Little Things Make Big Things Happen

“It’s the little details that are vital.  Little things make big things happen.” - John Wooden

“In the successful organization, no detail is too small to escape close attention.” - Lou Holtz

These quotes are from two men who had very successful careers.  John Wooden won 10 national championships as UCLA’s men’s basketball coach in the 1960’s and 1970’s, and Lou Holtz won a national championship as Notre Dame’s football coach in 1988.  Both men are known not only for their successful coaching careers, but also for their words of wisdom during and after their careers of coaching collegiate athletes.  These quotes about the importance of details apply to sports and to life in general.  They also apply to the practice of medicine, as you will see in the case below.

A 38-year-old female patient with a history of abnormal pap smears was seen by Dr. Ben Garrett, an OB/GYN, to undergo a colposcopy.  Prior to the procedure, a nurse prepared a tray with the necessary solutions, biopsy containers, and tools.  One of the containers on the tray had cotton balls which should have been soaked in a very light acidic solution consisting of 50% vinegar and 50% sterile water.  However, the nurse mistakenly soaked the cotton balls in trichloroacetic acid (“TCA”).  She mistook the large gallon jug of TCA for a gallon jug of premixed vinegar/sterile water solution.  TCA is highly corrosive and is used by Dr. Garrett to burn genital warts.

The nurse took the tray to the exam room for Dr. Garrett to use in the examination.  Dr. Garrett placed the soaked cotton balls inside the patient’s vagina to detect any possible lesions.  The cotton balls typically stay in place for 3 to 5 minutes.  Unfortunately, Dr. Garrett had a bad cold, which inhibited his ability to smell.  Had he not been experiencing a cold at the time, it is possible (maybe likely) that he would have appreciated the fact that the nurse had not used the vinegar/sterile water solution given the absence of the distinctive smell of vinegar.

Shortly thereafter, a medical office assistant walked by the patient’s exam room and noticed the patient was in pain.  The patient said she was hurting and burning.  The medical office assistant told the patient that some burning is normal because vinegar is an acid, but she noticed the patient was in more pain than normal.  The medical office assistant told Dr. Garrett about the unusual level of the patient’s pain.  Dr. Garrett examined the patient and determined the cotton balls had been soaked in TCA rather than in the vinegar/sterile water solution.  Dr. Garrett flushed the patient’s vagina with copious amounts of water and applied K-Y jelly to her skin.  He prescribed Premarin vaginal cream twice per day and asked that she return to see him in 3 days.  For the next 10 months, the patient was treated with creams, physical therapy, a Tens unit, a nerve block, and steroid injections.

A lawsuit was filed against Dr. Garrett, the medical office assistant, and the hospital that employed the nurse who prepared the colposcopy tray.  (It is unknown why the patient did not also name the nurse as a defendant in the lawsuit.)  As of the time of the filing of the lawsuit, the patient continued to complain of pain, bleeding, depression, and the inability to have intercourse.

The nurse who prepared the colposcopy tray started working in Dr. Garrett’s office just 5 days before this incident.  She had previously worked for Dr. Mike Walker, another OB/GYN, for 3 years.  She was very familiar with the colposcopy procedure because Dr. Walker also regularly performed colposcopies.  Dr. Walker also soaked the cotton balls in a vinegar/sterile water solution.  However, the solution used in Dr. Walker’s office was in a premixed container labeled “Acetic Acid Solution” and was similar in size and color to the TCA container used in Dr. Garrett’s office.  Also, Dr. Walker did not use TCA in his practice, instead using CO2 to cryogenically burn genital warts.  Unfortunately, the nurse thought the bottle of TCA in Dr. Garrett’s office was the type of premixed vinegar/sterile water solution that was used in Dr. Walker’s office.  She saw the word “acid” and assumed it was the acetic acid solution.  She didn’t know that Dr. Garrett’s staff mixed their own solution and stored it in a gallon water jug.  This was the first time the nurse had ever used TCA.

The details that were overlooked in this case caused the wrong solution to be used during the colposcopy and made the overall defense of this case almost impossible. The nurse assumed the TCA container in Dr. Garrett’s office contained the same type of vinegar/sterile water solution that was in the container labeled “Acetic Acid Solution” in Dr. Walker’s office.  Another detail that was discovered by defense counsel after the lawsuit was filed is the fact that the nurse added handwriting to the label on the container of soaked cotton balls that said “Trichloroacetic acid.” The nurse had never used TCA, but if Dr. Garrett had read the label on the cotton ball container, he would have known that they had been soaked in TCA rather than in a vinegar/sterile water solution.  While it could be argued that Dr. Garrett should be able to rely upon the nurse to perform her duties appropriately and within the standard of care, a jury might reach the conclusion that Dr. Garrett should have taken the time to read the label that the nurse created and ensure that the cotton balls had been properly prepared.  Another reason this case would have been difficult to defend is the type of injury that the patient experienced. The patient’s medical bills over the 10+ months of treatment were significant, and juries have awarded high amounts for pain and suffering for injuries to sensitive areas of the body in the past.  Because of the difficulty in defending the care at issue in the case, the type of injury the patient experienced, and the extended medical treatment that was required because of the injury, SVMIC and the hospital entered into a joint resolution of this case.

As was mentioned at the beginning of this article, details can be very important in many situations, and that would include the treatment of patients.  While it is understandable that medical practices are very busy, it is always a good practice to remember the importance of noticing and acting upon each detail in providing medical treatment to a patient.