H E A L T H L A W The “O-Ring” in Medical Malpractice Cases ■ JOHN SHUFELDT, MD, JD, MBA, FACEP T he moment is forever etched in my mind. It occurred while I was in my fourth year of medical school during a radiology rotation in Scottsdale, AZ. I was doing everything I could not to fall asleep while sitting in the dark film-read- ing room, listening to a tonally flat radiologist dictate plain film reports. I got up to splash some cold water on my face and as I was walking back from my drinking fountain bath, I witnessed history. On that cold day in January (36 degrees in Florida at launch time) the Challenger spacecraft took off from Cape Canaveral, FL carrying six astronauts and one civilian school teacher. Fifty-nine seconds into the flight, two “O-rings” failed which allowed hot gasses and flames from the booster en- gine to burn through the joints holding the solid rocket booster to the external fuel tank, ultimately causing an ex- plosion and the disintegration of the Challenger. The subsequent 12,000-page document produced by the blue ribbon panel appointed to review the disaster opened Chapter 5 of their report with this understatement; “The de- cision to launch the Challenger was flawed.” Engineers at Morton Thiokol, the group that designed the solid rocket motor, never tested the O-rings below 53 de- grees. They warned NASA engineers repeatedly about their concerns and argued unsuccessfully to delay the launch. NASA, at the time, was under immense pressure to get the flight off and ultimately disregarded the warnings. I use the Challenger disaster to illustrate a point common to most medical malpractice events: It is seldom one mistake or error that leads to a medical misadventure that ulti- mately results in a malpractice suit. John Shufeldt is the founder of the Shufeldt Law Firm, as well as the chief executive officer of NextCare, Inc., and sits on the Editorial Board of JUCM. He may be contacted at JJS@shufeldtlaw.com. w w w. j u c m . c o m I will use a case I recently was involved in as an attorney to further illustrate this point. At the end of the brief overview, I will review all the different medical “O-rings” which allowed the event to occur unchecked. Case History A health plan nurse triage line instructed a 35-year-old obese woman complaining of chest pain and shortness of breath to go to a local urgent care center for evaluation. Du- tifully, the patient presented to an urgent care center located in her Eastern seaboard hometown with the complaint of a non-productive cough, URI symptoms, and chest pain with deep breath. Upon questioning, she admitted to dyspnea on exertion and was in fact tachypneic on presentation. Her heart rate was recorded at 120 beats per minute. Her temperature, weight, and BP were not recorded. Her pulse ox was 92%. She was a smoker and on oral contraceptives; however, nei- ther of these facts were recorded on the patient-completed medical history assessment because the pen she was given ran out of ink and the staff were in a hurry to close up for the day so they accepted the partially completed form. Further history was not obtained. If it had been, however, it would have revealed that the patient had just returned from Hawaii three days before her visit. The patient’s brief exam was recorded as unremarkable JUCM T h e J o u r n a l o f U r g e n t C a r e M e d i c i n e | A p r i l 2 0 0 8 37