and pasted the assessment and plan (A/P) section of the patient’s record
for 12 office visits during the next two years, updating the A/P or reviewing medical entries
from the ED or other department.

C.  The PCP was found liable in the death.

• A study published in 2017 reviewed inpatient progress notes written in 2016 by direct care hospitals, residents, and medical students totaling 23,630 notes by 460 clinicians.  In a typical note, 18% of the text was manually entered, 46% copied, and 36% imported.

Risks of CPF:

• Inaccurate or outdated information can lead to medical errors.
• Redundant information, which makes it difficult to identify the current information.
• Inability to identify the author or intent of documentation.
• Inability to identify when the documentation was first created.
• Propagation of false information: inflates, duplicates or creates fraudulent healthcare claims.
• Internally inconsistent progress notes.
• Unnecessarily lengthy progress notes.

Role of the Medical Legal Consultant:

Attorney-Client Education

• EHR documentation standards
• Discoverable items not included in the designated record set
• Regulatory requirements: user specific

Development of interrogatories & requests for production

Development of discovery responses

Recommend expert witnesses – specific to the EHR at issue

Witness Preparation

Educate staff/end users of the EHR

• Assess knowledge of the workflow
• Evaluate if end users have observed the native EHR in printed format
  A. Determine if they know how to read the printed version
• Types of assessments
  A. Standardized by EHR platform
  B. Customized by provider
  C. Use of free text

Evaluate the type of, and how much training the end user received prior to
using the EHR.  Evaluate what the training consisted of

Evaluate if the organization has consistency across EHR user roles,
access and permissions

Evaluate the organizations processes specific to record set-up, changes, revisions, additions,
and retirement of modules to the EHR

Ways to Mitigate Risk / Joint Commission Best Practice Recommendations:

• Chart timely: during the same scheduled shift
• Limit use of copy/paste functionality
• Be cognizant of scope of practice
• Disable drafts
• Utilization of the EHR report feature to track, trend, and audit. Ensure that copy/paste practices are regularly monitored, measured, and assessed
• Provide a mechanism to make copy/paste material easily identifiable
• Ensure adequate staff training, and education regarding the appropriate, and safe use of CPF
• Develop policies, and procedures addressing the proper use of the CPF to assure compliance with governmental, regulatory, and industry standards
• Address the use of features such as copy/paste in the organization’s information governance processes
• Monitor compliance, and enforce policies, and procedures regarding use of copy/paste, and institute corrective action as needed.

Resources:

The Joint Commission. Sentinel Event Alert 54. “Safe Use of Health
Information Technology.” March 31, 2015. Retrieved from: https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert-54-safe-use-of-health-information/#.YpkLlFTMIos

The Joint Commission. “The Joint Commission Standards.” https://www.jointcommission.org/standards

The Joint Commission. Quick Safety 10. “Preventing Copy-and-
Paste Errors in EHRs.” Updated July 2021. Retrieved from: https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety–issue-10-preventing-copy-and-paste-errors-in-ehrs/preventing-copyandpaste-errors-in-ehrs/#.YpkLcFTMIos

P.S. Comment and share – How will this information change your documentation practices, or how you analyze the EHR?

In this blog, I’ll be reviewing the national, and New York State statistics related to maternal mortality associated with obstetrical hemorrhage.  I’ll also highlight one of the risk factors associated with obstetrical hemorrhage, and discuss the standards of care that should be employed to mitigate the risk of maternal morbidity and mortality. 

Statistics: Obstetrical hemorrhage is a preventable cause of maternal morbidity and mortality and continues to be one of the leading causes of maternal death in the U.S.

How the U.S. compares to 10 other developed countries:

In New York State, postpartum hemorrhage is the 2^nd most frequently reported postpartum complication, and accounted for 29% (18) of maternal deaths between 2012-2013 according to the NYS Maternal Morbidity and Mortality Review Report (2017).

Prolonged oxytocin exposure as a risk factor: In a recent (published May, 2022) retrospective cohort study performed by Boston University School of Medicine, prolonged (greater than or equal to 12 hours) oxytocin exposure for induction of labor increased the risk of obstetrical hemorrhage by 52% compared to those women exposed for less than 12 hours.  Use of obstetrical risk assessment tools alert the perinatal team to the risk of obstetrical hemorrhage and prompts evidence-based interventions.

The importance of standardized safety bundles: The American College of Obstetricians and Gynecologists (ACOG) recommends the use of the Obstetrical Safety Bundle as a means to guide standardized management of obstetrical emergencies associated with maternal morbidity and mortality in accordance to evidence-based practice.  ACOG’s Safe Motherhood Initiative (SMI) focuses on the four leading causes of maternal death: maternal sepsis, obstetric hemorrhage (severe bleeding), venous thromboembolism (blood clots), and severe hypertension in pregnancy (high blood pressure).

The Obstetrical Hemorrhage Safety Bundle includes:

• Risk assessments: prenatal, antepartum, labor & delivery, and postpartum.
• Use of a staged obstetrical hemorrhage checklist to guide interventions in real-time.
• Team debriefing recommendations and a standardized debriefing form.
• Suggested standardized obstetrical hemorrhage tool kit.
• Recommendation to perform quantitative blood loss assessment (QBL) with every delivery.

The Joint Commission Perinatal Safety Standards: Effective January 1, 2021, the Joint Commission implemented new perinatal safety standards required of all Joint Commission accredited hospitals.   One of the new standards aims to improve care for women experiencing maternal hemorrhage.  The Joint Commission requirements focus on evidence-based written procedures, education, training, and drills for staff and providers, education for patients and families, and quality review.  The requirement also focuses on evidence-based risk assessments and hemorrhage supply kits. 

References:

ACOG’s Obstetrical Hemorrhage Safety Bundle. https://www.acog.org/community/districts-and-sections/district-ii/programs-and-resources/safe-motherhood-initiative/obstetric-hemorrhage

MedPage Today. 2022. https://www.medpagetoday.com/meetingcoverage/acog/98676

NYS Department of Health. 2017. NYS Morbidity and Mortality Review Report

OECD Health Data. 2020

P.S. Comment and share your experience with a maternal death case associated with obstetrical hemorrhage. What were the deviations in the standards of care? 

In this blog I’ll be reviewing the difference between rotational and non-rotational maneuvers in the management of a shoulder dystocia.  I’ll also discuss the efficacy in relieving the shoulder dystocia, and the risk of brachial plexus injury, comparing both types of maneuvers.   

Non-rotational maneuvers: pose the least risk on the degree of stretch on the brachial plexus nerve.  Examples include: McRoberts maneuver, suprapubic pressure, and delivery of the poster arm. 

According to ACOG, in cases where the McRoberts maneuver and suprapubic pressure are unsuccessful, delivery of the posterior arm can be considered as the next maneuver to manage shoulder dystocia. Recent evidence has shown that delivery of the posterior arm has a high degree of success in accomplishing delivery.  In a computer-generated model, delivery of the posterior arm required the least amount of force to effect delivery and resulted in the lowest amount of brachial plexus stretch.  The use of the above maneuvers will relieve 95% of cases of shoulder dystocia within 4 minutes. 

Below Image (delivery of the posterior arm) requires the delivering provider to insert a hand into the vagina and deliver the posterior arm by sweeping it across the fetal chest

Rotational maneuvers: Examples include: The Rubin maneuver,  the Woods Screw maneuver

• The Rubin maneuver requires the delivering provider to insert a hand into the vagina and on the back surface of the posterior fetal shoulder.  The provider then rotates the fetal shoulder anteriorly towards the fetal face with his/her hand.
• The Woods Screw maneuver requires the delivering provider to rotate the fetus by exerting pressure on the anterior, collar bone region of the posterior shoulder to turn the fetus until the anterior shoulder emerges from behind the maternal symphysis (pubic bone).

Below Image (Rubin Maneuver)

References:

The American College of Obstetricians and Gynecologists. (2014). Neonatal brachial plexus palsy. ACOG Task Force on Brachial Plexus Palsy

The American College of Obstetricians and Gynecologists. (2017). Shoulder dystocia [Clinical Practice Bulletin #178]

 P.S. Comment and Share: What has been your experience in a brachial plexus case involving a shoulder dystocia?  How did the standards of care, specific to type of maneuvers, and type of traction employed, impact the outcome of the case?  

When is missed or delayed colorectal cancer (CRC) considered negligence?

In this blog, I’ll be reviewing the elements that are reviewed to identify if a missed, or delayed CRC diagnosis constitutes negligence.  I will also provide some examples of breaches in the standards of care specific to missed CRC cases.  As a means to promote greater awareness of colorectal health, and CRC awareness, I will also share current statistics, screening recommendations from authoritative sources, risk factors for CRC, and CRC symptoms.

Evaluating your CRC Case for Negligence / Mitigating Risk for Medical Negligence:

Having an awareness of the current standards of care, and rendering care in accordance to current standards of care specific to risk-based screening, and treatment reduces the risk of medical negligence.  A missed or delayed diagnosis of CRC is associated with greater morbidity and mortality.  Literature suggestions that delays in diagnosis are related to avoidable factors, such as improving the quality of bowel preparation, ensuring further investigations in patients with incomplete endoscopies, and colonoscopies, having endoscopies performed in accredited endoscopy centers, and timely follow up when non-cancer pathology is identified.  

Secondary to the fact that 2%-6% of CRC cases are missed following colonoscopy, most professional societies recommend counseling patients about this “miss rate.”

When evaluating a missed CRC diagnosis case for negligence, the four legal elements of negligence must be proven:

1. Duty: Did the defendant have a duty to the plaintiff?
2. Breach of Duty: Did the defendant fail to deliver care that an ordinarily careful, reasonable, and prudent person would do under the same or similar circumstance? Were there acts of omission related to the standards of care being met?

A. Failure to identify that the patient was at high risk for CRC.

B. Failure to recognize the patient’s symptoms as a risk factor for CRC.

C. Failure to order CRC screening.

D. Failure to include CRC in the differential diagnoses.

E. Failure to order appropriate tests, and/or referrals following a diagnosis of CRC

3. Damages & Injuries: Were there damages or injuries, such as economic and non-economic damages, that the plaintiff is alleging?

4. Causation: Did the acts of the defendant cause the damages, or injuries that the plaintiff is claiming?

Statistics:

• CRC is the third most commonly diagnosed cancer in men and women combined in the U.S.
• CRC is the second leading cause of cancer death in men and women combined in the U.S.

Estimates for 2022:

• 151,030 people will be diagnosed with CRC in the U.S.
• 52,580 people will die from CRC in the U.S.

Young-onset CRC is on the rise

• Rates for people under 50 increased 2.2% each year
• Median Age of Diagnosis: Age 66 (both men and women)
  

Screening:

All men and women without a family history, or risk factors for colorectal cancer (CRC) should begin CRC screenings at age 45, according to the American Cancer Society.

With screening, CRC is one of the most preventable cancers, and highly treatable if caught early.

If you have certain risk factors, you may need to be screened earlier than 45.

Risk Factors:

• Family history of CRC or polyps
• African American
• Have a genetic link to CRC such as Lynch Syndrome
• Have a personal history of cancer
• Have ulcerative colitis, inflammatory bowel disease, or Crohn’s disease

Types of screening chart

Symptoms: CRC often does not cause symptoms early on.  When symptoms do occur, they may include: 

• Change in bowel habits such as diarrhea and/or constipation, a change in the consistency of your stool, or stools that are more narrow than usual.
• Persistent abdominal discomfort such as cramps, gas, or pain. Feeling full, bloated, with or without  nausea & vomiting.
• Rectal bleeding.  You may notice blood in or on your stool that is bright red, or the stool may be black, tarry, or brick red.
• Weakness and/or fatigue associated with anemia (a low red blood cell count).
• Unexplained weight loss

References:

Colorectal Cancer Alliance. (2022). American Cancer Society’s Cancer Statistics Center and Colorectal Cancer Facts & Figures 2020-2022.

Hayes B., et al. (2019). Why are we missing colorectal cancer? A study investigating the cause of delays in diagnosis. BMJ Journal. 68:A190

P.S. Comment and share your experience with reviewing the standards of care to develop your delayed or missed CRC diagnosis case, while considering the “miss rate.”