Excessive Dosing, Inadequate Monitoring Blamed in Death

Excessive Dosing, Inadequate Monitoring Blamed in Death
A 39-year-old man with a history of pain complaints went to a Virginia hospital emergency department (ED) with a migraine. The defendant attending physician ordered IV medications; however, after several unsuccessful attempts to establish an IV line, the treating nurse administered 8 mg hydromorphone intramuscularly (IM). The patient was given a second dose of hydromorphone (6 mg IM) about an hour later before being transferred to a nonemergent room; there, he fell asleep. Loud snoring was noted, but the nurse responsible for monitoring the patient was not alarmed.

The patient then experienced respiratory arrest. Attempts to resuscitate him were unsuccessful.

Plaintiff for the decedent alleged negligence in improperly monitoring him and in failing to recognize signs of distress in a timely fashion. The plaintiff also claimed that the second dose overmedicated the decedent, leading to respiratory arrest. The plaintiff alleged negligence by the attending physician for ordering the second dose of hydromorphone and for transferring the decedent from the ED to a nonemergent room.

The claims against the defendant attending physician went to trial. The defendant claimed that the decedent was stable and showed no signs of acute distress at the time of transfer.

OUTCOME
The hospital settled for a confidential amount prior to trial. According to a published account, a defense verdict was returned in the trial against the attending physician.

COMMENT
This patient was given hydromorphone 8 mg IM at 5:55 am and hydromorphone 6 mg IM at 7:11 am as first-line treatment for migraine. He was discharged from the ED 10 minutes after receiving the second dose and transported to a gastroenterology suite for a previously scheduled colonoscopy. There, he was sparsely monitored, became apneic, and died.

Was the standard of care breached in this case?

The patient appears to have been offered a high-dose narcotic as abortive therapy for migraine, contrary to current recommendations (Gilmore and Michael. Am Fam Physician. 2011;83[3]:271-280). Use of opiates in these circumstances is problematic, and yet opiates are still often prescribed as first-line agents in some practices.

If this were a headache of moderate to severe intensity, triptans would have been the preferred abortive agent. No evidence was presented that this 39-year-old patient had a contraindication to triptans, dihydroergotamine, isometheptene, or intranasal lidocaine. He was given narcotics as first-line treatment for migraine.

Migraine can be extraordinarily painful, and we clinicians are ethically and legally bound to offer the best treatment available to arrest that pain. For most patients, high-dose parenteral narcotics are not favored for the management of migraine because of the potential for precipitating rebound headaches and because opiate dependence can lead to continuing, escalating demands for more narcotic intervention—and worsening headaches.

In this case, the dose of 14 mg of hydromorphone administered over 1 hour and 16 minutes is staggering—even for a patient who is not opiate-naïve. Further, in the IM route of administration (compared with IV), absorption and peak effect are imprecise. Even if the clinician were to argue that the patient’s narcotic tolerance necessitated this dose, the clinician was compelled to ensure that the patient was adequately monitored.

Migraine will become the clinician’s headache if the approach is nonchalant. First, always fully assess a patient with migraine to determine whether the headache is consistent with prior episodes; an atypical presentation may require neuroimaging or an alternate diagnostic approach. Second, always perform a proper examination, even when the headache is described as typical. Third, offer therapeutic interventions that follow evidence-based guidelines. Opiate use should be offered (if at all) at the end of a treatment ­algorithm.

For patients with putative allergies to all abortive treatments other than narcotics, it is wise for a neurologist or pain management group to evaluate the patient and establish a solid, agreed-upon treatment plan. This plan should acknowledge that more appropriate treatment is unavailable, that the patient has been fully informed of the risks and limitations of opiate agents, and that the patient agrees to follow this clearly defined plan.

Like hydromorphone  and other opiate agents, meperidine is another drug with issues. Though still prescribed by some, meperidine is in specific disfavor because of the abuse potential and the risk for seizures induced by normeperidine (a metabolite of meperidine). Its once-touted benefit—avoidance of sphincter of Oddi spasm—is mythical and not a valid reason to keep meperidine stocked. A last highly specialized use may be to treat severe refractory rigors—but it is safe to say that meperidine should be closer to a museum for antiquated medications than to your migraine patient. Jurors will fault clinicians when patients become addicted or have seizures when safer options exist. Don’t use it.

Improve your management of migraine patients and lower your malpractice risk by performing a full assessment and following evidence-based guidelines to choose appropriate agents. In any case in which high-dose narcotics must be administered to abort a high-­intensity migraine, a jury will expect the patient to be carefully monitored for respiratory depression until his/her sensorium is fully cleared following the agent’s peak effect.

Simply put, opiates must not be given in ambulatory settings in which the patient is expected to be discharged after 20 to 30 minutes of observation. This medication is not a flu shot, and the plaintiff’s attorney will hammer this point home if your narcotized migraine patient leaves your practice setting and steps in front of a vehicle. Protect the patient and avoid malpractice risk. —DML

Woman Given Morphine Despite Well-Documented Allergy
A 66-year-old Utah woman underwent surgery at the defendant hospital. The defendant surgeon ordered morphine to be administered following surgery—despite documentation in the patient’s record that she was allergic to morphine, and despite the fact that she was wearing a wristband indicating that she was allergic to morphine. The morphine was administered by hospital nurses over the course of several hours.

The patient became asystolic about 14 hours after receiving the first dose. She was revived but had suffered anoxic brain injury. She died two days later.

The decedent’s son-in-law alleged that he had seen a hospital employee remove the wristband indicating her allergy to morphine and throw it into the wastebasket; the son-in-law retrieved it.

The plaintiffs also claimed that a review of the medical record showed that the word “morphine” had been erased under the section entitled “Allergies.” This was discovered in a comparison of the hospital records with identical records supplied by one of the defendant doctors. In that doctor’s records, the word “morphine” was included.

OUTCOME
According to a published report, a confidential settlement was reached.

COMMENT
Because the settlement was confidential, we don’t know what the payment was—but we can be sure it was substantial.

Jurors abhor attempts to cover up mistakes, even when the jury pool is relatively conservative. Instead of viewing the matter as an error, jurors will impute the worst motives and will exact significant punitive damages. In Utah, for example, where this case occurred, punitive damages are not permitted unless the plaintiff can show by “clear and convincing evidence” that the defendants acted maliciously, with intentional fraudulence, or with reckless indifference toward the rights of others (Utah Code Ann §78-18-1).

This may be a case in which the clinician and staff succumbed to the stress of the moment and acted poorly and unprofessionally. Nevertheless, the staff members’ actions to cover up the mistake, by discarding the patient’s wristband that specified the allergy and erasing the note of the patient’s morphine allergy in the medical record, cause problems far beyond the initial mistake.

Because the malicious act (the cover-up activity) occurred after the fact, it did not directly injure the patient and could not form the basis for punitive damages in a malpractice action. However, the cover-up activity may be the basis for punitive damages for the family’s derivative “intentional infliction of emotional distress” claims. Generally, this type of claim must involve conduct that would prompt the average person hearing the facts to exclaim, “Outrageous!” That test is met here.

If presented with a case that may result in malpractice liability exposure, do not lose your head, blow your cool, or act rashly. Always act in the best interest of the patient and let the record reflect your efforts to protect the patient. Do not use the medical record for defensive discussion out of step with normal charting practices. Chart directly, dispassionately, and professionally, and avoid embellishment or hyperbole. Never alter, destroy, or conceal records.

Furthermore, do not react defensively or with hostility, and do not discuss the case openly during or immediately after the incident; any statements you make may be directly admissible against you or others as evidence. Do not initiate an “incident report” or otherwise “write up” a fellow worker: These documents are business records that will be discoverable by a plaintiff’s attorney, and they can be used against you, the facility, and your peers.

Likewise, the patient’s bedside is not the place for emotional discussions; there, the patient’s well-being must be the only concern. Instead, use the special process that was created to candidly and confidentially discuss matters of patient quality of care: the peer-review process. This process offers an appropriate setting to challenge treatment, question decisions, express remorse or misgivings, and cry, if needed. Ultimately, the peer review process is designed to improve patient care, and the plaintiff’s attorney cannot force disclosure of these discussions. If the plaintiff’s attorney asks questions about the substance of a peer review committee meeting, defense counsel will object on the basis of peer review privilege and block that inquiry.

In sum, should a mistake occur, do not panic. Protect the patient, and plan to discuss the case at a formal closed-door peer review conference. Note: As peer review law varies state by state, be sure that your peer review–related actions fall within your state’s defined scope of privilege. —DML

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

Excessive Dosing, Inadequate Monitoring Blamed in Death
A 39-year-old man with a history of pain complaints went to a Virginia hospital emergency department (ED) with a migraine. The defendant attending physician ordered IV medications; however, after several unsuccessful attempts to establish an IV line, the treating nurse administered 8 mg hydromorphone intramuscularly (IM). The patient was given a second dose of hydromorphone (6 mg IM) about an hour later before being transferred to a nonemergent room; there, he fell asleep. Loud snoring was noted, but the nurse responsible for monitoring the patient was not alarmed.

The patient then experienced respiratory arrest. Attempts to resuscitate him were unsuccessful.

Plaintiff for the decedent alleged negligence in improperly monitoring him and in failing to recognize signs of distress in a timely fashion. The plaintiff also claimed that the second dose overmedicated the decedent, leading to respiratory arrest. The plaintiff alleged negligence by the attending physician for ordering the second dose of hydromorphone and for transferring the decedent from the ED to a nonemergent room.

The claims against the defendant attending physician went to trial. The defendant claimed that the decedent was stable and showed no signs of acute distress at the time of transfer.

OUTCOME
The hospital settled for a confidential amount prior to trial. According to a published account, a defense verdict was returned in the trial against the attending physician.

COMMENT
This patient was given hydromorphone 8 mg IM at 5:55 am and hydromorphone 6 mg IM at 7:11 am as first-line treatment for migraine. He was discharged from the ED 10 minutes after receiving the second dose and transported to a gastroenterology suite for a previously scheduled colonoscopy. There, he was sparsely monitored, became apneic, and died.

Was the standard of care breached in this case?

The patient appears to have been offered a high-dose narcotic as abortive therapy for migraine, contrary to current recommendations (Gilmore and Michael. Am Fam Physician. 2011;83[3]:271-280). Use of opiates in these circumstances is problematic, and yet opiates are still often prescribed as first-line agents in some practices.

If this were a headache of moderate to severe intensity, triptans would have been the preferred abortive agent. No evidence was presented that this 39-year-old patient had a contraindication to triptans, dihydroergotamine, isometheptene, or intranasal lidocaine. He was given narcotics as first-line treatment for migraine.

Migraine can be extraordinarily painful, and we clinicians are ethically and legally bound to offer the best treatment available to arrest that pain. For most patients, high-dose parenteral narcotics are not favored for the management of migraine because of the potential for precipitating rebound headaches and because opiate dependence can lead to continuing, escalating demands for more narcotic intervention—and worsening headaches.

In this case, the dose of 14 mg of hydromorphone administered over 1 hour and 16 minutes is staggering—even for a patient who is not opiate-naïve. Further, in the IM route of administration (compared with IV), absorption and peak effect are imprecise. Even if the clinician were to argue that the patient’s narcotic tolerance necessitated this dose, the clinician was compelled to ensure that the patient was adequately monitored.

Migraine will become the clinician’s headache if the approach is nonchalant. First, always fully assess a patient with migraine to determine whether the headache is consistent with prior episodes; an atypical presentation may require neuroimaging or an alternate diagnostic approach. Second, always perform a proper examination, even when the headache is described as typical. Third, offer therapeutic interventions that follow evidence-based guidelines. Opiate use should be offered (if at all) at the end of a treatment ­algorithm.

For patients with putative allergies to all abortive treatments other than narcotics, it is wise for a neurologist or pain management group to evaluate the patient and establish a solid, agreed-upon treatment plan. This plan should acknowledge that more appropriate treatment is unavailable, that the patient has been fully informed of the risks and limitations of opiate agents, and that the patient agrees to follow this clearly defined plan.

Like hydromorphone  and other opiate agents, meperidine is another drug with issues. Though still prescribed by some, meperidine is in specific disfavor because of the abuse potential and the risk for seizures induced by normeperidine (a metabolite of meperidine). Its once-touted benefit—avoidance of sphincter of Oddi spasm—is mythical and not a valid reason to keep meperidine stocked. A last highly specialized use may be to treat severe refractory rigors—but it is safe to say that meperidine should be closer to a museum for antiquated medications than to your migraine patient. Jurors will fault clinicians when patients become addicted or have seizures when safer options exist. Don’t use it.

Improve your management of migraine patients and lower your malpractice risk by performing a full assessment and following evidence-based guidelines to choose appropriate agents. In any case in which high-dose narcotics must be administered to abort a high-­intensity migraine, a jury will expect the patient to be carefully monitored for respiratory depression until his/her sensorium is fully cleared following the agent’s peak effect.

Simply put, opiates must not be given in ambulatory settings in which the patient is expected to be discharged after 20 to 30 minutes of observation. This medication is not a flu shot, and the plaintiff’s attorney will hammer this point home if your narcotized migraine patient leaves your practice setting and steps in front of a vehicle. Protect the patient and avoid malpractice risk. —DML

Woman Given Morphine Despite Well-Documented Allergy
A 66-year-old Utah woman underwent surgery at the defendant hospital. The defendant surgeon ordered morphine to be administered following surgery—despite documentation in the patient’s record that she was allergic to morphine, and despite the fact that she was wearing a wristband indicating that she was allergic to morphine. The morphine was administered by hospital nurses over the course of several hours.

The patient became asystolic about 14 hours after receiving the first dose. She was revived but had suffered anoxic brain injury. She died two days later.

The decedent’s son-in-law alleged that he had seen a hospital employee remove the wristband indicating her allergy to morphine and throw it into the wastebasket; the son-in-law retrieved it.

The plaintiffs also claimed that a review of the medical record showed that the word “morphine” had been erased under the section entitled “Allergies.” This was discovered in a comparison of the hospital records with identical records supplied by one of the defendant doctors. In that doctor’s records, the word “morphine” was included.

OUTCOME
According to a published report, a confidential settlement was reached.

COMMENT
Because the settlement was confidential, we don’t know what the payment was—but we can be sure it was substantial.

Jurors abhor attempts to cover up mistakes, even when the jury pool is relatively conservative. Instead of viewing the matter as an error, jurors will impute the worst motives and will exact significant punitive damages. In Utah, for example, where this case occurred, punitive damages are not permitted unless the plaintiff can show by “clear and convincing evidence” that the defendants acted maliciously, with intentional fraudulence, or with reckless indifference toward the rights of others (Utah Code Ann §78-18-1).

This may be a case in which the clinician and staff succumbed to the stress of the moment and acted poorly and unprofessionally. Nevertheless, the staff members’ actions to cover up the mistake, by discarding the patient’s wristband that specified the allergy and erasing the note of the patient’s morphine allergy in the medical record, cause problems far beyond the initial mistake.

Because the malicious act (the cover-up activity) occurred after the fact, it did not directly injure the patient and could not form the basis for punitive damages in a malpractice action. However, the cover-up activity may be the basis for punitive damages for the family’s derivative “intentional infliction of emotional distress” claims. Generally, this type of claim must involve conduct that would prompt the average person hearing the facts to exclaim, “Outrageous!” That test is met here.

If presented with a case that may result in malpractice liability exposure, do not lose your head, blow your cool, or act rashly. Always act in the best interest of the patient and let the record reflect your efforts to protect the patient. Do not use the medical record for defensive discussion out of step with normal charting practices. Chart directly, dispassionately, and professionally, and avoid embellishment or hyperbole. Never alter, destroy, or conceal records.

Furthermore, do not react defensively or with hostility, and do not discuss the case openly during or immediately after the incident; any statements you make may be directly admissible against you or others as evidence. Do not initiate an “incident report” or otherwise “write up” a fellow worker: These documents are business records that will be discoverable by a plaintiff’s attorney, and they can be used against you, the facility, and your peers.

Likewise, the patient’s bedside is not the place for emotional discussions; there, the patient’s well-being must be the only concern. Instead, use the special process that was created to candidly and confidentially discuss matters of patient quality of care: the peer-review process. This process offers an appropriate setting to challenge treatment, question decisions, express remorse or misgivings, and cry, if needed. Ultimately, the peer review process is designed to improve patient care, and the plaintiff’s attorney cannot force disclosure of these discussions. If the plaintiff’s attorney asks questions about the substance of a peer review committee meeting, defense counsel will object on the basis of peer review privilege and block that inquiry.

In sum, should a mistake occur, do not panic. Protect the patient, and plan to discuss the case at a formal closed-door peer review conference. Note: As peer review law varies state by state, be sure that your peer review–related actions fall within your state’s defined scope of privilege. —DML

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.

Excessive Dosing, Inadequate Monitoring Blamed in Death
A 39-year-old man with a history of pain complaints went to a Virginia hospital emergency department (ED) with a migraine. The defendant attending physician ordered IV medications; however, after several unsuccessful attempts to establish an IV line, the treating nurse administered 8 mg hydromorphone intramuscularly (IM). The patient was given a second dose of hydromorphone (6 mg IM) about an hour later before being transferred to a nonemergent room; there, he fell asleep. Loud snoring was noted, but the nurse responsible for monitoring the patient was not alarmed.

The patient then experienced respiratory arrest. Attempts to resuscitate him were unsuccessful.

Plaintiff for the decedent alleged negligence in improperly monitoring him and in failing to recognize signs of distress in a timely fashion. The plaintiff also claimed that the second dose overmedicated the decedent, leading to respiratory arrest. The plaintiff alleged negligence by the attending physician for ordering the second dose of hydromorphone and for transferring the decedent from the ED to a nonemergent room.

The claims against the defendant attending physician went to trial. The defendant claimed that the decedent was stable and showed no signs of acute distress at the time of transfer.

OUTCOME
The hospital settled for a confidential amount prior to trial. According to a published account, a defense verdict was returned in the trial against the attending physician.

COMMENT
This patient was given hydromorphone 8 mg IM at 5:55 am and hydromorphone 6 mg IM at 7:11 am as first-line treatment for migraine. He was discharged from the ED 10 minutes after receiving the second dose and transported to a gastroenterology suite for a previously scheduled colonoscopy. There, he was sparsely monitored, became apneic, and died.

Was the standard of care breached in this case?

The patient appears to have been offered a high-dose narcotic as abortive therapy for migraine, contrary to current recommendations (Gilmore and Michael. Am Fam Physician. 2011;83[3]:271-280). Use of opiates in these circumstances is problematic, and yet opiates are still often prescribed as first-line agents in some practices.

If this were a headache of moderate to severe intensity, triptans would have been the preferred abortive agent. No evidence was presented that this 39-year-old patient had a contraindication to triptans, dihydroergotamine, isometheptene, or intranasal lidocaine. He was given narcotics as first-line treatment for migraine.

Migraine can be extraordinarily painful, and we clinicians are ethically and legally bound to offer the best treatment available to arrest that pain. For most patients, high-dose parenteral narcotics are not favored for the management of migraine because of the potential for precipitating rebound headaches and because opiate dependence can lead to continuing, escalating demands for more narcotic intervention—and worsening headaches.

In this case, the dose of 14 mg of hydromorphone administered over 1 hour and 16 minutes is staggering—even for a patient who is not opiate-naïve. Further, in the IM route of administration (compared with IV), absorption and peak effect are imprecise. Even if the clinician were to argue that the patient’s narcotic tolerance necessitated this dose, the clinician was compelled to ensure that the patient was adequately monitored.

Migraine will become the clinician’s headache if the approach is nonchalant. First, always fully assess a patient with migraine to determine whether the headache is consistent with prior episodes; an atypical presentation may require neuroimaging or an alternate diagnostic approach. Second, always perform a proper examination, even when the headache is described as typical. Third, offer therapeutic interventions that follow evidence-based guidelines. Opiate use should be offered (if at all) at the end of a treatment ­algorithm.

For patients with putative allergies to all abortive treatments other than narcotics, it is wise for a neurologist or pain management group to evaluate the patient and establish a solid, agreed-upon treatment plan. This plan should acknowledge that more appropriate treatment is unavailable, that the patient has been fully informed of the risks and limitations of opiate agents, and that the patient agrees to follow this clearly defined plan.

Like hydromorphone  and other opiate agents, meperidine is another drug with issues. Though still prescribed by some, meperidine is in specific disfavor because of the abuse potential and the risk for seizures induced by normeperidine (a metabolite of meperidine). Its once-touted benefit—avoidance of sphincter of Oddi spasm—is mythical and not a valid reason to keep meperidine stocked. A last highly specialized use may be to treat severe refractory rigors—but it is safe to say that meperidine should be closer to a museum for antiquated medications than to your migraine patient. Jurors will fault clinicians when patients become addicted or have seizures when safer options exist. Don’t use it.

Improve your management of migraine patients and lower your malpractice risk by performing a full assessment and following evidence-based guidelines to choose appropriate agents. In any case in which high-dose narcotics must be administered to abort a high-­intensity migraine, a jury will expect the patient to be carefully monitored for respiratory depression until his/her sensorium is fully cleared following the agent’s peak effect.

Simply put, opiates must not be given in ambulatory settings in which the patient is expected to be discharged after 20 to 30 minutes of observation. This medication is not a flu shot, and the plaintiff’s attorney will hammer this point home if your narcotized migraine patient leaves your practice setting and steps in front of a vehicle. Protect the patient and avoid malpractice risk. —DML

Woman Given Morphine Despite Well-Documented Allergy
A 66-year-old Utah woman underwent surgery at the defendant hospital. The defendant surgeon ordered morphine to be administered following surgery—despite documentation in the patient’s record that she was allergic to morphine, and despite the fact that she was wearing a wristband indicating that she was allergic to morphine. The morphine was administered by hospital nurses over the course of several hours.

The patient became asystolic about 14 hours after receiving the first dose. She was revived but had suffered anoxic brain injury. She died two days later.

The decedent’s son-in-law alleged that he had seen a hospital employee remove the wristband indicating her allergy to morphine and throw it into the wastebasket; the son-in-law retrieved it.

The plaintiffs also claimed that a review of the medical record showed that the word “morphine” had been erased under the section entitled “Allergies.” This was discovered in a comparison of the hospital records with identical records supplied by one of the defendant doctors. In that doctor’s records, the word “morphine” was included.

OUTCOME
According to a published report, a confidential settlement was reached.

COMMENT
Because the settlement was confidential, we don’t know what the payment was—but we can be sure it was substantial.

Jurors abhor attempts to cover up mistakes, even when the jury pool is relatively conservative. Instead of viewing the matter as an error, jurors will impute the worst motives and will exact significant punitive damages. In Utah, for example, where this case occurred, punitive damages are not permitted unless the plaintiff can show by “clear and convincing evidence” that the defendants acted maliciously, with intentional fraudulence, or with reckless indifference toward the rights of others (Utah Code Ann §78-18-1).

This may be a case in which the clinician and staff succumbed to the stress of the moment and acted poorly and unprofessionally. Nevertheless, the staff members’ actions to cover up the mistake, by discarding the patient’s wristband that specified the allergy and erasing the note of the patient’s morphine allergy in the medical record, cause problems far beyond the initial mistake.

Because the malicious act (the cover-up activity) occurred after the fact, it did not directly injure the patient and could not form the basis for punitive damages in a malpractice action. However, the cover-up activity may be the basis for punitive damages for the family’s derivative “intentional infliction of emotional distress” claims. Generally, this type of claim must involve conduct that would prompt the average person hearing the facts to exclaim, “Outrageous!” That test is met here.

If presented with a case that may result in malpractice liability exposure, do not lose your head, blow your cool, or act rashly. Always act in the best interest of the patient and let the record reflect your efforts to protect the patient. Do not use the medical record for defensive discussion out of step with normal charting practices. Chart directly, dispassionately, and professionally, and avoid embellishment or hyperbole. Never alter, destroy, or conceal records.

Furthermore, do not react defensively or with hostility, and do not discuss the case openly during or immediately after the incident; any statements you make may be directly admissible against you or others as evidence. Do not initiate an “incident report” or otherwise “write up” a fellow worker: These documents are business records that will be discoverable by a plaintiff’s attorney, and they can be used against you, the facility, and your peers.

Likewise, the patient’s bedside is not the place for emotional discussions; there, the patient’s well-being must be the only concern. Instead, use the special process that was created to candidly and confidentially discuss matters of patient quality of care: the peer-review process. This process offers an appropriate setting to challenge treatment, question decisions, express remorse or misgivings, and cry, if needed. Ultimately, the peer review process is designed to improve patient care, and the plaintiff’s attorney cannot force disclosure of these discussions. If the plaintiff’s attorney asks questions about the substance of a peer review committee meeting, defense counsel will object on the basis of peer review privilege and block that inquiry.

In sum, should a mistake occur, do not panic. Protect the patient, and plan to discuss the case at a formal closed-door peer review conference. Note: As peer review law varies state by state, be sure that your peer review–related actions fall within your state’s defined scope of privilege. —DML

Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.