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The Ten Most Expensive Medical Errors

By Barry Bialek, MD – Senior CoverMD Contributing Editor

Summary

In this article, Dr. Bialek looks at the top ten most expensive medical errors, based on cost of health care and loss of income. Medical errors play a pivotal role in determining medical malpractice insurance rates. By trying to eliminate common medical errors physicians can protect themselves and help lower the cost of their medical malpractice insurance rates.

Medical errors - The cost to society

Trying to figure out the most expensive medical errors is like asking, “Which mountain is the world’s tallest?” It depends on how you measure. Is it Mt Everest, because its summit – at 29,035 feet – is the highest above sea level? Or is it Hawaii’s Mauna Kea, which rises more than 32,000 feet from its base on the ocean floor to its summit, 13,796 feet above sea level? What about Ecuador’s Mt Chimborazo, whose peak – at 20,561 feet above sea level – is the furthest from the center of the earth?

Trial verdicts account for less than 10% of medical errors that are brought into the legal arena, so they do not always reflect the norm. These verdicts often also have a punitive factor, i.e., the jury awards more than requested by the plaintiff, as a punishment to the physician or hospital. Finally, there is a patchwork of tort reform, designed to limit the payout, regardless of the verdict. On another track, since medical malpractice settlements are not open to the public, the real numbers are impossible to navigate.

The simplest way to identify the ten most expensive medical errors is to add the cost of health care to the loss of income. These are the only real costs that can be compared across states, are independent of the skill of a plaintiff’s attorney, and do not impose the widely varied limits of tort reform.

Seven of the ten costliest common injuries are severe brain injuries. Of these, birth trauma victims who live the longest cost the most. This injury usually leads to cerebral palsy (CP), and with recent advances in home care, these infants can have a normal life expectancy.

The next two costliest common injuries lead to quadriplegia. And the last is death from untreated unstable angina. This is due to lost salary, because many of these patients were still working and supporting families at the time of their death.

Looked at another way, the two categories of medical error that can lead to each one of these top ten are avoidable delays in diagnosis and treatment. (See chart below for greater detail)

The following are snapshot cases representing each of the top ten most expensive medical errors, based on cost of health care and loss of income.

A. Medical errors leading to severe brain injury

1. Birth trauma

Janice’s labor began early one March morning after a normal, full-term pregnancy. Everything started out well, but her labor slowed down and had to be augmented with Pitocin. The L&D nurse didn’t pay close attention to the monitor, so she didn’t notice as the contractions started piling up, one on top of the next. Janice didn’t notice either, because her epidural numbed the pain.

By the time the L&D nurse realized what was going on and an emergency Caesarean Section was performed, Janice’s newborn son, James, had already suffered from the lack of oxygen to his brain, a condition diagnosed as hypoxic-ischemic encephalopathy (HIE). Though severely brain injured, James will probably live into his 70s.


2. Brain injury due to Ventriculo-Peritoneal (VP) shunt malfunction

Aaron made more cerebro-spinal fluid than he could drain out of his skull. This caused too much pressure around his brain and his first seizure, when he was an infant. He was diagnosed and treated neuro-surgically at the local children’s hospital with a tube that drained the extra fluid from his brain into his abdomen (VP shunt). Over Aaron’s first fifteen years, the shunt stopped working three times. The resulting headaches took him back to the hospital, where he was accurately diagnosed, treated, and released after a 24-hour stay each time.

When Aaron was 19, the VP shunt stopped working a fourth time, but he was then a university student in a different city. It was Friday night and he had been partying. The local ER physician sent Aaron away, thinking he was drug-seeking. Aaron was brought back the next evening, comatose. He will not regain consciousness.


3. Brain injury due to asphyxiation in the post-operative recovery room

Tiffany was the 12-year-old star of her middle school basketball team, when her appendix became infected. Her mom took her to the urgent care clinic, where the physician quickly diagnosed appendicitis and sent Tiffany to the local hospital. Once at the hospital, Tiffany’s appendicitis was confirmed and Dr. S took out her appendix in a routine appendectomy. She was a big girl for her age, so the anesthesiologist doubled her dose of Fentanyl, a potent narcotic. In the recovery room, Tiffany stopped breathing, due to the respiratory suppressive effects of Fentanyl, but her nurse didn’t notice in time, and Tiffany suffered severe brain injury.


4. Brain injury due to untreated post-concussive hemorrhage

David, 45 and seriously overweight, had been a long-haul trucker for 25 years. The Iowa roads that early December morning were icy, causing his truck to slide out of control and across the median. Taken by ambulance to the local emergency room, David was examined by the ER physician, who should have performed a head CT. Instead, David was discharged, and he checked into a local motel to get some rest before heading back out on the road. He continued bleeding slowly into his skull overnight. David was discovered late the next morning by the housekeeping staff. He was still alive, but would never regain consciousness.


5. Brain injury due to Warfarin toxicity leading to hemorrhagic stroke

Stephanie was a spry 66-year-old woman with atrial flutter. In this condition, a blood clot can form on the heart’s mitral valve, then break off and travel to the brain, where it blocks the flow of blood and causes a stroke.

Stephanie was given Warfarin to prevent clots from forming on her heart’s mitral valve. That’s the good news. The bad news is that it’s rat poison – it poisons the clotting system throughout the body, not just on her mitral valve. The delicate balance is maintained by frequently measuring two routine blood tests – PT and INR. Stephanie’s PT and INR reached dangerous levels, but she was not notified by the laboratory staff, so she didn’t know to decrease her dosing. A few days later, while watching Oprah, she suffered a spontaneous intracranial hemorrhage. She didn’t die, but her severe brain injuries mandate 24-hour care.


6. Brain injury due to undiagnosed / untreated Transient Ischemic Attack (TIA)

Martha was 58 and loved playing golf with her husband, Larry. Earlier that afternoon, while on the eighth fairway, she tried to call to Larry, but couldn’t form the words. He drove her straight to the local ER.

By the time she arrived, Martha’s speech had returned to normal. The ER physician found her neurological system normal and heard no abnormal sounds over her carotid arteries. After two hours in the ER, Martha was discharged and told to follow up with her family doctor and to ask him for a neurology referral.

Three days later the plaque broke off Martha’s left carotid artery, then flowed to and blocked her middle cerebral artery, leaving Martha conscious, but never again coherent.

7. Brain injury due to falls

Lilly, 72 years old, was getting off the procedure table after a routine colonoscopy. The drugs she had been given to relax made her lightheaded and she fell, striking her head and right knee. Since she didn’t lose consciousness, the nurse placed Lilly in a nearby chair until she felt better, then sent her home. The next morning, Lilly’s husband awoke to find her unconscious, but breathing, having suffered a subdural hemorrhage (SDH).


Numbers 8 and 9 are medical errors that led to quadriplegia. Here again, the cost is due mainly to the cost of skilled health care, over many years.

B. Medical errors leading to quadriplegia


8. Quadriplegia resulting from spinal cord injury due to missed unstable cervical spinal fracture

At 19, Mark was the proud owner of a vintage Mustang convertible. He and his girlfriend, Jenny, were driving the Georgia back roads one summer night after enjoying a few Margaritas. A deer ran across the road and they crashed when swerving out of the way.

Jenny called 911 from her cell phone. The ambulance crew arrived at the scene of the accident, placed Mark and Jenny on separate back boards, and took them to the local ER.

Mark was full of Tequila-fueled testosterone, preventing the ER physician from getting a good x-ray of his cervical spine. The physician was unimpressed by Mark’s demeanor and his blood alcohol level, and during the exam he allowed Mark to come off the back board. While sitting up, Mark’s undiagnosed and unstable neck fracture shifted, cutting his spinal cord and leaving him quadriplegic


9. Quadriplegia resulting from spinal cord injury due to missed spinal epidural abscess

Betty, 41, had been active and healthy all her life. Her gall bladder hit her first. While in the hospital recuperating from gall bladder surgery (cholecystectomy), Betty developed a hospital-acquired wound infection. After treatment with antibiotics, the infection healed.

Three months later, Betty noticed tingling down both arms and legs. Several days later, her arms and legs felt “numb,” so she called her family doctor. She was told her doctor was on vacation, but she could be seen by the physician’s assistant.

Betty was examined that afternoon, but the exam was cursory, not well-documented, and with follow-up “as needed.” The next morning, Betty awoke, paralyzed from the neck down, due to an undiagnosed abscess in her spinal canal that had been compressing her spinal cord.

The abscess, as it turns out, was from the same germ that caused her surgical wound infection. It had spread to her heart (infective endocarditis) and then to her spinal canal.

Number 10 is a medical error that led to death. Since people in this age group are often working and supporting families, their income is included in verdicts. (This policy varies from state to state.)

C. Medical errors leading to death

10. Death due to myocardial infarct (MI) after unstable angina

Sam, 47 years old, owned an insurance agency. After 20 years, he had a small staff, a growing family, and a large belly. He regularly suffered from indigestion.

One morning while driving to work, his indigestion felt different, enough so that he drove to a nearby urgent care to get it checked out. The office was filled with people suffering from the flu and the physician was busy, apparently too busy to read the EKG he ordered – the EKG that revealed Sam’s unstable angina. Since Sam’s pain abated with a GI cocktail (Maalox, Donnatal, and lidocaine), he was discharged with a diagnosis of dyspepsia.

Later that afternoon, he died at his desk from a massive myocardial infarct, leaving a widow and four children.


The Ten Most Expensive Medical Errors in the US – Identified with Categories of Error

 

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1.  Brain injury       due to birth trauma

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2.  Brain injury       due to VP shunt malfunction

 

 

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3.  Brain injury       due to recovery room asphyxiation

 

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4.  Brain injury       due to untreated post-concussive hemorrhage

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5.  Brain injury       due to anti-coagulant toxicity

 

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6.  Brain injury       due to untreated TIA

 

 

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7.  Brain injury       due to due to falls

 

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8.  Quadriplegia     due to missed unstable cervical spinal fracture

 

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9.  Quadriplegia     due to untreated spinal epidural abscess

 

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10. Death                due to MI after unstable angina

 

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Categories of Error
1. Technical medical error
2. Failure to use indicated tests
3. Avoidable delay in treatment
4. Failure to take precautions
5. Failure to act on test results
6. Inadequate monitoring after a procedure
7. Inadequate patient preparation before a procedure
8. Inadequate follow-up after treatment
9. Avoidable delay in diagnosis
10. Improper medication dose and/or method of use


About the Author

Barry Bialek M.D. - CoverMD.com Senior Contributing Editor
Barry Bialek, MD

Barry Bialek, MD is a board-certified family physician living in Boulder, Colorado. His practice includes both family medicine and emergency medicine. For the past 10 years, Dr. Bialek has served as the in-house medical consultant to one of the most successful plaintiff's personal injury law firms in the US. His job was to advise on every medical step of every medical malpractice case. This gives Dr. Bialek a unique perspective on medical malpractice and how best to avoid it.

Dr. Bialek has held clinical faculty positions with the departments of family medicine at both the University of Toronto (Canada) and the University of Arizona. Dr. Bialek is currently a member of the faculty of the University of Colorado, College of Engineering, where he teaches his other passion: sustainable community development in Nepal.


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