Changed Records
Nurse from Pennsylvania

Would it have been possible to prevent blindness in an extremely immature infant? Despite showing all the associated risk factors for development of retrolental fibroplasia (RLF), the infant’s eyes were not examined until the 121st day of life. The exam revealed bilateral retrolental fibroplasia at Grade V, with poor prognosis for vision. Medical Advisors was asked to determine whether or not an eye examination should have been done at an earlier date. If so, would that have prevented eye damage? Following birth, the infant was placed in the intensive care nursery for therapy of respiratory distress syndrome–Hyaline membrane disease. The child required mechanical ventilation for the first 60 days of her life, followed by an additional 60 days under an oxygen hood. During this time, the infant’s blood gasses were constantly monitored. More than 50 times during this period, oxygen concentration in the blood exceeded recommended levels. The infant did not begin oral feedings until her second month of life. She had received vitamin E shots on the second and fourth day of life, followed by daily oral vitamin doses, beginning in her third month of life. The child suffered from multiple septic infections, jaundice and anemia. The anemia probably resulted from the large amounts of blood drawn in order to monitor oxygen and electrolyte status.

Our expert observed that the standard timing for eye examinations is between four to six weeks after birth, since the disease usually makes its appearance between ten days and one month after birth. He also noted that vitamin E deficiency, as well as exposure to high concentrations of oxygen are associated with development of RLF. Most importantly, however, a critical discrepancy was noted in the records. In an apparent move to cover culpability, someone had altered the baby’s eye exam report to show Grade III, rather than Grade V. When presented with this apparent alteration in the records, the case was settled in the child’s favor.

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