Case Scenario: CURSORY EXAMS ARE RISKY

All of the elements necessary to establish negligence were well established in Niles v. City of San Rafael. 8 On June 26, 1973, at approximately 3:30 PM, Kelly Niles, a young boy, got into an argument with another boy on the ball field. He was hit on the right side of his head. Kelly rode home on his bicycle and waited for his father, who was to pick him up for the weekend. At approximately 5:00 PM, his father arrived. By the time they arrived in San Francisco, Kelly appeared to be in a great deal of pain. His father then decided to take him to Mount Zion Hospital, which was a short distance away. He arrived at the hospital emergency department at approximately 5:45 PM. On admission to the emergency department, Kelly was taken to a treatment room by a registered nurse. The nurse obtained a history of the injury and took Kelly's pulse and blood pressure. During his stay in the emergency department, he was irritable, vomited several times, and complained that his head hurt. An intern who had seen Kelly wrote "pale, diaphoretic, and groggy" on Kelly's chart. Skull X-rays were ordered and found to be negative except for soft tissue swelling that was not noted until later. The intern then decided to admit Kelly. A second-year resident was called, and he agreed with the intern's decision. An admitting clerk called the intern and indicated that Kelly had to be admitted by an attending physician. The resident went as far as to write "admit" on the chart and later crossed it out. A pediatrician who was in the emergency department at the time was asked to look at Kelly. The pediatrician was also the paid director of the Mount Zion Pediatric Out-Patient Clinic. The pediatrician asked Kelly a few questions and then decided to send him home. The physician could not recall what instructions he gave Kelly's father, but he did give the father his business card.

The pediatrician could not recall giving the father a copy of the emergency department's "Head Injury Instructions," an information sheet that had been prepared for distribution to patients with head injuries. The sheet explained that patients should return to the emergency department should any of the following signs appear: a large, soft lump on the head, unusual drowsiness (cannot be awakened), forceful or repeated vomiting, a fit or convulsion (jerking or spells), clumsy walking, bad headache, and/or one pupil larger than the other. Kelly was taken back to his father's apartment at about 7:00 PM. A psychiatrist friend stopped by and examined Kelly. He noted that one pupil was larger than the other. Kelly was taken back to the emergency department. A physician on duty noted an epidural hematoma during his examination and ordered that a neurosurgeon be called. Today, Kelly can move only his eyes and neck. A lawsuit was brought against the hospital and pediatrician for $5 million. The city of San Rafael and public school district were included in the lawsuit as defendants. Expert testimony by two neurosurgeons during the trial indicated that Kelly's chances of recovery would have been very good if he had been admitted promptly. This testimony placed the proximate cause of the injury with the hospital. The final judgment was $4 million against the medical defendants, $2.5 million for compensatory damages, and another $1.5 million for pain and suffering.

Discussion: The many lessons for discussion in Niles v. City of San Rafael include the following:

1. An organization can improve the quality of patient care rendered in the facility by establishing and adhering to policies, procedures, and protocols that facilitate the delivery of quality care across all disciplines.

2. The provision of quality health care requires collaboration across disciplines.

3. A physician must conduct a thorough and responsible examination and order the appropriate tests for each patient, evaluating the results of those tests before discharging the patient.

4. A patient's vital signs must be monitored closely and documented in the medical record. Corrective measures must be taken when a patient's medical condition signals a medical problem.

5. A complete review of a patient's medical record must be accomplished before discharging a patient.

6. Review of the record must include review of test results, nurses' notes, residents' and interns' notes, and the notes of any other physician or consultant who may have attended the patient.

7. Failure to fully review a patient's record can lead to an erroneous diagnosis, and the premature dismissal of a case can result in liability for both the organization and physician.