The Daily

Overdose (No. 2)

In my last Weekly Blog, I reviewed an Accreditation Decision Report I secured from internal Hospital and JCAHO investigations of a fatal overdose. These reports are usually confidential and contain information not available in other sources. That kind of sensitive information is rarely available but can be critical to a successful outcome in medical malpractice litigation.

In this post, I review internal peer review documents obtained from the Hospital itself. In Florida, the Agency for Healthcare Administration is responsible for receiving and reviewing complaints against healthcare providers of all types. These reports are usually confidential unless AHCA makes a finding of  ‘probable cause’. Because AHCA is understaffed and underfunded, probable cause findings are extremely rare.

Anyone can file an AHCA complaint and forms are available for notifying AHCA of the nature of your complaint against a license holder. In the subject case, I obtained the Hospital’s Uniform Complaint Form and Profile against it’s own nurse – together with the “CONFIDENTIAL Risk Management Code 15 Report” to AHCA required by Florida Statute Section 395.0197(6) following any “adverse or untoward incident” arising from healthcare delivered in the Hospital.

Beyond the narrative detailing the miscommunication between anesthesiologist and nurse that resulted in the overdose, the Code 15 Report includes information about other key witnesses – the Pharmacy Director, the Pharmacy Manager and the Recovery Room Director. These individuals possessed critical evidence of institutional or ‘system errors’ at the Hospital. These system errors in the pharmacy led to a complete lack of control over the purchase, distribution and training on drugs available in all areas of the Hospital. As a result, the JCAHO confidentially looked into a series of drug overdoses and adverse medical events over a period of years at the Hospital. Without this evidence, the Hospital and anesthesiologist might have been successful in blaming the episode entirely on one “rogue” nurse when, in fact, it was the Hospital’s out of control pharmacy that caused the chain of events leading to the fatal overdose.

This kind of evidence is only part of the proof necessary to get to the bottom of your medical malpractice case. As I mentioned, it will rarely be made available to you or your lawyer. That is why it is critical to hire a lawyer with experience in handling medical malpractice cases.

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