HLT-313V Topic 2 DQ 1

Using the GCU Library, locate and summarize an allied health malpractice or negligence case study. If possible, select a case within your chosen field of study. What went wrong? What workplace safety, risk management, and/or quality improvement steps were involved? What could have been done differently? If you were in charge of making sure this type of event never occurred again, what steps would you implement into the risk management plan?
You are required to use and cite a minimum of two references from the GCU Library to support your response.

Solution

I found a malpractice case involving a sonographer who failed to detect a serious fetal abnormality during a routine 20-week ultrasound. The patient was told that everything looked normal, but after the baby was born, it was diagnosed with a congenital condition that should have been visible during the scan. The parents filed a malpractice lawsuit, stating that they were not properly informed and weren’t given the chance to prepare emotionally, financially, or medically for their child’s condition. According to a study by Johnson and Lee (2020), misdiagnosis during obstetric sonography is often linked to poor image quality, inadequate training, or rushed procedures. In this case, the ultrasound images were blurry and incomplete. Even though the sonographer was unsure about the quality of the images, they still finalized the report without seeking a second opinion or recommending a follow-up scan. This caused the OB-GYN to believe everything was fine, and no further testing was ordered. What went wrong in this situation was a breakdown in communication and a lack of proper risk management protocols. There were no steps in place for double-checking questionable scans or requiring confirmation from a second sonographer or radiologist. Workplace safety was not directly violated, but patient safety was definitely impacted. The lack of a quality improvement system meant that there was no review process to catch the mistake before it caused harm. As noted by Smith et al. (2021), implementing peer review systems in diagnostic imaging departments greatly reduces diagnostic errors and improves patient outcomes. If I were responsible for making sure this never happened again, I would first require a scanning protocol checklist to be completed with each ultrasound. I would also develop a peer review process, especially for high-risk pregnancies or unclear results. Ongoing training and continuing education should be mandatory to keep sonographers up to date with current standards. Finally, I would promote a work culture where sonographers feel comfortable asking for help when they are uncertain. These steps would help prevent future misdiagnoses and promote safer, higher-quality patient care.

Johnson, R., & Lee, M. (2020). Diagnostic errors in obstetric ultrasound: Causes and prevention. Journal of Diagnostic Medical Sonography, 36(2), 85–91. https://doi.org/10.1177/8756479320901132

Smith, T., Alvarez, K., & Chen, D. (2021). Peer review and quality assurance in sonography: A strategy for reducing medical errors. Journal of Allied Health, 50(4), 212–218. https://doi.org/10.3109/00900000.2021.1945932

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