How to Get Answers to Questions When Unexpected Medical Outcomes Occur.

I think that most doctors would be surprised to know that when people contact me about a potential medical malpractice case, they are not primarily concerned with being financially compensated for the consequences of a medical mistake. Rather, more often than not, what motivates a patient or a family member to call my office is the fact that they are not getting answers to questions they have from their health care providers.

The overwhelming majority of medical malpractice telephone calls I receive are from family members of patients who are still under active care seeking answers to questions that are not being provided by doctors. An unexpected outcome occurs and no explanation for this is provided. Family members become concerned that they do not have real understanding of their loved one's current medical condition. The lack of information causes them to worry that there might be additional risks they are not aware of. Inevitably, I tell people in these circumstances that it is too early to consider the issue of whether they have a viable medical malpractice claim and I encourage them to contact the hospital's patient advocate to help them get answers to their questions medical questions. I also provide them with the information below, to educate them about their legal rights.

Under the American Medical Association Code of Ethics, physicians have an ethical obligation to advise a patient when they commit consequential acts of medical malpractice when "a patient suffers significant medical complications that may have resulted from the physician's mistake or judgment." Am. Med. Assn. Code of Medical Ethics A-02 Edition, E-8.12 Patient Information, 77. Similarly, the American College of Physicians Ethics Manual mandates disclosure of errors if disclosure of this information is "material to the patient's well-being." Lois Snyder & Cathy Leffler, Ethics Manual, Fifth Edition, 142 Annals Internal Medicine 560, 563. Finally, the Joint Commissions on Accreditation of Health Care Organizations requires that patients be informed of unanticipated results that differ from the expected outcome in a significant way when a medical error occurs at a hospital. Joint Comm'n on Accreditation of Health Care Orgs., Revisions to Joint Commission Standards in Support of Patient Safety and Medical/Health Care Error Reduction 12 (2001).

In New Jersey, the Patient Safety Act, N.J.S.A. 26:2H-12.23 (PSA) imposes a legal duty to immediately disclose medical errors to patients who are harmed by them. N.J.S.A. 26:2H-12.25.  Under the PSA, a patient must be informed no later than the end of the episode of care, or, if discovery occurs after the end of the episode of care, in a timely fashion, when the patient is a victim of "a serious preventable adverse event." N.J.S.A. 26:2H-12.25(d). A "serious preventable adverse event" is any adverse event that is preventable and results in death, loss of body part, or disability or loss of bodily function either lasting more than seven days, or that is still present at the time of discharge. N.J.S.A. 26:2H-12.25(a). In addition to requiring adverse events to be reported to the victims of medical malpractice, the Patient Safety Act also requires health care providers to report medical errors to the Department of Health and Human Services (the "Department"). N.J.S.A. 26:2H-12.25(c).

As of (a) March 3, 2008, for hospitals, (b) August 30, 2008, for ambulatory care facilities, home health care agencies and hospice providers, and (c) starting March 3, 2009, for nursing homes and assisted living facilities, health care providers have 24 hours after the discovery of a serious preventable adverse event to notify a patient that it has occurred. N.J.A.C. 8:43E-10.7(b). Patients are to be notified in person if they are still at the facility or by telephone or by certified mail if they are not. N.J.A.C. 8:43E-10.7(c). Disclosure to a patient must be accompanied by documentation in the patient's medical chart which indicates: (a) that the disclosure was made, (b) the time, date and individuals present when the disclosure was made and (c) the name of the person to whom the disclosure was made. N.J.A.C. 8:43E-10.7(f). Medical providers failing to disclose a serious preventable adverse event to a patient are subject to a fine of $1,000 if the event was also not disclosed to the Department of Health and Senior Services, but $5,000 if they reported the event to department, N.J.A.C. 8:43E-3.4(15).

If a patient suffers a significant permanent injury as a result of a preventable medical mistake, then after the health care event is over, consultation with a medical malpractice attorney should be considered. If questions about an unexpected outcome are going unanswered in the midst of a medical crisis, however, a patient should contact the hospital's patient advocate and insist on a full explanation of the care provided and description of their current medical condition. Doctors have an ethical obligation to provide this information.

Settlement at trial of a medical malpractice case on behalf of a 28-year-old Brick, New Jersey, resident who suffered neurological damage following orthopedic surgery to his knee.

Partner John Ratkowitz (Click here for bio)resolved an orthopedic malpractice claim on behalf of a 28-year-old resident of Brick, New Jersey, who suffered nerve damage following orthopedic surgery to his left knee.

The plaintiff underwent knee surgery on September 13, 2005. Following the surgery, his left leg was placed in a cylinder cast that went from his foot to his thigh. On September 14, 2005, he began to notice increased swelling in the lower part of his left leg in the ankle and foot area. As the day went on the swelling continued. He developed first a tingling sensation, then later in the day numbness and pain. Eventually, later in the late afternoon or early evening, as his symptoms increased, and the plaintiff telephoned the operating surgeon's office. No physicians were available¸ and the answering service advised that they would have an on-call physician return his call. Approximately an hour later a physician telephoned the plaintiff and advised him that he should elevate his foot and apply ice to his leg to reduce the swelling and symptoms.

Elevation and ice did not alleviate the plaintiff's symptoms and the next morning, September 15, 2005, he and his mother both telephoned the orthopedic practice several times to see what they should do about this. Around 10 o'clock in the morning, a person from the practice telephoned the plaintiff's mother, advising that she could either bring the plaintiff into the office to be seen that morning or she could wait until Friday which was the next day and bring him in to his regularly scheduled appointment. The plaintiffs were told that if they visited that morning, they wouldn't be able to see the operating surgeon, because he was at the hospital. They elected to wait until the next day, since the operating surgeon was the only orthopedist the plaintiff had ever seen.

While the plaintiff did not know this, the tingling and pain was peroneal nerve compression due to swelling inside the cast. Between the calls and the first doctor visit, the problem became irreversible.

The plaintiff took the position that injury to the peroneal nerve as a result of swelling inside a cast is a well-known potential complication that is entirely avoidable and that accepted standards of medical care required the defendant to immobilize the plaintiff's leg in a way that didn't put that nerve at risk.

The defense argued that the all medical providers acted within accepted standards of care,

Mr. Ratkowitz settled the case shortly after it was assigned to a trial judge. The terms of the settlement are confidential.

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The Relevance of Never Events in Medical Malpractice Litigation

Excerpted from "Never Events in Medical Malpractice Litigation," September 2010, Vol. 27, No.126. Medical Malpractice Law & Strategy. By John Ratkowitz and Robert Sanfilipo

The National Quality Forum is a nonprofit organization which aspires to set priorities and goals for improvement in healthcare in the United States. To pursue its mission it established the concept of "Never Events," a list of serious complications that should never occur in a safe hospital. Arnold Milstein, Ending Extra Payments for “Never Events” – Stronger Incentives for Patients Safety, 360 (23) New Eng. J. Med. 2388, 2388-90 (2009).

 On February 8, 2006, President Bush signed the Deficit Reduction Act of 2005, Section 501(c) of Pub. L. 109-171, instructing the Department of Health and Human Services (the Department) to create its own list of Never Events, so that Medicare payments could be decreased when preventable complications occur in hospitals. On October 1, 2008, the Centers for Medicaid and Medicare Services (CMS) identified eight categories of complications for which it would no longer reimburse hospitals if they developed during a hospital admission: foreign objects left in the body after surgery, air emboli, infusion of incompatible blood, falls and traumas, catheter associated urinary tract infections, mediastinitis after coronary-artery bypass grafting, certain infusion associated infections, and pressure ulcers. Sharon K. Inouye, et al., Medicare Nonpayment, Hospital Falls, and Unintended Consequences, 360 (23) New Eng. J. Med. 2390, 2390-92 (2009). This list was later expanded to include poor glycemic control, deep-vein thrombosis or pulmonary embolism associated with knee or hip replacement surgery, and certain orthopedic and bariatric surgical-site infections. Milstein, supra, at 2388. In January 2009, CMS went further and indicated that it would cease payments to hospitals and physicians when surgery was performed on the wrong patient, when the wrong surgical procedure was performed, or when surgery was performed on the wrong side or wrong body part. Id. at 2388. These actions of federal regulators were said to be an effort to "align financial incentives with the quality of care, thereby promoting both quality and efficiency." Inoye, et al., supra, at 2391.

Major private insurers have decided to follow the lead of the federal government by adopting similar reimbursement denials when patients have been harmed in hospitals through categories of preventable medical errors. Among these insurers are Aetna Inc., Cigna HealthCare, Anthem Blue Cross Blue Shield in New Hampshire, Blue Cross Blue Shield of Massachusetts and WellPoint. Rachel Morgan, R.N., National Conference of State Legislatures, Medicare Nonpayment For Medical Errors, (2008), http://www.ncsl.org/Portals/1/documents/health/MCHAC.pdf. Additionally, in July 2008, CMS contacted all State Medicaid Directors and urged them to adopt policies echoing its denial of payments for Never Events in order to avoid the potential negative fiscal impact that non-payment of Never Events by Medicare might have on states, given the problem of dual eligibility under these plans. Id. Clearly, refusing payment for avoidable medical expenses is a public policy trending towards expansion.

Commentators have questioned the wisdom of Medicare's policy decision to refuse to pay for Never Events. See Inouye, et al., supra; See also, See also Peter J. Pronovost, et al., The Wisdom and Justice of Not Paying for “Preventable Complications,” 299(18) J. Am. Med. Ass’n. 2197, 2197-99. Even critics of the policy, however, have characterized Medicare's decision not to reimburse for costs related to leaving objects in the body after surgery as “wise and just." Id. at 2199. When discussing the propriety of including retained foreign objects as one of the original eight categories of Never Events in its non-reimbursement policy, the Department pointed out that in the field of health care, "there are widely accepted and clear guidelines for the prevention of [these] events." 72 Fed. Reg. 426,206 (Aug. 22, 2007). Consequently, according to the Department, this kind of mistake "should not occur." Id.

In 2006, there were 764 instances in which Medicare was billed for care related to retained objects following surgery. Id. Although there is not a comprehensive database that sets forth information about every medical malpractice case filed involving allegations of a retained foreign object, Westlaw does contain a national database of verdicts, judgment and settlements compiled from regional and national jury verdict reporters. However, articles submitted to these reporters are strictly on a voluntary basis. Further, medical malpractice defendants almost always require confidentiality as part of any settlement agreement. Thus, Westlaw's database is no doubt a very small sample of cases filed and litigated. At the same time, it is also one of the only tools available (to plaintiffs' lawyers) to examine how categories of certain types of claims are handled from inception to resolution.

A search of medical malpractice cases involving the retention of surgical sponges in Westlaw’s national jury verdict data base reveals that there have been twelve medical malpractice cases involving retained sponges throughout 2008 and 2009. See An v. Shaw, No. 06 L 11100, 2009 WL 5091924 (Ill. Cir. Ct. Oct. 29, 2009); Anonymous Female Patient v. Anonymous Physician, Anonymous Nurse and Anonymous Clinic, 2009 WL 6366089 (Va. Cir. Ct. Oct. 5, 2009); Sneeze v. State of Louisiana, No. 154,568, 2009 WL 6528661 (La. Dist. Ct. Jul. 27, 2009); Edmondson v. Oakwood Healthcare, No. 07-721460-NH, 2009 WL 3699101 (Mich. Cir. Ct. Jun. 4, 2009); Anonymous 31 Year Old Female v. Anonymous OB/GYN And Anonymous Hospital; 2009 WL 6366051 (Ohio Com. Pl. Jun. 1, 2009); Khaulipour v. St. Ann's Hospital, Kington, and Jiricko, No. 07-CV-001264, 2009 WL 3748727 (Ohio Com.Pl. May 18, 2009); Davis v. Jacobs, No. 06-CV-3409, 2009 WL 1740332 (N.C. Super. Ct. Jan. 16, 2009); Haden v. Kramer, Patrick County Family Practice, P.C. and R. J. Reynolds Patrick County Memorial Hospital, Inc., No. CL07149, 2008 WL 6400289 (Va. Cir. Ct. Oct. 16, 2008); De La Cruz vs. Purdom, No. VC048742, 2008 WL 7165022 (Cal. Super. Ct. Jun. 16, 2008), Young v. Levitt, No. 277895V, 2008 WL 4614405 (Md. Cir. Ct. Jun. 16, 2008); Hanner v. Mark Jones, No. 02-VS-041911, 2008 WL 4614375 (Ga. State Ct. May 19, 2008); Green vs. Sheila Miller, No. CV-2004-1038, 2008 WL 4847169 (Ala. Cir. Ct. Feb. 27, 2008) and Lynch v. St. Vincent Hosps. and Health Servs., No. 49C01-0503-CT-10724, 2008 WL 4276346 (Ind. Cir. Ct. Feb. 28, 2008). In two of the cases, the plaintiffs did not seek compensation from the hospital or medical facility, but rather pursued causes of action exclusively against the treating physicians. In four of the other ten cases, the medical facilities settled without the necessity of a lawsuit. Of the six remaining cases, two of them were settled after suit was filed but prior to trial. The final four cases resulted in two verdicts against hospitals as well as two verdicts in which the hospitals prevailed. Thus, from the sample of the twelve cases appearing in Westlaw's national jury verdict data base in 2008 and 2009, despite the fact that Medicare and private insurance companies have concluded that retained sponges are entirely preventable events which should not occur and should not be paid for, these cases are still being litigated and defended by hospitals in a negligence setting.

In New Jersey, hospital protocols are admissible and can constitute evidence of the prevailing standard of care applicable to medical providers. Rosenberg v. Tovorath, 352 N.J. Super. 385, 406 (App. Div. 2002). Additionally, practice guidelines published by professional medical organizations have also been deemed evidence of what accepted standards of medical care are. Perna v. Pirozzi, 92 N.J. 446, 463-464 (1983). Similarly, if a statute sets forth the appropriate standard of care that should be followed by a medical provider, that statute is admissible as standard of care evidence. DiGiovanni v. Pessel, 104 N.J. Super. 550, 562-563 (App. Div. 1969). Pronouncements from administrative agencies pertaining to issues of medical care have also been deemed admissible to establish governing standards of medical care. Swank v. Halivopoulos, 108 N.J. Super. 120, 126-127 (App. Div. 1969).

It will be interesting to see how the decision by Medicare and the insurance industry, to declare certain categories of events non-compensable because they should not occur in safe hospitals will impact future medical malpractice litigations. Although commentators have suggested that it is "wise and just" to categorize retained foreign objects following surgery as Never Events, these cases are still being defended and litigated. Given the evidentiary nature of professional practice guidelines and administrative regulations, it is reasonable to expect that public policy decisions regarding the compensability of Never Events and the standard of care in medical malpractice litigations will eventually converge.

$3.9 Million Settlement at Trial on Behalf of Two Ironworkers Injured at a Construction Site.

On October 11, 2006, two union ironworkers were severely injured while working at the Broad Street Station Restoration Project in Newark, New Jersey. The project was owned by New Jersey Transit, which had hired a general contractor, Conti Enterprises, Inc. of South Plainfield, New Jersey. Conti had full responsibility for managing the project, both by contract and safety regulations.

The ironworkers were working for a subcontractor on the project, Railroad Construction Co., Inc. of Paterson, New Jersey. On the date in question, they were operating a scissors manlift on a precast concrete platform, which would eventually be used by train passengers when the station was fully operational. At about 2:30 am, on the late shift, they were "bolting up" a canopy at the station, which would be used by train passengers for protection from the elements.

Suddenly, as they were traveling on the motorized scissors lift across the platform, one of the precast planks flipped onto the railroad tracks, catapulting the lift and both workers to the tracks below, causing traumatic bodily injuries. As it developed, the precast platform had not been properly secured by the general contractor, Conti, who had supervisory and contractual responsibility for doing so, and responsibility for alerting its subcontractors of any such dangers.

One ironworker sustained a lower back injury requiring surgical fusion with pedicle screw instrumentation, which required a bone graft at L5-S1. He also fractured his dominant right hand, which required two surgeries and pinning due to a malunion. He also had an open fracture of his left knee, and lost approximately one-third of his left patella, as a result of an open reduction and extensor mechanism repair, with associated scarring. A vocational/economic expert that his past and future net wage loss would amount to between $1.5 and $1.9 million.

The second ironworker sustained ten fractured ribs with painful chest wall syndrome, a concussion, traumatic structural damage in the right inner ear which required two surgeries and resulted in vestibular dysfunction with dizziness and loss of balance, and a profound hearing loss in the same ear, which required a hearing aid. Vocational testimony was presented that this disability forced him to give up a 22 year career as an ironworker and take other jobs in non-union positions that did not pay as well. A vocational expert asserted that he would lose between $1.35 and $1.6 million in past and future wages, by virtue of the physical limitations that prevented him from continuing as union steel worker.

John Ratkowitz and Amos Gern tried the case between November 3 and November 19, 2009. The first ironworker settled his case after one week of trial, on November 13, for $2.9 million. The claims of the second ironworker went to verdict on November 19, before a jury which returned a gross award of $494,138, reduced by 34% for comparative negligence. However, Starr Gern was able to negotiate a high-low settlement of $1,000,000 to $2,000,000 prior to the verdict. As a result, the second ironworker will receive a settlement of $1,000,000 in spite of the jury verdict, and all potential appeals were waived.

Settlement at trial of over $1.4 Million in Orthopedic Malpractice Case on behalf of Livingston, New Jersey resident following Jury Selection.

The plaintiff injured his left elbow when he fell after his scooter struck a hole in a residential street. The following day, he came under the care of the defendant, a pediatric orthopedic surgeon, who performed surgery. Following the surgery, the plaintiff was casted. Approximately six weeks later, when the cast was removed, the plaintiff had little range of motion in the left elbow joint. Within weeks, the joint completely froze. After visiting several orthopedic surgeons in New York City for second opinions, the plaintiff was advised that he required major reconstructive surgery because his left elbow fractures healed in a place higher than their original location.

Suit was filed against the defendant physician and two entities who had responsibilities related to maintaining the street where the accident occurred. The case was litigate for three years and it involved complex issues of causation and apportionment of responsibility.

The plaintiff's medical expert opined that the elbow fractures healed in the wrong position because they were pinned in the wrong place by the defendant during the surgery. The expert further opined that if the defendant had performed the surgery appropriately, the plaintiff would have been left with a functioning pain-free left elbow, with minimal loss of motion. The defendants argued that the fractures were pinned correctly, but drifted following the removal of the surgical pins six weeks later.

Despite undergoing multiple surgeries to correct the malaligned joint, the plaintiff is left with a 30% functioning left elbow.

Partners John Ratkowitz (Click Here for Bio) and Amos Gern settled the case following jury selection prior to opening arguments.

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Surgeon Settles Negligent Cosmetic Surgery Case for $145,000 After Falsification of Records Exposed

The plaintiff visited the defendant plastic surgeon in order to address what she observed to be sagging in her breasts. Rather than recommending a simple mastopexy procedure, the defendant physician recommended that the plaintiff have breast augmentation with implants and a periareolar mastopexy. Ultimately, the plaintiff required further surgery because the periareolar breast augmentation and mastopexy failed to solve her problems. Indeed, the plaintiff contended that these procedures made her condition worse. She was also left with significant scarring, ptosis and capsular contraction.

The defendant contended that he provided the plaintiff with the appropriate informed consent. The defendant advised that he actually recommended a simple mastopexy procedure, but the plaintiff refused to follow this recommendation.

The medical chart that the defendant produced during discovery in the course of the litigation supported his factual position. Nevertheless, the medical chart that was produced by his office before the lawsuit was filed supported the plaintiff's contentions. John Ratkowitz was able to settle the case soon after the defendant was deposed and the two sets of medical records were revealed.

$450,000 Settlement at Mediation for Plaintiff Suffering Severe Hip Injury After Stepping Off Bus

The settlement was reached on December 4, 2004, during a post- mediation settlement conference. The matter was scheduled to be tried in the Hudson County Superior Court on February 7, 2005. The settlement followed an October 22, 2004 mediation hearing.

The accident occurred on June 6, 2002, as the plaintiff was exiting a commuter bus. The plaintiff paid his fare and descended the stairs of the bus, waiting for the doors to open so that he could exit. After the doors opened, he realized in mid-step that the bus was still moving. He attempted to stop his forward motion, but the momentum of the slowing bus pitched him forward and to his left out the front door. He landed first on his left foot, but his leg collapsed underneath him and he fell to his left side, sustaining multiple fractures of the hip and pelvis that required extensive reconstructive surgery at Columbia Presbyterian Hospital. The surgery was followed by a thirty-day hospital admission and extensive rehabilitation therapy.

The plaintiff advised the responding officers at the scene that he simply fell, and that the accident was nobody's fault. Despite this, he also repeatedly and consistently informed health care providers immediately after the accident that he fell when attempting to exit a moving bus. The defendants denied that the bus was moving. Both sides retained biomechanical experts to address this factual dispute.

In the midst of the bodily injury litigation, a declaratory judgment action was filed by the insurance company for the defendant carrier, in an attempt to deny coverage for the accident.

In addition to a biomechanical expert, the plaintiff retained an expert in bus safety. The plaintiff also had an orthopedic, a neurology and a urology expert who were prepared to testify about the plaintiff's injuries.

Attorney John Ratkowitz represented the plaintiff throughout the course of the litigation and in the declaratory judgment action.