Common Causes of Medical Negligence in Intensive Care
Patients treated in an intensive care unit (ICU) often have complicated and life-threatening conditions, which may require treatments that are often invasive and sometimes potentially dangerous. Not surprisingly, adverse events are frequent and may lead to a claim for medical negligence. As well as an increase in mortality, patients may be left with long-standing health issues, including muscle weakness, cognitive disorders and post-traumatic stress disorder. Thus, litigation following incidents arising in the ICU is relatively common and settlement costs are likely to be high, reflecting the often-poor outcome for the patient. Between 1995 and 2005, the number of claims against the NHS following treatment in an intensive care unit (ICU) rose steadily, although more recently there has been a decrease. However, many claims are not made until several years after the alleged incident, so the apparent reduction may simply reflect claims that are yet to be made.
Analysis of the claims issued against the NHS show that the commonest categories concern positioning and skin/care, infections and respiratory/airway conditions. Claims in the first category predominately relate to pressure sores and are also responsible for the highest proportion of severe non-fatal outcomes. While the issue of pressure sores is often overlooked, their occurrence is very common. They are caused by many factors, but the number of patients who are elderly, frail or obese, or who present with other comorbidities, is increasing and the problem of pressure sores is therefore unlikely to diminish. To counter this, guidelines and national recommendations have been drawn up, although many of the proposed measures should already form part of the standard protocol for ICU nursing care.
Although not the commonest overall reason for a claim, incidents involving respiratory/airway issues account for around one-third of claims relating to the death of a patient. Airway supervision is lower in an ICU than an operating theatre. Furthermore, patients in ICU are often dependent on ventilators and oxygen supplies and also require frequent turning. These factors mean that ICU patients are at an increased risk of airway compromise, the consequences of which are likely to be serious. Steps to minimise the risk include identifying patients with breathing difficulties through the provision of continuous capnography, and relevant staff training and equipment to deal with an airway emergency.
Perhaps unsurprisingly, missed and delayed diagnoses are also a common reason for subsequent patient mortality. Overall, this category, when combined with incidents involving delayed and inadequate treatment or a failure to monitor or identify any deterioration in a patient’s condition, makes up a large proportion of all claims. Furthermore, successful claims are likely to have high rates of compensation, reflecting the serious impact these errors can have on the treatment outcome. Lapses of judgement underpin most of these errors, rather than an inherent lack of knowledge or rule-based mistakes. Failure to carry out the intended treatment includes medication errors, the majority of which occur during administration of the drugs. These may range from giving the wrong dose to missing a dose entirely. Mistakes during prescribing are less common. One further issue is that ICU patients, who are by definition seriously ill, are at an increased risk of drug-drug interactions, due to the multiple interventions needed to treat them. The risk is heightened further by the high proportion of elderly or very young patients typically found in an ICU, as these age groups appear to be particularly sensitive to medication interactions.
Around a quarter of all claims relating to hospital-acquired infections involve MRSA. Although most of these are not serious, some can be life-threatening, particularly if the infection affects surgical wounds, the bloodstream or the lungs. Complications of MRSA infection include endocarditis, gangrene, necrotising fasciitis and infections of the bones and joints. If left untreated, MRSA infection can also lead to sepsis, but infection control is complicated by the fact that many types of antibiotics are ineffective. This may lengthen the patient’s stay in hospital considerably. Prevention measures include swabbing of all patients on admission to identify those who are already carrying MRSA and are therefore at higher risk and adherence to strict cleanliness and hygiene protocols to reduce the possibility of cross-infection between patients.
Regardless of the actual condition, one factor underlying many claims is a lack of communication. This is particularly important in the ICU, where care is often team-based, due to the complex nature of the conditions treated. Poor communication has been identified as a contributory factor in many adverse events. Open and effective communication between team members allows each member to contribute fully and prevents conflicting messages about progress and outcome being reported to the patient. Part of this communication should be the keeping of comprehensive notes for each patient.
By its very nature, treatment in an ICU is high-risk and claims for medical negligence are relatively common. Furthermore, outcomes for ICU patients are often worse than for other areas of medicine, so settlement costs are often high. However, good care and communication in the ICU, along with strict adherence to protocols, can actually reduce the likelihood of litigation occurring in the first place or succeeding, should a claim arise.
Further reading:
Michell, W. (2011). Malpractice in the intensive care unit [Editorial]. Southern African Journal of Critical Care, 27(1), 2–4.
Pascall, E., Trehane, S.-J., Georgiou, A., & Cook, T. M. (2015). Litigation associated with intensive care unit treatment in England: an analysis of NHSLA data 1995–2012. BJA: British Journal of Anaesthesia, 115(4), 601–607. https://doi.org/10.1093/bja/aev285
