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The Honolulu Advertiser
Posted on: Sunday, February 5, 2006

Hospital cases end tragically

 •  PDF: Tripler Army Medical Center malpractice claims from 1985 to 2005 that were resolved with payments
 •  Chart: Malpractice claims (opens in a new window)
 •  $5.5 million in damages little solace for local family
 •  Limited public data offers mixed picture

By Rob Perez
Advertiser Staff Writer

Tripler Army Medical Center is the major treatment facility for thousands of Hawai'i's military personnel, their families, veterans and others.

JEFF WIDENER | The Honolulu Advertiser

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Tripler Army Medical Center is the largest Army medical facility in the Pacific.

Hospital beds: 229

Monthly patient visits: 52,400

Patient load: Tripler ranks seventh among U.S. military hospitals for ambulatory care and fourth for inpatient volume

Eligible patient population: 400,000-plus

Service region: Hawai'i, Japan, Guam, other Pacific islands

Staff: About 3,000, including roughly 200 military physicians

Overall accreditation: Renewed December 2004

Operating budget: $373.4 million

Training: 1,200-plus medical students and physicians annually

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Izzy Peterson suffered brain damage after he was given carbon dioxide instead of oxygen after his birth at Tripler.

Family photo

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A lawsuit by Jennifer Adams’ family contends that an improperly administered anesthesia procedure led to her death and her baby’s brain injury.

Family photo

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Tina Long (shown with husband, Jason) showed signs of a serious disorder when she died without close monitoring, her family says.

Family photo

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After a newborn was severely injured when he was given the wrong gas at Tripler Army Medical Center, the Department of Defense issued this alert to its medical facilities to prevent similar mistakes from happening.

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Tina Long, 26 and pregnant, was admitted to Tripler Army Medical Center in April, complaining of headaches, vision problems and swelling. Her blood pressure was elevated and she had protein in her urine. All were symptoms of a potentially serious disorder called preeclampsia.

The hospital ran tests on Long, who was 8 1/2 months along, then placed her in a room without monitoring her closely, her family says.

About 90 minutes after someone from the nursing station last spoke to Long via a speaker system, she was discovered unresponsive in her bed. Resuscitation efforts failed, and Long and her unborn baby, Hunter, were pronounced dead, according to the autopsy report.

Two months later, a newborn boy, Romi're Dupuy, experienced respiratory problems at Tripler, prompting medical personnel to place a breathing tube down his throat. But instead of maneuvering the tube through the trachea, a doctor mistakenly guided it into the esophagus, which leads to the stomach, puncturing that passageway and causing serious injury, the family said. Romi're spent more than two months in the hospital recovering.

Both cases happened several months after a Tripler physician in January 2005 mistakenly gave a newborn baby, Izzy Peterson, carbon dioxide instead of oxygen almost immediately after his birth. The baby inhaled the wrong gas for more than 40 minutes before the error was discovered. He nearly suffocated and suffered permanent brain damage.

In all three cases, the families are pursuing medical malpractice claims or lawsuits, seeking compensation for what they allege was substandard care at Tripler.

The cases have generated questions about the overall quality of care provided at the landmark pink O'ahu hospital that serves as the major treatment facility for thousands of Hawai'i's military, their families, veterans and others. It is ranked among the busiest hospitals in the military, with a coverage area that spans half the globe.

Four physicians contacted by The Advertiser who have expertise in treating children or in surgical procedures said the three cases were unusual. But while the doctors were reluctant to make judgments about the two more recent incidents, not knowing the complete details, they said the Baby Izzy case was particularly troublesome.

"It seems the system is broken that would allow such a severe mistake to happen," said Dr. Timothy Craig, a Penn State professor of medicine and pediatrics who has practiced at military hospitals and generally gives them good marks. "This raises red flags."

Tripler officials say that the hospital provides high-quality care and that outside inspectors regularly laud its services.

"When external surveyors and inspectors brief hospital leaders about their findings, most comment about our practices being the best they have ever seen — anywhere," Tripler officials said in a statement.

Comparing the overall quality of care at Tripler with that provided at other hospitals, whether military or civilian, is difficult because of a lack of comprehensive, publicly available data.

The limited information available shows that Tripler compares favorably with other hospitals in Hawai'i but does not compare as well on a national basis.

Hawai'i hospitals as a group do not fare well in those national comparisons. In one recent survey, for example, local hospitals scored below the national averages in all 11 categories rated for treatment of heart-attack and heart-failure patients.

Tripler officials did not provide requested information for some important healthcare quality measures, including patient satisfaction surveys, lists of certifications and accreditations, and internal and external evaluations that the officials said verify Tripler is a first-class institution with an outstanding treatment history.

Prompted by the Baby Izzy case and others with troubling outcomes, The Advertiser examined available quality-of-care and medical malpractice data at the 229-bed military hospital.

Among the findings:

  • The federal government has spent tens of millions of dollars over the past two decades to resolve about 170 cases among more than 600 filed in which patients or their families accused Tripler of shoddy care.

    The tab to taxpayers has totaled more than $60 million in court judgments, out-of-court settlements and resolution of medical malpractice claims. The government, for instance, has paid more than $14 million to resolve about 150 claims since 1985. In one 1998 claim, a family received $130,000 for an incident in which a Tripler patient allegedly needed corrective surgery to remove a sponge left behind during an earlier operation.

    Court judgments and out-of-court settlements have added about another $47 million to the tab. But that isn't a complete accounting, given that out-of-court settlements sometimes are not disclosed publicly.

  • Tripler and other federal entities have been unwilling or unable to quantify how much malpractice cases at Tripler have cost over the past decade, leaving taxpayers in the dark about a tab they ultimately covered.

  • Since 1985, the government has lost 14 of 23 nonjury trials in which malpractice was a key issue. The government has lost five of its past six cases since 1995, including one it lost on appeal, according to Personal Injury Judgments Hawaii, a publication that tracks tort verdicts in state and federal courts here. In the 14 losses, a federal judge determined that substandard care contributed to a patient's death or injury, and in all but one instance awarded damages of at least six figures to the plaintiffs. The largest judgment, $11.3 million in 1997, was awarded to a family whose baby suffered brain damage because of negligent care.

  • While some of the more costly cases occurred in the 1980s and early '90s, allegations of poor care continue to dog Tripler. Patients or their families filed 331 medical malpractice claims from January 1995 through July 2005, according to Army data obtained by The Advertiser through the Freedom of Information Act. In the previous 10 years, 312 claims were filed.

    In an October statement about Tripler's overall operation, officials said the hospital provides safe, compassionate, high-quality care. They said the malpractice claims against the hospital follow national trends, with more filed for high-risk care performed commonly, such as complex maternal care and neonatal intensive care.

    "We see nothing in our data that suggests our care is less safe than at other military medical centers or civilian hospitals providing comparable services," the officials said in their written response to Advertiser questions.

    In addition, they said Tripler remains accredited and certified "in every way" by outside organizations that evaluate its services.

    Its main accreditation was renewed by the Joint Commission on Accreditation of Healthcare Organizations in December 2004, with the commission finding Tripler in full compliance with the reviewed standards. Accreditations come up for renewal every three years, though that scheduling will become more random beginning next year.

    Tripler officials declined comment on cases in litigation: "We take each claim on its merit, investigate it and take appropriate action."

    In November, Tripler officials told The Advertiser they would no longer respond to requests for information, directing further inquiries to the hospital's Mainland headquarters. Since then, that Texas office has not provided most of the information sought by the newspaper.

    400,000 ELIGIBLE

    The Moanalua Ridge hospital gets an estimated 50,000 patient visits a month, while another 14,000-plus occur at Schofield Barracks Health Clinics, part of the Tripler system. More than 400,000 people are eligible to receive care at Tripler.

    The hospital also serves as a teaching institution for more than 1,200 medical personnel each year, including students at the University of Hawai'i medical school. That arrangement allows resident physicians or other trainees to work alongside their mentors, similar to what happens at other teaching hospitals in the state and elsewhere.

    The vast majority of Tripler cases never generate malpractice complaints.

    Many patients typically are satisfied with their care or, if something bad happens, are satisfied with the explanation.

    Shigeo Doc Kawamoto, a veteran of World War II, counts himself among the people pleased with Tripler's services. He periodically gets medical tests done at the hospital.

    "They take good care of me," Kawamoto said. "They treat me well."

    Some patients are reluctant to pursue claims, while active-duty members are prohibited from doing so. Military personnel — about a third of Tripler's patient pool — are barred by law from filing malpractice claims against the U.S. government for injuries linked to their military service, even if an injury stems from gross negligence by a government worker.

    For those patients or families who formally seek compensation, the first step is to file a malpractice claim with the government. If that isn't resolved within six months, a lawsuit can be filed in federal court. A judge, not a jury, renders a verdict.

    Among the Army's seven medical centers in the U.S., Tripler's 331 claims and 61 paid claims over the past decade were second only to the totals at William Beaumont Army Medical Center, a hospital at Fort Bliss, Texas, that has 94 licensed beds. The Army didn't respond to requests asking about Beaumont's numbers.

    Tripler officials said the hospital's malpractice claim statistics can't be compared with Army medical centers elsewhere because of differences in state laws, malpractice tort reform, the aggressiveness of malpractice attorneys and other local factors unrelated to quality of care.

    Three local malpractice attorneys dispute that, saying a legitimate claim will be valid anywhere, regardless of the idiosyncrasies of a particular area.

    Tripler officials also said, "We cannot comment on whether people in Hawai'i file more claims than in other places."

    No organization compiles state-by-state comparisons of filed malpractice claims, according to those who track other malpractice data.


    Industry executives and attorneys say medicine can be an inexact science, and mistakes happen at every hospital.

    Mistakes at Tripler, however, have a greater chance of becoming public because of open-government regulations, particularly if lawsuits result. Mistakes at private institutions, especially the more egregious errors, tend to be dealt with secretly at the insistence of the hospitals and doctors, half-a-dozen plaintiff attorneys said.

    "Our really slam-dunk (civilian) cases settle with confidentiality," said plaintiff attorney Rick Fried.

    Even lawyers who have filed malpractice lawsuits involving Tripler say the hospital provides better care today than years ago.

    "By and large, I think Tripler is a terrific public health institution," said attorney Eric Seitz, who represented a client in a recently settled lawsuit alleging substandard care at Tripler. "There are some wonderful doctors there."

    Yet developments over the past year have once again raised questions about quality of care.

    In the Baby Izzy case, a portable carbon dioxide tank was used instead of an oxygen tank, resulting in a "sentinel event," according to a federal patient safety alert on the mishap. Sentinel events typically refer to medical incidents that unexpectedly result in death or serious injury.

    After the gas mix-up, the hospital apologized to the family and said immediate corrective action was taken.

    "Providing carbon dioxide instead of oxygen is inexcusable," said Dr. Peter Lurie, deputy director of health research for Public Citizen, an advocacy group that focuses on healthcare and other consumer issues.

    The incident prompted the U.S. Department of Defense in March to issue the militarywide alert advising medical institutions to take immediate steps to prevent similar mishaps.

    Izzy's brain damage was so severe, he is dependent on medical devices for his survival. He will need 24-hour nursing care the rest of his life.

    Shalay Peterson, Izzy's mother, said Izzy will never be able to lead a normal life or do the typical things that kids do together with their families.

    "We've been robbed of all that," she said.

    Izzy's parents have sued the government for malpractice, and plaintiff attorneys say a judgment, if the case goes to trial and the family wins, could be one of the highest in Tripler history. The current record is the $11.3 million award in 1997 to the family of the brain-damaged baby. With interest, the government paid about $12.5 million.

    The government denied in court documents that Tripler was negligent with Izzy's care. The case is pending.


    Tina Long was admitted last April with these symptoms: high protein levels in her urine, severe headaches, swelling, blurred vision and elevated blood pressure of 159/100 when it had been an average of 120/77 in prior months, according to Michael Archuleta, the family's attorney in Texas. All those general symptoms were noted in the autopsy report.

    For pregnant women, high blood pressure and protein in the urine are the key symptoms of preeclampsia, according to Eleni Tsigas of the Preeclampsia Foundation. Preeclampsia is a rapidly progressing hypertensive condition that affects pregnant women and can be harmful to the unborn baby and mother. Severe headaches, swelling of the hands and face, and blurred vision are among other indicators.

    Women who have high blood pressure during pregnancy typically are closely monitored because that condition may progress to preeclampsia, Tsigas said.

    When Long was hospitalized in April, the diagnosis — made about 12 hours before she died — was to "rule out preeclampsia," according to the autopsy report. A "rule-out" diagnosis usually means the disorder is suspected but not enough evidence is available at the time to make a definitive call, doctors say.

    Archuleta said Long's case was a textbook one for preeclampsia. Yet Tripler not only failed to monitor the patient adequately but didn't do the one thing that would have taken care of the problem — deliver the baby, according to Archuleta, who also is a doctor and says he has delivered about 100 babies.

    The cause of Long's death was listed as probable peripartum cardiomyopathy (a weakened, damaged heart during pregnancy), with toxemia of pregnancy — another name for preeclampsia — noted as a contributing cause, according to her autopsy.

    "There's a difference between warehousing a patient and treating a patient," Archuleta said. "Tina was warehoused."

    Long's family filed several malpractice claims against Tripler, seeking $40 million in compensation. The claims are pending.

    Tripler officials declined comment because it is an ongoing case.

    The family of Romi're Dupuy, the baby whose esophagus allegedly was punctured, also filed several claims, seeking $15 million. Tripler likewise declined comment.


    Another pending case that surfaced last year involved a Marine now stationed on the Mainland who in May sued the federal government on behalf of his late wife's estate, alleging that Tripler's negligent care led to her death and their newborn son's brain injury. Vincent Adams said in the lawsuit that an improperly administered epidural — a type of anesthesia procedure used for childbirth — led to complications in December 2002 during delivery and afterward that injured their son and caused the death of Jennifer Adams four months later in Florida.

    Vincent Adams said in a March 2003 videotaped interview that a Tripler doctor told him a high epidural caused his wife to stop breathing.

    William Copulos, Adams' attorney, said a high epidural or high spinal epidural refers to one that is administered in such a way that the anesthetic travels upward in the body. In Jennifer Adams' case, the epidural needle was inserted in her cerebral spinal fluid space instead of the epidural space, allowing the anesthetic to travel up the spinal column, anesthetizing her heart and diaphragm, Copulos said.

    A Florida medical examiner determined in May 2003 that Jennifer Adams' death was due to complications from a high spinal epidural, according to the examiner's report. The Adams lawsuit is pending. The government denied in court documents that the care was negligent.

    The issue of quality of care also came up in an August court ruling by U.S. District Judge Susan Oki Mollway. A woman patient who was sexually molested by a male licensed practical nurse at Tripler in 2001 subsequently sued the government, accusing Tripler of negligence.

    Mollway awarded the woman and her husband $906,000, finding that Tripler's inattention to the patient and inadequate supervision of the male nurse who treated her were substantial factors in the sexual assault. The nurse pleaded guilty to sexual abuse and was sentenced in 2002 to 6 1/2 years in prison.

    A first-year intern and a supervisory nurse who oversaw the care of the woman at the intensive-care unit paid little attention to the patient that night, even though the woman kept losing and regaining consciousness and a diagnosis was unclear, according to Mollway's ruling.

    The government is appealing the ruling. The U.S. attorney's office, which is handling the appeal, declined comment.


    In a June interview, Navy Capt. Kevin Berry, deputy commander for clinical services at Tripler, said the hospital regularly keeps on top of quality issues and patient safety. The hospital, for instance, has a full-time safety manager whose focus is to identify issues that have patient safety implications and to develop plans to reduce or eliminate the potential to cause harm. In addition, Tripler is inspected by one dozen to three dozen external organizations, Berry said.

    "There are literally thousands of layers to a medical quality assurance program," he said.

    If something goes wrong and a peer-review process determines substandard care was given, those responsible are held accountable, he said.

    But Tripler officials said the hospital rarely has incidents that require reporting physicians to state or national boards. They said they do not keep statistics on such reports.

    Plaintiff attorney Mark Davis, who noted that his law firm over the years has won all 15 or so of its Tripler malpractice cases that went to trial, said common issues tended to surface: understaffing, poor continuity of care, lapses in record-keeping, inadequate supervision of personnel.

    Tripler said it maintains staffing standards similar to or more stringent than those used by some civilian hospitals, reviews staff levels frequently and makes adjustments as needed, including periodically referring patients to other hospitals here or on the Mainland.

    Most other issues raised by malpractice attorneys are conjecture, Tripler said.

    Yet some of those very issues have surfaced in recent cases.

    In the sexual assault case, Judge Mollway noted that the supervisory nurse had asked for more help that night, expressing concern that the intensive-care unit where the eventual assault occurred was understaffed. The nurse received no response to her request, according to the ruling.

    In the Tina Long case, the patient never saw the same doctor regularly, contributing to her inconsistent or poor care, the family said. During her hospitalization in April, a physician asked Long's mother to retrieve medication for her daughter from a downstairs pharmacy because no hospital staffer was available to get it, the family said.

    In the Baby Izzy case, Shalay Peterson said that when she asked for Izzy's records in preparation for a move to the Mainland, she was given a file that included documents from a different case, one of a boy who died at Tripler.

    In the Adams case, the epidural was administered by a nurse anesthetist, but once the patient started having problems, the anesthesiologist should have been summoned to intervene, according to Copulos, the family's attorney. That didn't happen, he said.

    Reach Rob Perez at rperez@honoluluadvertiser.com.