how a simple miscommunication among mds had tragic results

Solid communication among medical professionals is not only vital to running a successful practice but an absolute necessity when it comes to patient care both here in Pennsylvania and across the nation. If doctors, nurses, pharmacists, laboratory technicians and other staff members are not on the same page when it comes to a particular patient, the results can be nothing short of disastrous.

To illustrate, consider a case out of the state of Washington, where the family of an 8-year-old girl was recently awarded over $15 million — believed to be one of the largest medical malpractice awards in state history. Here, a judge found that the failure of two physicians to properly communicate with one another regarding a seemingly simple issue resulted in the girl’s suffering a catastrophic brain injury.

The girl, we’ll call her MacKenzie, was born with a serious heart defect in 2004 that necessitated a transplant at a very young age. However, in the years following the transplant, MacKenzie made remarkable progress in terms of her health and was living the life of the typical child.

In 2008, MacKenzie’s mother placed a call to the cardiologists at the hospital where the transplant was performed in order to learn more about what medicines she could safely use to treat a cold her daughter had developed.

The cardiology fellow who took the call later conferred with MacKenzie’s treating physician, who informed him not to recommend a particular over-the-counter nasal decongestant spray as it could put undue stress on her heart.

In a shocking turn of events, the fellow somehow misunderstood the orders and proceeded to recommend the very over-the-counter nasal decongestant spray that the treating physician had specifically ruled out.

Tragically, MacKenzie went into cardiac arrest after her mother unwittingly gave her the nasal spray. The oxygen deprivation she suffered during the time it took to stabilize her was so great that she suffered permanent brain damage. In fact, physicians later determined that she would be unable to walk, talk or feed herself, and would require 24-hour care for the remainder of her life.

MacKenzie’s parents understandably turned to the courts for justice, filing a medical malpractice lawsuit against the cardiologists and the hospital where they worked, claiming that their daughter’s devastating injuries were the direct result of medical negligence.

For its part, the hospital argued that the cardiac arrest was not the direct result of the nasal spray, but rather a direct result of complications from MacKenzie’s previous transplant.

The presiding judge ultimately found these arguments unavailing and awarded the family $15.2 million, stating that the use of the nasal spray was the direct result of “negligent advice” and that this, in turn, could be traced to a failure to communicate by the cardiologists.

MacKenzie’s mother perhaps best summarized what should be taken away from this tragic case.

“We need to be very clear in orders. Even the smallest thing that sounds like it’s harmless might not be,” she said. “Something like this just didn’t have to happen. It didn’t have to happen.”

Please visit our website to learn more about your options if medical professionals fail to abide by the applicable standards of care.

Source: KOMO News, “Judge awards $15M to family of brain-damaged Snoqualmie girl,” Lindsay Cohen, July 12, 2013; Insurance Journal, “University of Washington to pay $15M after medical mistake,” July 16, 2013

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