When a severe adverse medical event occurs, hospitals must follow the protocols in place. They are required to proactively investigate and implement new protocols to prevent the same mistake from happening again. Generally, hospitals must follow a process called a root cause analysis (RCA) to investigate contributing factors and implement corrective actions.
A hospital investigation after a medical error is serious and often complex. In this blog post, we’ll discuss how hospitals investigate incidents of serious patient harm. The attorneys at Brockstedt Mandalas Federico LLC have spent years holding healthcare professionals and institutions accountable after their foreseeable mistakes have led to serious consequences for patients. Contact our firm today.
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Worried the Hospital's Internal Investigation Is the Only Record of What Happened?
It can feel unsettling to learn that a hospital's own review of a medical error is kept confidential. That does not mean you are left without answers. Our attorneys know how to build a case using the medical records, expert opinions, and evidence you are entitled to.
Schedule A Free ConsultationHow Does a Hospital Investigation After a Medical Error Go?
At the outset, it is important to remember that each occurrence is unique and may require specific steps, but generally, serious patient safety events result in thorough investigations.
Patient Safety and Stabilization
First and foremost, the hospital must prioritize care to treat the injury and secure the patient’s safety. This obviously applies only in instances where the harm can be treated. If the event results in the patient’s death, then this is moot.
Secure Physical and Computer Evidence
Hospitals typically secure physical evidence, including equipment, supplies, instruments, or anything used during the adverse occurrence. Computer and electronic evidence, including patient health records, must also be preserved.
Key Takeaways
What to Know About Hospital Investigations After a Medical Error in Maryland
Hospitals run their own internal review after a serious medical error, but that process works differently from a malpractice claim. Here is what matters most if you are considering one.
- Maryland's Hospital Patient Safety Program requires certain serious adverse events to be reported to the Department of Health, and hospitals must investigate internally through a multidisciplinary review.
- Root cause analysis (RCA) reports from that internal investigation are generally confidential and are typically not admissible as evidence in a medical malpractice claim.
- A malpractice claim instead relies on evidence gathered independently: medical records, expert opinion and testimony, witness accounts, and reconstruction technology where relevant.
- Maryland classifies adverse events by severity, from Level 1 (serious injury or death) to Level 3 (minor, no intervention needed), but that internal classification does not by itself determine whether malpractice occurred.
Report the Incident to Supervisors and the Department of Health
Medical personnel must report the incident to supervisors and upper-level hospital management personnel. Certain serious adverse events must also be reported to the Maryland Department of Health in accordance with the Hospital Patient Safety Program regulations.
Investigation Begins
Typically, a multidisciplinary investigation will follow, in which professionals, including doctors, nurses, and other clinicians, will bring their specialties together to examine the incident.
The investigation will include creating a chronological timeline of what happened by interviewing personnel involved in the incident and witnesses, reviewing medical records and charts, and pulling device logs to reconstruct a timestamped account of the events.
Implement New Systems and Safety Protocols
The hospital will gather what it has learned from the investigation and how the adverse error occurred, and develop a plan to implement new systems. The goal is to create new safety protocols and systems to ensure the same error does not happen again.
In Maryland, if a patient suffers serious harm or death as the result of a catastrophic medical error, the hospital is required to follow strict rules promulgated under the Hospital Patient Safety Program. This may require submission of an initial report to the Maryland Department of Health within a specified period after the event is identified and a timely investigation. This may need to be followed with additional information, including corrective actions designed to reduce the risk of recurrence.
Implement an Action Plan
Following the investigation and learning what caused the catastrophic error, the hospital must implement an action plan to fix the underlying problem. The plan should have included set timelines to prevent the error from recurring.
The purpose and goal of each of these steps is to take proactive corrective action. This may mean modifying or revising current protocols or completely redesigning safety standards. Changes can include equipment and software upgrades, the implementation of multistep checklists, and the redesign of safety measures.
What Factors Can Contribute to Catastrophic Medical Error?
Sometimes it may be one person or thing that causes the adverse medical event.
However, oftentimes it can be multiple things that contribute to the failure, including:
- Lapse in communication,
- Lack of training,
- Inadequately trained personnel,
- Environmental flaws (e.g., equipment failure),
- Poor hospital policies, and
- Insufficient staff.
All of these factors will be investigated and addressed.
What Are the Adverse Event Categories?
In Maryland, adverse or unexpected events related to a patient’s medical care are categorized by their actual and potential severity of harm.
For example, a Level 1 adverse event may include an unexpected medical error that causes serious injury or death, while Level 2 might represent a near-harm event that requires immediate medical intervention to prevent death or serious disability. Level 3 events would include less severe medical occurrences that do not result in death or serious disability and do not require medical intervention to prevent death or serious disability.
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Let Us Gather the Evidence That Actually Counts
A hospital's internal review may never see the inside of a courtroom, but your medical records, expert testimony, and witness accounts can. Our team knows what evidence is admissible and how to put it together on your behalf. A conversation with us costs nothing and comes with no obligation.
Schedule A Free ConsultationCan You Use RCA Reports in Your Medical Malpractice Claim?
Generally, no, RCA reports are typically confidential and only reported to the medical review committee and the Department of Health. This means they are generally inadmissible in court as evidence in your medical malpractice claim.
However, this information is not needed to establish a medical malpractice claim. An experienced lawyer will conduct a thorough investigation and gather admissible, relevant evidence to prove your case.
This can include:
- Medical records,
- Expert opinion and testimony,
- Reconstruction technology,
- Video footage, and
- Witness testimony.
Even though the RCA is generally not admissible to prove your case, your attorney will conduct their own medical malpractice investigation. A skilled attorney knows what evidence is needed to prove your medical malpractice claim.
BMF: Experienced Medical Malpractice Lawyers
Patients have rights under Maryland and federal hospital regulations to receive information about their care and to file complaints regarding patient-safety concerns. A medical error resulting in serious patient harm or death requires an immediate legal evaluation by an experienced medical malpractice attorney. Strict deadlines and complex legal and proof requirements mean you must act quickly to preserve your rights.
At Brockstedt Mandalas Federico LLC, we have been representing harmed medical patients for decades. We are prepared to investigate claims involving hospitals, physicians, and other healthcare providers and pursue the compensation available under Maryland law. Contact our office today to schedule a confidential consultation and learn more about how we can help you.
Official Legal and Other Sources
To ensure the accuracy and clarity of this page, we referenced official legal resources during the content development process:
- Maryland Hospital Patient Safety Program
- Maryland Code, Courts and Judicial Proceedings. §§ 3-2A-01
- Maryland Code, Courts and Judicial Proceedings § 3-2A-04
Phil Federico is a partner at Brockstedt Mandalas Federico where he helps lead the Mass Tort / Class Action and Environmental Law practices, transitioning into these areas after beginning his career as a medical malpractice litigator.
Phil has led and been involved in historic and groundbreaking litigation with verdicts and settlements exceeding one billion dollars.