Question: 1. Please review the risk assessment process by watching the following video:
Safety Risk Assessment Video Training (By Doig Corporation)
After you watch the video, please conduct a risk assessment on the situation surrounding the lawsuit found at the Law Suit and the Questions File.
Attached with the files.
Conduct a systems level risk analysis:
Please use the following impact and probability framework to complete the risk table in part a.
Impact Framework
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Impact Level
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Criteria
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1
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Minor: No or minor injury/adverse health outcomes
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2
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Moderate: Moderate injury/adverse health outcome (increased length of stay)
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3
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Serious: Major injury/adverse health outcome (e.g. possibility of permanent lessening of bodily functioning)
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4
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Major: Possibility of death or major permanent loss of function (motor, sensory, physiologic, or intellectual)
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5
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Catastrophic: Multiple deaths
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Probability Framework
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Probability Level
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Criteria
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1
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Very low
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2
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Low
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3
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Medium
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4
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High
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5
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Very High
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a. Identify atleast 4 risks (at the systems level) and complete the risk table below.
Risk Table
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No.
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Risk Description
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Probability
(1=low, 5=high)
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Impact (1=low, 5=high)
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Risk Category - Low/Med/High
(Probability x Impact)
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Rank of Risks
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b. Please describe the most impactful risk you found and what actions could be taken to minimize or mitigate the risk.
Law Suit: Fatal Air Embolism Case Study: Tort Liability, Error Prevention, and Interprofessional Communication
The following case-study is adapted from an Idaho medical malpractice case involving the wrongful death of a patient. After a trial, a jury awarded the surviving family members a little over $6 million in economic and noneconomic damages, and this jury verdict was upheld by the Idaho Supreme Court after an appeal.
The background below is adapted from the Idaho Supreme Court's decision and materials obtained from the public court record. I have changed the names of parties in this case to labels reflecting their role in the case (re-labeled names are in bold the first time they are used).
Following this background from the court record, I have provided several additional resources related to the blood reinfusion bag at issue in this case.
FACTUAL AND PROCEDURAL BACKGROUND
On August 2, 2004, Patient underwent lumbar spine surgery at Hospital and died when an air embolus entered her blood stream from the reinfusion bag. Two anesthesiologists were on hand for the surgery-Primary Anesthesiologist (Dr. Primary) and Relief Anesthesiologist (Dr. Relief). Drs. Primary and Relief were under contract with Anesthesiology Group, which provides all anesthesiology services at Hospital. Technician, the certified cell saver technician employed by Autotransfusion Company, was also on hand for the surgery. Autotransfusion Company is a corporation that contracts with various hospitals in the Treasure Valley to provide autotransfusion services during surgeries. As a cell saver technician, Technician was responsible for gathering the patient's blood during surgery and cleaning the blood in the cell saver machine before the cleaned blood was delivered from the machine back into the patient through the reinfusion bag.
Before Technician became a cell saver technician, she underwent training offered by Haemonetics Corporation, which manufactures the cell saver machines used by Autotransfusion Company. Technician testified that during this training the instructor pointed out the warning on the Haemonetics reinfusion bag, which states "Warning: Do not use with pressure cuff. Use of pressure cuff may lead to fatal infusion of air," and emphasized that this advice was always to be followed. Technician also testified she was informed that the machine delivered a significant amount of air to the reinfusion bag, and that air could be fatal. In addition, Technician acknowledged she was trained in what to do if she encountered a physician wanting to apply a pressure cuff or similar device to a reinfusion bag.
During Patient's surgery, Technician had processed the blood four times and had 500 milliliters of blood in the reinfusion bag to be returned to the patient at the time she transferred the bag to Dr. Primary by placing the bag on an IV pole. Once Dr. Primary had the reinfusion blood running into the patient, Technician left the room to remove another machine. While Technician was out of the room, Dr. Relief relieved Dr. Primary so he could take a lunch break. After Dr. Primary left the room, Dr. Relief sought to speed up the reinfusion process. Dr. Relief found a pressure cuff and placed it on the bag; she later testified she had not noticed the warning on the bag that specifically cautioned against applying a pressure cuff. According to Dr. Relief, when Technician returned to the room she did not say anything to Dr. Relief about not using the pressure cuff; Technician claims she told Dr. Relief a pressure cuff should not be used on the reinfusion bag. It is undisputed that no conversation took place between Dr. Primary and Technician after Dr. Primary returned from his break.
When Technician noticed the blood had completely emptied from the reinfusion bag, she tapped Dr. Primary on the arm to inform him the bag was empty. He asked her how long the line had been empty, and she replied she did not know. Dr. Primary then realized there was air in the line going into the patient and they had a serious problem. Attempts at resuscitation were unsuccessful and Patient's suffered a fatal air embolism.
Patient's husband and two children brought suit, claiming Patient's wrongful death was caused by the combined medical fault of the two anesthesiologists and Technician. The jury returned a special verdict apportioning fault as follows: (1) Technician-49%; (2) Dr. Relief-36%; and (3) Dr. Primary-15%. The jury also found the conduct of both Technician and Dr. Relief was "reckless." Total economic damages were awarded against, Dr. Primary, and Dr. Relief in the amount of $2,012,083, and non-economic damages were awarded for $4,000,000.
Please answer the following questions with at least 100 to 300 words each>
1. How does this situation reflect the "moral distress" discussed in Clinical Ethics that may be experienced by allied health professionals such as nurses, technologists, and technicians?
2. What problems are presented by a situation where a minimally trained technician may need to confront a highly trained specialist physician?
3. The jury found that Technician and Dr. Relief were not only negligent, but also "reckless"? How exactly do you believe that the two were "reckless"? (Hint: Review the Idaho Code section and definitions. Would the family have been awarded $4 Million in noneconomic damages if there was no finding of recklessness?)
4. Do you agree with the jury's apportionment of fault (Technician 49% at fault; Dr. Relief 36%; Dr. Primary 15%)? Why or why not and explain your answer.