Medical Malpractice and Formation Medical Career


Medical malpractice has always been one of the most complicated investigation subjects due to a variety of pitfalls when resolving a court case. As a result, a single case can be addressed in court for several years, followed by a number of appeals. A prime example of such a sophisticated medical malpractice case is the case of R. Iturralde v. Hilo Medical Center USA. The case considered surgeon’s malpractice, along with a series of appeals presented by the defendant aimed at justifying illegal actions.

The stakeholders of the case included the plaintiff – Rosalinda Iturralde, the patient’s younger sister, and caretaker, and the defendants – Hilo Medical Center in Honolulu, State of Hawai’i, Hawai’i Healthcare Corporation (collectively HMC), and Dr. Robert Ricketson (Iturralde v. Hilo Medical Center USA, 2012). In 2001, Arturo Iturralde underwent a surgery, during which a screwdriver shaft was inserted into his spinal cord instead of titanium implant rods. Dr. Robert Ricketson, the surgeon who implanted the shaft, failed to inform the patient about the incident. As a result, the patient’s condition deteriorated quickly, and he died from urosepsis. The first court held the HMC and the Dr. Ricketson jointly responsible for the incident. However, the court did not follow the decision of the jury, as it appointed 75% of harm to Arturo to pre-existing conditions. Thus, the case was brought to the court of appeals to deal with the problem. The primary aim of the following paper is to define the significant legal components and policies related to the case that would potentially influence the events’ outcome.

Medical Malpractice Component

Legal Components

In terms of the medical law system, the very notion of law consists of various of semantic paradigms that define the idea of securing one’s right to access proper healthcare. Law, being a framework of rules and responsibilities that later form a foundation for ethical behavioral patterns, is a ground terminal for further defining the malpractice case components (Phahlamohlaka & Coetzee, 2018). Speaking of the following malpractice case, some of the significant components of the case should be outlined in order to conduct further analysis:

  • Case partie: The case’s plaintiff party is represented by the victim’s caretaker and relative – Rosalinda Iturralde. The defendant parties were Hilo Medical Center in Honolulu, State of Hawai’i, Hawai’i Healthcare Corporation (collectively HMC) and Dr. Robert Ricketson
  • Facts and circumstances: Speaking of the facts and circumstances that led the parties to the court, the following precedents might be outlined: (a) malpractice case demonstration, which involved a former surgeon implementing a piece of a screwdriver into the patient’s spine; (b) steady worsening of the patient’s condition after the surgery; (c) doctor’s attempt to hide the surgery details from the hospital and caretakers; (d) nurse’s statement on the committed malpractice that eventually led the case to the state court.
  • Question or fact decision: The case’s central issue is related to the extent to which the defendant party should be held responsible for the incident’s outcome. When it comes to the rule of law applicable to the situation, there were no questions, as the issue was regarded through the prism of Chapter 662 of Hawaii Revised Statutes (HRS).

There are five central elements of negligence that should be proven to hold the defendant liable for negligence. First, it is crucial to prove that the defendant had duty before the plaintiff. In the discussed case, HMC and Dr. Ricketson had the duty to perform a surgery. Second, the defendant needed to have breached the standards of fulfilling the duty before the plaintiff. The standards were breached, as a screwdriver shaft was implanted instead of titanium rods. Third, the plaintiff needs to prove the fact that the breach led to significant harm. The cause-effect relationships were confirmed during the first hearing, as installation of screwdriver shaft led to deterioration in the patient’s condition. Fourth, the plaintiff needs to prove that there was a proximate cause. Finally, the plaintiff needs to confirm that harm actually happened. In this case, the harm was evident, as the patient died.

Malpractice Policies

When dealing with malpractice management in terms of local healthcare, it is essential to outline all the legal system policies that could potentially be applied to the case. First, the vast majority of the legislative foundation for the medical malpractice cases is described in the HRS document that encompasses the scope of legal communication between the parties. Moreover, Hawaiian federal law presupposes a series of policies accountable for the malpractice incidence. The variety of these policies sometimes formulates a significant dissonance when discussed in court. For example, Hawaiian medical workers are inclined to apologize for the damages provided without acknowledging one’s fault as evidence (Medical Malpractice Center, n.d.). Hence, it might be concluded that the discussed malpractice case, while justified by several policies aimed at defending the consumers’ rights, could still become a subject of controversy due to the same procedures.

There could be a variety of malpractice policies that could have prevented the incident from happening. For instance, the hospital should have had a policy of making an inventory of all shipments and comparing them to the orders made. At the same time, the hospital may have had the policy to complete a checklist that everything is ready for the surgery. Moreover, the hospital needs to have a list of actions that should be performed in case of emergencies during the operation. For example, the hospital should require that the surgeon should make the decision only with the permission of the Chief Medical Officer. Implementation of any one of the policies listed above could have prevented the harm.

Standards of Care

The worldwide healthcare policy development process is followed by a variety of standards that encourage the best possible experience for the patients. In the context of the following malpractice case, one of the significant worldwide care standards was breached. When asking for professional help from the medical facilities, people expect the procedures to be legally approved by federal institutions (Frakes & Jena, 2016). In the Iturralde case, the patient was intentionally cured in the ways unapproved by the medical policies, putting one’s life in danger even because the doctor was to act fast. The present case held the defendant viable for violating HRS §663-10.9 and HRS §663-10.5

Cultural Background

Almost everyone would agree upon the statement that any violation of medical competency has no ethnic affiliation whatsoever, making it inappropriate for any culture. However, the cultural background of the defendant might influence how the breach could be handled. First, the overall American sense of individualism has always been a driving force for the court proceedings and a continuous appealing process. Thus, people with different cultural backgrounds might not make much effort to resolve the case with the best possible profit from the decision. In the present case, the cultural background was not considered. In particular, the patient was not an English speaker. This implies that he did not realize the fact that he was implanted a screwdriver shaft instead of a titanium rod, as the surgeon could not inform him dew to the language barrier. The hospital failed to find an interpreter or call the relatives to inform the patient about the problem. Only the nurse realized that she could communicate the problem to the caregiver of the patient.


Speaking of the case accountability, the Hawaiian law presupposes the responsibility division between the healthcare facility and the employee to the extent which would correspond to the level of the damage caused for the patient. In the following case, HMC was entitled to cover 25% of the damages, leaving the rest for Dr. Ricketson to pay. However, the decision was appealed in a number of ways in order for the doctor to cover the whole amount of damage fee without being divided between defendants. Hence, taking everything into consideration, it might be concluded that the following malpractice case is quite exhaustive in terms of guilt definition, while the question of responsibility division was unclear and required a series of appeals to define the extent to which defendants were to be held responsible.

Ethical Component

Ethical Issues

When making a decision about pursuing a medical career, an individual is to take full responsibility for one’s actions due to their major and direct impact on other people’s life expectancies and health. Thus, it goes without saying that medical employees are to preserve some moral obligations when dealing with the treatment process. According to Almoallem et al. (2020), the most common problems medical personnel faces are disagreement with treatment, conflicts with relatives, conflicts with administration policy, and making decisions about do-not-resuscitate or life-sustaining treatment. In the discussed case, Dr. Ricketson violated the hospital’s policy and did not check if the titanium rods were ready for implantation. Additionally, he made the decision towards a dangerous treatment instead without consulting with colleagues. Finally, the surgeon failed to inform the patient and his relatives about the mistake. In other words, Dr. Ricketson was negligent before the operation and tried to cover the negligence by ignoring the principle of non-malfeasance and failing to inform all the stakeholders about the incident.

Ethical Theories

All ethical theories, including utilitarianism, rights-based ethics, duty-based ethics, justice-based ethics, and virtue-based ethics result in reaching a decision based on various approaches to the same issue. The perception of these decisions is often modified when experienced in terms of some stressful situations that require immediate action (O’Mathúna et al., 2018). Hence, while some of the theories are used in favor of the ones who bring the most benefit to society in general, others are based upon the fact that every human being was born as an individual with exclusive rights to live a long and happy life. Whereas all of the theories might contradict each other at some point of discussion, all of them help practitioners justify their decisions through the prism of causal connection.

However, when any of the theories are applied to the Iturralde v. HMC case, it becomes clear that all of the basic human rights were neglected by the healthcare practitioner. The patient, as a human being in the first place, was entitled to receive proper medical aid regardless of his virtue or social benefit. According to the primary sociology patterns, such behavior would only be appropriate in cases when many lives are simultaneously at stake, making it mandatory to choose the ones who deserve to be saved more than others, still regarding this behavioral pattern as dehumanizing. Hence, when there is no major need to choose people according to their theoretical efficiency in society, the rights-based theory is the most suitable foundation to resolve the situation. The surgery held by the practitioner was primarily aimed at preserving one’s health, making it a major goal to justify fundamental human privilege to live. In terms of the rights-based theory, hence, it was the surgeon’s task to ensure one’s life duration instead of searching for an immediate situation outcome.

Shared Decision-Making Model

Over the past years, the issue of interpersonal communication in terms of the treatment process has become a subject for a continuous discussion due to the dissonance in the process of patients advising on their treatment. Whereas many practitioners still tend to avoid discussing the details of the treatment plan with individuals, researchers have been actively trying to define the most beneficial model of shared decision-making in order to involve patients in the process to an extent safe for their physical and mental health. Agency for Healthcare Research and Quality (AHRQ, 2020) recommends a coherent shared decision-making model named SHARE. The model is based upon five steps: seeking the patient’s participation, helping the patient to understand possible treatments, assessing values and preferences, reaching a decision with the patient, and evaluating the patient’s decision (AHRQ, 2020).

The negative consequences of implanting a screwdriver shaft instead of a titanium rod were obvious. Therefore, Dr. Ricketson should have followed the five steps described above to decrease associated risks and enable patient’s participation in selecting a treatment instead of trying to conceal the fact of malpractice. Implementing SHARE is associated with increased patient satisfaction and decreased will to bring care providers to court (AHRQ, 2020). At the same time, Dr. Ricketson should have considered the cultural differences and tried to involve the family in the decision-making process to avoid language barrier problems. Rosalinda could have been of great help during treatment, as she would explain to her brother all the options and helped the care providers avoid being sued for malpractice.

Proposing and Defending Ethical Guidelines

Ethical guidelines should focus on four basic principles of health care are autonomy, beneficence, non-maleficence, and justice. Thus, it is crucial that healthcare organizations should have ethical guidelines for malpractice cases based on these principles (Gilman & Bedigian, LLC). First, such guidelines should insist on immediate disclosure of the case of malpractice to the patient and other central stakeholders, as this promotes autonomy. Second, these guidelines should include exploring the options with the patient for further treatment and selecting, as it also promotes autonomy. Third, after the patient selects the desired option, care providers should assess it in terms of possible harms and benefits to promote beneficence over maleficence. Fourth, the option should be assessed for any legal issues to promote justice. Finally, all the crucial stakeholders, including families and caregivers are to be consulted to confirm that the selected options suits everyone. These simple guidelines promote all four general principles of healthcare ethics and decrease the chances of malpractice trials.


Preventative Strategies

The analysis of the case revealed that the hospital could have utilized several preventative strategies to avoid malpractice cases. First, preparedness for all the surgeries should be confirmed by at least two people. Both people need to sign a form that confirms that everything is ready for the surgery. All the possible concerns should be listed before the surgery in the document to make the final decision if it can be performed. Second, in case of emergencies, shared decision-making is crucial to minimize the risks adverse events and malpractice cases. The decision should be made collectively by several care providers and family members or the patient. Third, any problems and unexpected events should be reported to the stakeholders immediately to make further assessments about the discourse of treatment. Finally, cultural issues should be assessed systematically, to ensure that all the beliefs and values are considered.

Defending the Recommendations

The rationale behind the recommendations listed above is evident. First, if the surgery could start only after two care providers had checked for the presence of all needed materials and equipment, Mr. Iturralde would not have been inserted a screwdriver shaft, as the surgeon would be stopped by the nurse. Second, shared decision making in the critical moments could have helped to assess the risks and minimize the possibility of adverse events. Third, reporting all the problems to patients and their families will raise the awareness of the situation and reduce misunderstanding between the stakeholders. Finally, assessment of cultural issues will ensure that the principle of autonomy is considered.


Agency for Healthcare Research and Quality. (2020). The SHARE approach — Essential steps of shared decisionmaking: Expanded reference guide with sample conversation starters. Web.

Almoallem, A. M., Almudayfir, M. A., Al-Jahdail, Y. H., Ahmed, A. E., Al-Shaikh, A., Baharoon, S.,… & Al-Jahdali, H. (2020). Top Ethical Issues Concerning Healthcare Providers Working in Saudi Arabia. Journal of Epidemiology and Global Health, 10(2), 143-152.

Frakes, M., & Jena, A. B. (2016). Does medical malpractice law improve health care quality? Journal of public economics, 143, 142-158.

Gilman & Bedigian, LLC. (n.d.). The ethics of medical malpractice. Web.

Iturralde v. Hilo Medical Center USA. [2012]. No. 28792.

Medical Malpractice Center. (n.d.). Hawaii medical malpractice laws. Web.

O’Mathúna, D., Dranseika, V., & Gordijn, B. (2018). Disasters: core concepts and ethical theories. Springer.

Phahlamohlaka, M. C., & Coetzee, M. (2018). CaseRank: Ranking case law using precedent and principal component analysis. In 2018 Conference on Information Communications Technology and Society (ICTAS) (pp. 1-6). IEEE.