IHP-420 final milestone WORD
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Southern New Hampshire University *
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420
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Medicine
Date
Dec 6, 2023
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docx
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Uploaded by DrIronOpossum6
Meg Combatti
4/14/2022
IHP-420
Final Submission I
This case occurred in January 2001 when the plaintiff, Arturo Iturralde was admitted to
Hilo Medical Center, a state owned hospital in Hawaii. The reason for Arturo Iturralde being
admitted included weakness to bilateral extremities which required surgical intervention. While
under the care of the defendant Doctor Robert Ricketson, Mr. Iturralde acquired severe
complications due to both negligence and medical malpractice, which resulted in death
.
Arturo Iturralde required a surgical procedure to address his stenosis as well as
degenerative spondylolithesis of the L4 and L5 vertebrae. The procedure was a spinal fusion in
which Dr. Robert Ricketson performed. Dr. Ricketson did not have the necessary medical
equipment to properly perform this surgery and intentionally implanted a screwdriver shaft into
Mr. Iturralde’s spine in place of the missing rods from the M8 Titanium CD Horizon Kit he had
ordered from the company Medtronic. Although Dr. Ricketson was aware that a representative
from Medtronic would be able to bring the missing parts to the operating room with a 90-minute
timeframe, he felt the wait time was too long and decided to go outside the standard of care. Due
to Dr. Ricketson’s negligence, Mr. Iturralde required more surgeries as a result
.
The jury found that Dr. Ricketson and Hilo Medical Center acted negligently in the care
of Arturo Iturralde
’s health resulting in his death. The Intermediate Court of Appeals of the State
of Hawaii found Dr. Ricketson 65%
at fault and HMC to be 35% at fault. As a result, the court
awarded nearly $5.6 million dollars to Arturo Iturralde’s estate as well as his personal
representative, Rosalinda Iturralde for general damages
.
Dr. Ricketson ordered HMC to order an M8 Titanium CD Horizon Kit from the company
Medtronic which was to include all tools necessary to do the surgery. Medtronic did not have the
complete kit needed to do the surgery so the remaining parts were shipped from two other
facilities, one in Memphis and the other from Tulane. Hilo Medical Center did not perform an
inventory check and sent the instruments to the operating room to be sterilized. Dr. Ricketson
was advised by the nurse that the inventory had not been checked. However, Dr. Ricketson
proceeded with the surgery anyways. This occurred on January 29th, 2001. During the surgery,
titanium rods were to be placed in Arturo’s spine. Dr. Ricketson informed staff that the rods were
not included and maybe misplaced. Staff searched for the missing rods and placed a call to
Medtronic. Medtronics said they could have a representative deliver a new set of rods in 90-
minutes but Dr. Ricketson’s testimony was, “that he believed that the delay would be too risky
for the patient. He proceeded with the surgery, absent the titanium rods” (Intermediate Court of
Appeals of the State of Hawaii, 2012). Instead, Dr. Ricketson used a the shaft of a surgical
screwdriver which was not approved for human use nor was authorized to use and implant into
Arturo Iturralde. These actions of Dr. Ricketson, although were not intentionally malicious nor
planned when scheduling this surgery, his actions were unethical and stepped outside the medical
scope of practice and the Hippocratic Oath doctors must take, with one of the promises within
the oath being “first, do no harm” (Shmerling, 2020
.(
According to the case study,
“HMC extends hospital privileges to healthcare professional
who, through a credentialing process, document their “current professional competence, good
judgement, and adequate physical and mental health, and who adhere to the ethics of their
respective professions.” At the time Dr. Ricketson applied for hospital privileges at HMC, he had
a history of serious professional problems. He was subject to professional disciplinary orders in
Oklahoma, Texas and Hawaii had placed Dr. Ricketson on probation for failing to disclose prior
disciplinary actions. Despite these serious lapses, HMC granted Dr. Ricketson hospital
credentials.” HMC was aware of Dr. Ricketson’s negligent behavior yet still granted him
privileges. Dr. Ricketson also did not post-operatively inform Mr. Iturralde of the negligence that
occurred during his surgery; his Nurse, Janelle Feldmeyer did. But because of the language
barrier, the hospital reportedly had posted a security guard at his room
.
This case demonstrated that Dr. Ricketson
’s actions did not meet the standard of care
when handling this patient case. Fremgen refers to standard of care being that, “ordinary skill
and care that all medical practitioners” would use in similar circumstances. There were a variety
of instances where Dr. Ricketson did not hold up to the professional standard of care. He did not
confirm all surgical equipment that was necessary to do this procedure successfully was present,
he consciously made the decision to use the shaft of a medical screwdriver in place the steel rods
to implant in Mr. Iturralde’s spine and lastly Dr. Ricketson did not communicate the situation of
what happened during the surgery post-operatively. Although Dr. Ricketson played the largest
role of being at fault during this case,
HMC was also a key player in the fault of medical
malpractice and negligence as they hired Dr. Ricketson knowingly of previous accusations
towards him
.
Cultural barriers played a role in this case as there was a language barrier between Mr.
Iturralde and the medical staff. Because of this language barrier, it can leave some actions to
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uncertainty for how communication could have been overlooked. There were a few situations
that did not help ease the opportunity for communication at HMC; they did not appoint a
translator for the staff and patient to communicate effectively, HMC placed a security guard
outside of Mr. Iturralde’s room which made it difficult for healthcare staff to communicate with
him, especially Nurse Feldmeyer to speak with him regarding the situation that occurred, and
because communication was difficult, who is to say that Dr. Ricketson took advantage of feeling
like he did not need to make any extra effort to explain all the details of the surgery, pre or post
operatively. It’s situations like this where it only makes individuals with differing cultural
backgrounds, beliefs and/or language barriers feel unsafe when seeking medical treatment
.
In the resulting accountability of this case, The Circuit Court concluded that,
“HMC and
Dr. Ricketson were jointly and severally liable and adopted the jury’s apportionment of fault.
However, the court found that 75% of the damages were attributable to Arturo’s pre-existing
medical conditions. Accordingly, the Circuit Court concluded that HMC was only jointly and
severally liable for 25% of the total damage found by the court.” Even though Mr. Iturralde’s pre
existing may have played a factor in his health condition, the negligence and malpractice of Dr.
Ricketson definitely lead to the rapid decline in his health and ultimately played a large role in
his untimely death
.
When individuals decide to become healthcare professionals, there is an oath they take which
sets a precedence in how they will choose to act when providing patient care. For Nurses, they
take the Florence Nightingale Pledge, also known as the Hippocratic oath. This oath is the same
for physicians. It is one of the “oldest binding documents in history”. (Marks, 2021) In the case
of Iturralde vs. Hilo Medical Center, there are many ethical issues involved in the care and
treatment of Arturo Iturralde that led to the malpractice suit
.
According to the encyclopedia of Wikipedia, this oath,
“is one of the most widely known
of Greek medical texts. In its original form, it requires new physicians to swear, by a number of
healing gods, to uphold specific ethical standards. The oath is the earliest expression of medical
ethics in the Western world…”
The first of many ethical issues in this case starts with the
surgical devices needed to perform Mr. Iturralde’s surgery. The M8 Titanium CD Horizon Kit
from Medtronic was negligently handled when the proper inventory was not conducted until the
last minute. The lack of inventory resulted in Doctor Robert Ricketson to not have the proper
equipment required to properly perform the surgery and put him in a situation to negligently
implant a surgical screwdriver shaft into Mr. Iturralde’s spine. Had the equipment properly been
inventoried, Mr. Itturalde would not have been in a situation where the he got a screwdriver
shaft, that would later shatter, implanted in his spine, which is the second ethical dilemma that is
present in this case. Mr. Itturalde, nor his proxy was addressed in making the decision to go
ahead and implant this surgical tool in place of the titanium rods which were missing from the
Medtronic kit. Because consent was not given, the doctor made a negligent call to implant the
incorrect device which later shattered causing severe damage to Mr. Itturalde, causing a rapid
decline in his health resulting in death. The third major ethical dilemma is that Dr. Ricketson
never informed the patient or proxy of the situation that occurred in the operating room and the
patient was discharged from the hospital with typical post-operative instructions. Because of this,
the patient participated in physical therapy as required and went on with daily activities. Mr.
Iturralde was unstable when ambulating after surgery and while rehabbing took a fall which
resulted in the screwdriver shaft shattering. Had any of these ethical choices been addressed from
the beginning, the death of Arturo Iturralde could have, and very well may have been prevented
.
An ethical theory that could have provided a safe experience for Mr. Iturralde would be a
deontology approach. According to the
Handbook of Clinical Neurology
by Robert M. Taylor,
deontology, “‘is a system of ethical analysis, most closely associated with Immanuel Kant, that
bases the correctness of one’s actions on fulfilling the duties of the actor.’(Alexander and Moore,
2008).
Individuals have moral obligations to others, and if they fulfill those obligations, they are
acting ethically; if they do not, they are acting unethically.” In this case, Dr. Ricketson did not
have the best interest of the patient and acted unethically in many ways in the care of this patient
right from the beginning. First, Dr. Ricketson continued a surgery with the wrong equipment
because he felt that waiting for the correct equipment would take too long, which later put the
patient at risk. Secondly, Dr. Ricketson never got permission from the patient nor his proxy to
use the incorrect equipment in the surgery. And lastly, Dr. Ricketson never informed the patient
or his proxy of the situation that had happened in the operating room and the negligence he
inflicted on the patient which later affected the patient drastically causing his health to decline
rapidly
.
Shared Decision-Making Model is used to help improve the physician - patient
communication to become unanimous on the choices that will benefit the patient. When making
decisions about ones health, the patient and the doctor should work together to go over all
options and the risks associated with them. In this situation, I feel that the three-talk model is the
best tool to utilize as it has three concepts, team talk, option talk, and decision talk. Each of these
concepts allow for everyone involved in the case to inform, be informed, ask questions, and
come up with a plan of action. No questions are left unanswered and everyone is involved in the
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treatment plan. In the case of Iturralde v Hilo Medical Center, Dr Ricketson went ahead and
made decisions his own without communicating his actions with the patient or family. His
actions would have severe consequences for the patients health outcome that could have been
prevented had he taken the time to make sure the required tools were inventoried. Even if Dr.
Ricketson moved forward with using the incorrect equipment, had he communicated the
situation afterwards to the patient and family, a second surgery could have been performed to
correct the mistake made, which could have prevented the decline in Mr. Iturraldes health
.
I feel that if patients and doctors had positive relationships where it was a general
practice for open communication to occur, there would be less cases where mistakes and
negligent acts occur. People tend to have this general opinion that doctors, nurses and other
healthcare professionals know what they
’re doing and that we should not question their actions
or decisions. This generalization needs to change; patients need to advocate for themselves and
educate themselves on their health as well as treatment options. Doctors are trusted too loosely
when it comes to the care they provide patients; and while in some ways they should be,
considering they have abundant training…Doctors also have a scope of practice that they may be
bias in when considering different options of medical treatments. It is necessary that healthcare
providers follow facility policies, but also the oath that they take when deciding that they want to
do no harm to patients. It would benefit HMC and the healthcare workers to hold staff
accountable in following procedures and policies regarding their own code of ethics. By
following a set policy and procedures based on ethics and patient care, it could ensure that
ethical actions and behaviors are taken into consideration
.
Preventative strategies that physicians and other healthcare providers could implement to
avoid liability in the future could include having coworkers on the medical team go through a
checklist process where each member has to sign off on the requirements and necessary
procedures and processes. Before continuing on with an invasive procedure or operation, a set
number of healthcare workers must sign off on this checklist. Not only must these individuals put
themselves on the line for being responsible to make sure that everything is in check, there
should be a final look over by a supervisor that is in charge to sign off on proceeding
.
This preventative strategy would assist the healthcare provider in avoiding liability and
provide a safe, quality healthcare experience for the patient as it wold bring peace of mind to not
only the patient, but the healthcare staff and team. Policies and procedures are implemented for a
reason and when healthcare providers follow these regulations, the odds of mistakes and risks of
liability are severely limited. It is important that healthcare professionals and the organizations
they work for continue to raise the bar for success in benchmarking as it only helps performance
outcomes and performance activities
.
References
Fremgen, B. F. (n.d.).
Medical law and ethics, 5th Ed
. Pearson, 2016
Appeal from the Circuit Court of the Third Circuit (Civil No. 03-1-0017 (HILO)). Intermediate
Court of Appeals of the State of Hawaii (2012). Retrieved from
https://www.casemine.com/judgement/us/5914f68cadd7b049349909af#
Robert H. Shmerling, M. D. (2020, June 22).
First, do no harm
. Harvard Health. Retrieved
March 20, 2022, from https://www.health.harvard.edu/blog/first-do-no-
harm-201510138421
Marks, J. W. (2021, June 3).
Medical definition of hippocratic oath
.
MedicineNet. Retrieved April 3, 2022, from
https://www.medicinenet.com/hippocratic_oath/definition.htm
Wikimedia Foundation. (2022, February 14).
Hippocratic oath
. Wikipedia.
Retrieved April 3, 2022, from
https://en.wikipedia.org/wiki/Hippocratic_Oath
Taylor, R. M. (n.d.).
Deontology
. Deontology - an overview | ScienceDirect
Topics. Retrieved April 3, 2022, from
https://www.sciencedirect.com/topics/psychology/deontology
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