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CASE STUDY: Negligent Credentialing and Inadequate Emergency Response at Ambulatory Surgery Center Lead to Malpractice Lawsuit Following Patient Death

Jeanne E. Mapes, JD, CPCU, CPHRM


Claims involving improper credentialing often coincide with allegations of improper and inadequate training. This case examines a failed resuscitation effort at an ambulatory surgery center (ASC) in which credentialing issues, deficient emergency response procedures, and lack of staff training all contributed to a tragic outcome.

Case Details

The patient, Ms. P., was a female in her late forties suffering from a 6 cm left thyroid mass. She had a history of morbid obesity, obstructive sleep apnea, and reactive airway disease that she controlled with a daily inhaler. The patient also had tracheal deviation to the right. A thyroidectomy was scheduled for a follicular neoplasm on the left side.

The surgery was scheduled at an ASC, which was accredited as a hospital; the facility was owned by Dr. A (an otolaryngologist) and several other physicians. Following the thyroidectomy, the patient would need to stay overnight at the facility.

The ASC had patients sign a disclosure form that stated that the facility did not have an onsite physician after normal business hours, but that staff were prepared to handle emergency situations and trained in advanced cardiac life support and pediatric advanced cardiac life support. The form also stated that the ASC’s hospitalist made rounds at least once a day, and that patients’ physicians would be available by phone and contacted if needed.

The patient’s surgery went as planned without complications. The wound was closed with a liquid adhesive, and a Jackson Pratt drain was placed. The procedure was finished at 11:00 a.m. The surgeon, Dr. A, saw the patient in the recovery room about 45 minutes after the procedure was completed, and she was doing fine.

Shortly after the patient arrived in her room, she started to complain that her throat hurt and that it hurt to swallow. At about 1:00 p.m., the patient was offered hydrocodone-acetaminophen. She was worried that it would hurt too much to try to swallow it, so Dr. A ordered intravenous pain and antinausea medications.

The patient’s O2 saturation dropped to 84 percent and she was given a nonrebreather mask with 1 liter of oxygen flowing through it. Her oxygen level returned to normal. The next few hours were uneventful; she did not require continuous oxygen and was able to swallow ice chips. At around 6:15 p.m., the patient vomited undigested food, although she stated that she had not eaten anything since 8:00 p.m. the evening before.

A nursing shift change occurred between 6:30 p.m. and 7:00 p.m. The hospitalist, Dr. H, also arrived for his rounds around that time. The patient vomited again around 7:00 p.m.; Dr. H saw her at 7:10 p.m. and ordered ondansetron hydrochloride for nausea. Before the nurse could give the medication, the patient’s family came out of her room and said that the patient was having breathing problems. The nurse noted stridor. Dr. H suctioned the patient without any return.

The nurse ran down the hall and obtained a nasal airway and a bag-valve-mask resuscitator. The patient’s husband, who was a first responder, assembled the resuscitator and began ventilating the patient while the nurse inserted the nasal airway. Another nurse then took over the ventilation.

At this time, three physician owners of the ASC (an OB/GYN, an orthopaedic surgeon, and a urologist) were onsite attending a board meeting; Dr. A was attending the meeting via conference call. During the meeting, Dr. A learned from a nurse that the patient’s condition was deteriorating. He interrupted the meeting and asked the onsite physicians to visit Ms. P’s room and assess her.

At about 7:20 p.m., as the three physicians arrived in the patient’s room, she went into full cardiac arrest. A staff member called 911, and chest compressions were started. The orthopaedic surgeon tried to intubate the patient three times without success. Of note, he had not intubated a patient in 10 years. Bag ventilation continued throughout his attempts.

The nurse notified Dr. A of the evolving situation, and he began to drive to the ASC while remaining on the phone with the nurse. During the drive he learned that the onsite physicians were concerned that the patient might have a hematoma. Dr. A asked the onsite physicians to open the incision. While waiting for them to do that, he was told that they were looking for a scalpel. Dr. A informed them that the patient had a fresh wound that was closed with liquid adhesive; thus, they could open it with their fingers. Each of the onsite physicians, with the exception of Dr. H, was qualified to open the neck.

The neck was opened but no blood was found, and the patient continued to have respiratory distress. Dr. A asked whether the trachea was exposed and learned that it was. He then asked the onsite physicians to perform a tracheotomy. A scalpel was not on the crash cart, so a nurse went to find one. She had just procured one from an operating room on the other side of the small facility when the emergency medical services (EMS) crew arrived and took over the patient’s care. It is unclear whether a tracheotomy kit was on the premises; if it was, no one knew where it was located.

After one unsuccessful attempt, an advanced emergency medical technician was able to intubate the patient. The patient was transported to a local hospital. There, she developed anoxic encephalopathy and died 10 days later. An autopsy was not performed, and the cause of death remains unknown.

The patient’s estate initiated a malpractice lawsuit against Dr. A, Dr. H, the three physician owners who were onsite and assisted during the patient’s deterioration, and the ASC. The lawsuit was settled early in the discovery phase of litigation with a payment in the midrange; defense costs were in the low range.


Several factors converged to contribute to the devastating outcome in this case and the subsequent malpractice lawsuit. The first issue was a failure on the ASC’s part to properly credential Dr. H, the employed hospitalist.

Negligent credentialing refers to a type of liability in which a patient is injured by an incompetent or unqualified healthcare provider, and the healthcare organization is directly responsible to the patient because of a failure to properly conduct the credentialing process.1 Credentialing is not just the process of confirming a healthcare provider’s degrees, certifications, and training — nor does it end with the gathering of external credentials. The information obtained during credentialing needs to be reviewed with a critical eye.

In this case, red flags should have been raised during the review of the Dr. H’s credentials. Following his completion of medical school, he performed various jobs for almost a decade before entering a residency program and training as a neonatologist. Additionally, he had attempted to get board certified in neonatology numerous times without success. This information should have resulted in further questioning and review of Dr. H’s education and experience to determine whether he was competent and qualified to serve in a hospitalist role treating adult patients.

Credentialing also requires professional practice review. The healthcare provider who is undergoing credentialing needs to demonstrate that he/she can provide competent care to the organization’s patient population. Thus, new employees should undergo a proctoring or performance-monitoring period. No evidence was available that Dr. H’s performance was ever monitored, or — if it was — what standards were used.

The ASC should have had a hospitalist on staff that could anticipate and handle postoperative complications related to all types of procedures done at the facility, including the neck procedure performed in this case. Dr. H should have been competent to open the neck, deal with postoperative respiratory complications, and intubate an adult patient with a difficult airway, as well as any other core competency for a hospitalist.2 Interestingly, during his deposition, Dr. H said that he did not consider himself to be a hospitalist, and he confirmed that he was not qualified to open the patient’s neck or trained to do a tracheotomy.

Further, the ASC’s own medical staff bylaws stated that the covering physician should be board-certified or board-eligible in internal medicine. Both the ASC and Dr. H failed to recognize that he was not competent to act as a hospitalist at this facility.

In addition to negligent credentialing, other issues related to emergency response procedures and staff training also were evident in this case. The facility did not have proper equipment to handle airway emergencies, the physicians and nurses were unaware of what emergency equipment was available and where it was located, and a lack of emergency training led to a chaotic response when the patient went into full cardiac arrest.

To address the potential for medical emergencies, the facility should have had a written emergency response plan. That plan should have been based on an all-hazards risk assessment that identified the types of emergency situations that might likely occur in the facility. If an assessment had been done, airway compromise would have been identified as a recognized complication of neck surgery. In turn, the physician owners could have implemented a training and competency evaluation program to ensure that all providers and staff members were prepared for this possibility.

Beyond initial training and competency evaluation, annual training should have occurred to confirm that providers and staff members were prepared to respond quickly and appropriately to a situation involving a compromised airway. Training drills would have revealed any weaknesses in the response plan, particularly in relation to having and locating necessary emergency equipment.

Unfortunately, the staff’s inability to locate a difficult airway kit, the lack of a scalpel on the crash cart, and the failure to successfully intubate the patient while waiting for EMS wasted precious minutes during the emergency response, which may have contributed to her death.

This case had many unresolved questions as a result of the settlement occurring early in the discovery process. For example, why was Dr. H hired for a hospitalist position? Did the facility lack a proper credentialing process, or was the process not followed correctly? Why were the organization’s own bylaws requiring board certification or eligibility in internal medicine ignored? Without answers to these questions, understanding the full picture of this case is difficult.

In Summary

Despite the lingering questions in this case, what is known is that proper credentialing of healthcare providers and validation of competency is essential for safe patient care. Medical staff bylaws should define minimum credentialing requirements for practitioners and provide the framework for administrative procedures and processes to ensure that medical staff can provide safe and competent care.

Further, all healthcare organizations need to assess their potential risks for medical emergencies, develop thorough response plans, validate that providers are qualified to perform emergency procedures (e.g., tracheotomy), and conduct adequate emergency response drills for providers and staff members during orientation and routinely thereafter.

For more information, see MedPro’s guideline titled Credentialing and Privileging and article titled Managing Medical Emergencies: A Three-Pronged Approach for Healthcare Practices.


1 Watkins, A. E. (2005). Negligent credentialing lawsuits: strategies to protect your organization. Retrieved from http://hcmarketplace.com/media/supplemental/3664_browse.pdf

2 Nichani, S., Fitterman, N., Lukela, M., Crocker, J., & Society of Hospital Medicine. (2017). The core competencies in hospital medicine 2017 revision. Section 2: Procedures. Journal of Hospital Medicine, 12(4 Suppl 1), S44–S54.

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