Lisa Speckman was able to survive a rare, flesh-eating bacteria after the birth of her daughter at LDS Hospital -- but blamed a chain of medical errors for her loss of both legs and an arm.
Among the mistakes, according to a lawsuit she filed: a test result for an infection mistakenly recorded as negative; doctors who didn't order antibiotic treatment as blood samples showed signs of a problem; and nurses who failed to intervene to get her proper treatment.
Both LDS Hospital and the University of Utah, which placed residents, nurses and instructors there, settled the litigation out of court. A recent Salt Lake Tribune open records request found the U., a publicly funded entity, paid $1 million to settle. Private companies such as LDS Hospital don't have to disclose what they paid.
While the lawsuit may be over, the real question for those horrified by what happened to Speckman might be whether her case affected future care for the better. The question might go unanswered: Both the U. and LDS cite privacy laws as preventing them from saying whether they examined practices or made any changes as a result of the case.
"A good analysis of what went wrong might reveal a problem with hospital processes that could also impact other types of patients and prevent other types of harm," said Eric J. Thomas, a physician and professor at the University of Texas Medical School who has been conducting research on patient safety since 1992.
Thomas argues the culture of medicine and hospitals has not supported learning from cases like Speckman's.
"The broader challenge is to get hospitals to ... view errors as opportunities to learn," he said.
In general, spokesmen for University Health Care and Intermountain Healthcare said cases are used in an academic setting for teaching and as an opportunity for improvement.
The state also tracks 32 types of serious errors -- unanticipated deaths or permanent loss of function -- submitted by hospitals. The data is analyzed to determine what hospitals can do to avoid these types of mistakes.
"The hospital looks at what it can do to create safeguards, individually and through root cause analysis," said Iona Thraen, director of patient safety for the Utah Department of Health
But whether the Speckman case was ever included in this data is unknown. Patient names and the identities of the facilities are not used and incidents are described in very general terms.
The most common serious errors among the 89 reported in 2008 stemmed from surgery. The second most common source of errors was care management, which includes things like medication mistakes.
Clark Newhall, a Salt Lake City medical malpractice attorney who is also a physician, contends that these events generally are not used as learning tools.
Internal investigations are time-consuming, hospitals rarely have the resources for them and administrators tend to believe their staff members when they deny fault, he argues.
Speckman declined to comment on the settlement in her case, the terms of which are confidential.
A 3rd District Court lawsuit filed by Lisa Speckman claimed that months before she gave birth, prenatal test results indicated she had an infection. Speckman, who was herself a nurse at LDS Hospital, alleged those results were either recorded incorrectly or not included in her medical chart.
Then, when her blood pressure dropped and her abdomen began swelling after her daughter's birth on Feb. 25, 2005, Speckman was given a sleep aid rather than the diagnostic tests and antibiotics she needed, the suit contended.
Doctors eventually amputated both her legs above the knees, her right arm above the elbow and the tip of her middle finger on her left arm. Her reproductive organs, gall bladder and much of her large intestine were also removed, according to the lawsuit.
In court documents, the hospital denied having made errors.
Commonly known as flesh-eating disease, necrotizing fasciitis is an infection caused commonly by group A Strep bacteria, the same bacteria that causes Strep throat. A very strong variety of Strep can occur that leads to life-threatening cases. The bacteria usually enters the body through an opening in the skin, such as a paper cut or pin prick, or through the weakened skin of a bruise or blister.
Source: National Necrotizing Fasciitis Foundation.
