ORX Proceedings 2013_Layout 1 12/6/13 11:23 AM Page 55
2005. He was discharged 2 days after the surgery. The man's family said he was
discharged too early and his pain wasn't under control when he went home. He
died at home 3 days after discharge of what the coroner ruled was a painkiller
overdose. The hospital said the death, while tragic, wasn't a result of anything it
did but rather a result of the man's taking too many pain pills once he got home.
The case went to trial 7 years after the date of the incident. After that much
time, witnesses may be unavailable and memories are dim, but the medical
record remains. The handwritten notes were sloppy, both in meaning and penmanship. The electronic record was not much better. Dropdowns and charting
exceptions didn't correlate with assessments and nurses' notes.
"When the medical record is being scrutinized by 12 jurors, it's very disconcerting
as an administrator to realize the things you assume are happening are not," say
Ms. Kleinhesselink and Ms. Lester. "To have these failures blasted by the plaintiff's
lawyer during trial makes you want to climb under the defense table."
During the 8-day trial, plaintiffs' lawyers hammered away at contradictions,
inconsistencies and omissions in the notes. The plaintiff's nursing expert testified that the facility fell below the standard of care in pain assessment, and didn't fully comply with its policies and procedures.
The family's attorney asked the jury for $1.7 million. But the family got nothing. In the end, the jury found that the plaintiff had failed to present evidence
that tied the hospital directly to the death of the patient. There was great relief,
yes, but also a great lesson learned.
"Defending a case this old is very difficult," they say, "and we learned we
needed to make further changes to our documentation policies to better protect
our staff and the facility."
— D.O.
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