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[A case of unrecognized iatrogenic cardiac tamponade with the pareneteral nutrition fluid]
V A Fetisov1, S V Shigeev1, A A Gusarov1
1Federal state budgetary institution 'Russian Centre of Forensic Medical Expertise', Russian Ministry of Health, Moscow, Russia, 125284.
Insights
Medical errors, such as unrecognized cardiac tamponade during central venous catheterization, highlight the need for improved forensic medical expertise. Human factors often underlie inadequate medical care, regardless of facility.
Area of Science:
- Forensic Medicine
- Medical Law
- Medical Malpractice
Background:
- Commissionary expertise in medical practice presents unique challenges.
- Iatrogenic injuries during medical procedures require careful expert evaluation.
- Central venous catheterization is associated with potential complications.
Observation:
- A case of fatal cardiac tamponade due to parenteral nutrition fluid extravasation during subclavian vein catheterization is presented.
- The injury to the right atrium resulted from unrecognized iatrogenic cardiac tamponade.
- The patient's death was attributed to an unsafe catheterization technique.
Findings:
- Complexities in commissionary expertise necessitate attention from forensic medical experts and legal practitioners.
- Subjective, or "human," factors are frequently the primary cause of inadequate medical care.
- Such errors can occur in any healthcare setting, irrespective of resources or staff qualifications.
Implications:
- Enhanced training in procedural complications and diagnostic acumen is crucial for healthcare providers.
- Legal and medical professionals must collaborate to address challenges in medical malpractice cases.
- Systemic reviews and quality improvement initiatives are needed to mitigate human factors in medical errors.
Abstract:
The authors describe the peculiarities of the commissionary expertise with respect to medical practice and the difficulties facing this procedure using as an example a case of the lethal outcome caused by the injury to the right atrium as a result of unrecognized iatrogenic cardiac tamponade with the pareneteral nutrition fluid administered through the catheterized subclavian vein. It was shown that the great variety and complexity of the problems arising in such expertises should draw enhanced attention not only of forensic medical experts but also medical law specialists and other legal practitioners. It is argued that the majority of the cases of the inadequate medical care provided to the patients as exemplified by the case of death of the 43 year-old patient B resulting from the application of the unsafe technique of catheterization of the main blood vessels are usually due to the subjective ("human") factors. They may occur in any health care facility regardless of its location, staff composition and competence.
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