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Nov 24, 2024
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Uploaded by AgentJaguar2869
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Medical Error Case Study: The Deadly Epidural
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Medical Error Case Study: The Deadly Epidural
Medical errors are common in stressful and fast-paced environments. Emergency
departments, surgery departments, intensive care units, and operating rooms are most burdened
with medical errors. The patient's condition in terms of age and acuity is also likely to affect the
occurrence of medical errors. Finally, the ignorance of providers and inadequate supervision of
most providers lead to medical errors. Most of these errors are only reported within the
healthcare institutions, with a few leaking for access by the public. The discussion below
illustrates an incident that got public attention through the media. The case is assumed to have
occurred because of the ignorance or negligence of the Doctor. Below is a further illustration of
the incident.
What happened at the incident?
The incident involved the death of a patient following an epidural error. Sha Asia Semple
was a pregnant woman expected to undergo a routine procedure. The attending Doctor, Schelkov,
was expected to deliver anesthesia. The catheter was supposed to be placed four inches into the
patient's lower back (Carver, 2023). However, the doctor inserted the line longer than expected.
According to the report, the line went thirteen inches into the lower back, threatening the life of
the woman and the unborn baby. After administering an entire dose of anesthesia, the patient
died. The patient died while the unborn baby survived. The cause of death, according to the
report, occurred due to the anesthesia landing on the patient cerebrospinal fluid and circulating
around the entire central nervous system. The case was so severe that it spiked mass action
around the Brooklyn hospital. Having illustrated the incident below is an analysis of the people
involved in the case.
Who was involved?
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The first person that was involved was the patient. The patient is a pregnant woman who
lost her life, even though her baby survived. The patient is known to have complained about not
breathing correctly and feeling nauseous before they finally passed out. The family, including the
husband, Juwan Lopez, was devastated by the demise of Ms. Semple. The Brooklyn community
is another group of stakeholders who organized protests demanding justice for Ms. Semple
(Carver, 2023). The protests are what brought the case into the limelight. The Doctor, Schelkov,
was the primary stakeholder accused of negligence and ignorance that led to the patient's demise.
The Doctor's supervisor, a physician from the department, also acknowledged that it was not
Doctor Schelkov's mistake. The final person involved in the care procedure is the state’s board of
review. The state's Board of Review took it upon themselves to investigate the doctor based on
the current case and others in the past. Below are the ramifications suffered by the hospital and
the staff involved in the case.
Ramifications for the staff?
The Doctor was the first to receive direct ramifications. The Doctor was stripped of his
official medical license after the Board of Review found him guilty
(
Goldstein, 2023)
. The
hospital also faced ramifications and challenges after being recommended to reconsider the kind
of doctors they hire. Below is an illustration of some of the possible causes of the errors and
models of intervention.
Causes and Possible Interventions Preventing Errors
In conclusion, the procedure error analyzed above was caused by the Doctor's negligence.
The perfect way to prevent the error was to have a supervisor monitor the patient immediately
after the procedure (
Goldstein, 2023)
. Additionally, the Doctor had shown a history of negligence
in the past with other patients. As a result, he should have been under strict supervision and
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limited on the type of serious procedures he could take. As illustrated in the discussion above,
medical errors can occur for various reasons and must be avoided. In the future, errors can be
minimized through care collaboration and frequent engagement.
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References
Carver, N., Gupta, V., & Hipskind, J. E. (2023). Medical Errors. In
StatPearls [Internet]
.
StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK430763/
.
Goldstein, J. (2023, January 23).
A deadly epidural, delivered by a doctor with a history of
mistakes
. The New York Times.
https://www.nytimes.com/2023/01/23/nyregion/anesthesiologist-brooklyn-deaths.html
.