Legal Case Study
Following the review of a medical error about a 62-year-old woman with skin cancer who experienced wrong-site surgery I will summarize the legal and liability aspects of this case, as well as explore the legal and ethical implications of disclosing errors. In addition, I will discuss the pros and cons of having the provider disclose and empathize for the error to the patient. Finally, I will identify ways the nurse leaders can learn from this situation, help prevent similar kinds of medical errors from happening, and assist the providers and organization to effectively disclose information to patients after such an error occurs.
The closest definition to medical error would be from the institute of medicine by stating “failure of a planned action to be completed as intended…” (Thomas, 2009, p. 671). In this case the error appears to be a system problem and not just one person (in this case the surgeon). A medical error did occur: wrong sited surgery. Bottom line the standard of care was not met. When referring to the legal ramifications about this case form the patient’s perspective, we would be speaking about the repercussions of the wrong sited surgery. These issues would be the time delay for corrective surgery (this procedure was for removal of cancerous tissue), pain the patient suffered (for undergoing two separate procedures), and wrongful disfigurement to the patient’s face as she has the potential to have an additional scar at the wrong sited surgery.
In order to encourage physicians to fully disclose to a patient after an adverse event, there are 35 states that have enacted laws that make expression of sympathy following an error inadmissible in court to prove liability. This is referred to as the “I’m sorry” Law. In the past decade, five of these states have gone a step beyond, by adding a mandatory notification requirement on hospitals to adopt policies of full disclosure (Bender, 2007). In addition to law it is the ethical responsibility of all healthcare providers to disclose information to the patient about adverse or potential adverse outcomes.
Assessment of Liability
After reviewing the case study, the liability falls with all parties involved with the patient’s care, not just the surgeon. In this situation it was a process problem. There was obviously a universal protocol process at the facility as the case study identified several safety check processes. Unfortunately, there were several breakdowns in the process. First, the person who marked the patient was not the consented surgeon who was performing the procedure. As the patient mentioned she never had the opportunity to speak with the person who mismarked the spot. Second, the patient was not involved in the site marking. The patient mentioned if she had the opportunity to use a mirror to verify the marking she would have noticed it was incorrect. Third, the patient remembered that a “time out” never actually happened in the procedure...