Medical Care Review Services

Let's apply the IRAC method to a straightforward hypothetical case to demonstrate the thought process behind assessing care. Although this is a legal method, it can only be done with knowledge and insights of the medical field. The medical review we provide establishes issues, identifies and applies established rules, and provides an analysis to come to a conclusion. 

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Issue

A patient in a very busy Emergency Department at a local hospital complains of a severe migraine. The patient has a history of migraines. She has been seen twice in the last six months for treatment. Each time she received an injection for her migraine, and she was discharged with follow up recommended with her primary care physician. The same doctor who had previously seen her came in her room and asked, "Having another migraine?" He next said, "We'll get you taken care of." Patient had received an injection for her migraine and she was discharged.

 

Our review of the patients records revealed that no evaluation was completed by the physician. The nurse documented right arm weakness, slurred speak and facial drooping. The physician documented the symptoms of a migraine and entered an order for an injection of Ketorolac 60mg, which was later administered by a nurse after a change of shift. The patient returned home after discharge. Symptoms worsened. She went to bed to rest and allow the medication to work. The patient died overnight of a hemorrhagic stroke. 

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Rule

Medical Malpractice, (or in this case wrongful death, requires that there be professional negligence. That can often be indicated in a thorough review using the four elements describe above: Duty, Breach, Cause, Injury. In this case, the physician had a professional duty to review the patients current symptoms, perform an evaluation, review the nurses notes and use the available information to come to a diagnosis. Providers of similar training would have done so.

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Analysis

The doctor's previous experiences with the patient led to a confirmation bias that this was again just another migraine. Patient records indicate symptoms of a stroke and hospital practices and established standards of care should have resulted in a evaluation and work up that led to a diagnosis of a stroke not a migraine. A brain CT or MRI would have confirmed that the patient was having ischemic stroke (blockage). The American Heart Association, American Stroke Association, American College of Cardiology and other professional organizations have adopted  treatment guidelines that recommend that IV recombinant tissue plasminogen activator (tPA)  be administered within 3 hours of the last normal function for a person having an ischemic stroke. The standard of care to diagnose the type of stroke would have been brain imaging. An autopsy confirmed, the patient's blockage resulted in death from the hemorrhagic stroke after the clot caused a large vessel hemorrhage. Had tPA been administered it is unlikely that the patient would have died of a hemorrhagic stroke. 

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Conclusion

The physician didn't follow generally accepted treatment guidelines or hospital practices or policies. Care deviated from accepted practice standards described above. This resulted in a breached of his duty of care for the patient. The patient died of a stroke. The physician committed medical malpractice by not reviewing the patient symptoms and missing a diagnosis that would not have been missed by similar peers given the patient's presentation, information available at the time she arrive in the ED. The patient's death/injury was a result of the breach of duty of care owed to the patient. The physician and hospital are liable for the wrongful death of this patient because the breach of duty of care caused the death.

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Summary

Although this is a simple example, most medical cases are not as straightforward. Cases are complex and presentations confounding leading to undifferentiated (unknown) conditions that may lead to care being delivered that is later deemed unnecessary. That doesn't mean that care was inappropriate or that a provider did anything wrong. Clinical judgement varies and can lead to some variability in care when patients don't have definitive diagnoses. 

 

In addition, patients may experience a bad outcome as a result of some of these unnecessary treatments. That also doesn't necessarily mean anything was done wrong. We help determine if an injury was a result of poor care and may be a cause for action. Making determinations if care met practice guidelines requires a multidisciplinary team of medical professionals with in-depth knowledge of care delivery. That is where the experience of the EvaluCare faculty can help.

 

As you may have a sense in this example, we believe part of our service is to educate our clients and in so doing we help clients make informed decisions. We partner with you, and depending on the facts of a case, our guidance will increase the probability of a successful settlement.