WMBA 6604 Week 2 Malpractice Liability Analysis Example

Discharged After One Troponin: A Malpractice Liability Analysis of a Missed Heart Attack in a Pennsylvania Emergency Department, Element by Element, With the Hospital's Own Exposure and the Element Most Likely to Fail

Student Name

Walden University

WMBA 6604: Law, Ethics, and Policy in Healthcare Administration

Instructor Name

Month Day, Year

Discharged After One Troponin: A Malpractice Liability Analysis of a Missed Heart Attack in a Pennsylvania Emergency Department, Element by Element, With the Hospital's Own Exposure and the Element Most Likely to Fail

The Scenario

At 9:40 p.m. a 52-year-old man came to Conestoga Ridge Medical Center's emergency department, at an invented community hospital near Lancaster, Pennsylvania, with two hours of chest pressure that eased while he waited. His electrocardiogram showed no acute changes. One high-sensitivity troponin drawn at 10:05 p.m. was within the normal range. A physician employed by a contracted emergency medicine group discharged him at 11:30 p.m. with a diagnosis of chest wall pain and instructions to see his family doctor that week. No second troponin was drawn and no risk score was documented. At 6:15 a.m. he returned by ambulance with an anterior myocardial infarction. He survived after a stent was placed, with a reduced ejection fraction that ended his work as a commercial electrician. He sued the physician, the physician group and the hospital.

Duty

A physician who examines and treats a patient in an emergency department owes that patient a duty of care; the relationship arose when the physician took responsibility for the evaluation. The hospital owes its own duties, discussed separately below, because it accepted the patient through its emergency department and controlled the protocols, staffing and laboratory used in his care. Duty is not seriously contestable here.

Breach

The legal yardstick is the conduct of a careful emergency physician facing the same facts, a benchmark a jury learns from expert witnesses. The plaintiff's expert would rely on the 2021 chest pain guideline of the American Heart Association and American College of Cardiology, which recommends a structured risk assessment for patients with acute chest pain and, where a single troponin cannot rule out injury, serial measurements at intervals set by the assay (Gulati et al., 2021). A patient whose symptoms began about two hours before the first draw falls in the group for whom one normal value does not exclude a heart attack, because troponin may not have risen yet.

Measured against that standard, three facts suggest breach: no second troponin, no documented risk score and a discharge diagnosis that no examination finding in the record supports. The defense would argue that guidelines describe good practice rather than the legal minimum and that the physician exercised judgment. That argument is weakened by the absence of any note explaining the judgment. A choice to depart from a guideline can be defended; a silent departure is harder to defend.

Causation

Causation has two parts. Factual causation asks whether the breach contributed to the harm; legal causation asks whether the harm was the kind of result the breach made likely.

Factual causation is where the case is weakest for the plaintiff. Had a second troponin been drawn around 11 p.m., it may have risen and led to admission, anticoagulation and earlier catheterization. But the heart attack may also have developed later in the night from a plaque that would not have been detected or treated in time. Pennsylvania eases the plaintiff's burden on this point through an increased-risk rule (Hamil v. Bashline, 1978): when a defendant's negligence increased the risk of harm and the harm occurred, the question whether the increased risk was a substantial factor goes to the jury, even when the expert cannot say the outcome would certainly have been avoided. The plaintiff's expert need only testify, to a reasonable degree of medical certainty, that the discharge increased the risk of the injury that followed.

Legal causation is straightforward. Damage to the heart muscle from an untreated infarction is exactly the harm that the standard of serial testing exists to prevent.

Damages

Damages are itemized by category. Economic damages include past and future medical expenses for cardiac care and rehabilitation, and lost earning capacity: the plaintiff was 52, earning about $78,000 a year, and can no longer do physical electrical work. Noneconomic damages include pain, suffering and loss of life's pleasures, which Pennsylvania does not cap in medical cases. His wife may bring a claim for loss of consortium.

Table 1

Damages by Category

Composite figures for a classroom case.

The Hospital's Own Exposure

The hospital faces exposure in two ways even though the physician is not its employee.

The first is vicarious liability through ostensible agency. Section 516 of Pennsylvania's medical liability statute provides that a hospital may be held liable for a physician's negligence when a reasonably prudent person would be justified in believing that the care was being provided by the hospital, or when the hospital advertises or holds the physician out as its agent (Medical Care Availability and Reduction of Error Act, 2002). A patient who walks into a hospital emergency department and is treated under the hospital's name, by a physician wearing a hospital badge, rarely knows that the physician works for a contracted group. Unless the hospital's consent form and signs gave clear notice, this claim is strong.

The second is the hospital's own corporate negligence. The Pennsylvania Supreme Court has recognized that a hospital owes patients nondelegable duties, including duties to staff the hospital with competent physicians and to write and actually enforce rules that keep care safe (Thompson v. Nason Hospital, 1991). If Conestoga Ridge had no chest pain protocol requiring serial troponin testing, or had one that it did not enforce, the plaintiff can argue the hospital breached its own duty. The plaintiff must also prove the hospital had actual or constructive notice of the practice that caused the injury.

The Element Most Likely to Fail

Factual causation is the element most likely to fail. Duty is clear, breach is supported by a national guideline and an undocumented departure, and damages are substantial. But whether a second troponin at 11 p.m. would have changed the course of an infarction that declared itself seven hours later depends on cardiology testimony, and a defense expert can argue the event began after discharge. The increased-risk rule in Pennsylvania means the question will probably reach a jury, which raises the settlement value of the case even if causation remains genuinely uncertain. For the hospital, the practical lesson lies upstream: a protocol requiring a documented risk score and serial testing would have protected both the patient and the hospital.

References

Gulati, M., Levy, P. D., Mukherjee, D., Amsterdam, E., Bhatt, D. L., Birtcher, K. K., Blankstein, R., Boyd, J., Bullock-Palmer, R. P., Conejo, T., Diercks, D. B., Gentile, F., Greenwood, J. P., Hess, E. P., Hollenberg, S. M., Jaber, W. A., Jneid, H., Joglar, J. A., Morrow, D. A., . . . Shaw, L. J. (2021). 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain. Circulation, 144(22), e368-e454. https://doi.org/10.1161/CIR.0000000000001029

Hamil v. Bashline, 392 A.2d 1280 (1978).

Medical Care Availability and Reduction of Error Act, 40 Pa. Stat. § 1303.516 (2002).

Thompson v. Nason Hospital, 591 A.2d 703 (1991).