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ITURRALDE V. HILO MEDICAL CENTER USA Anne Murtha
Instructor: Beverly Duncan, R.N., MHSA, CPHQ
IHP-450 Ethical & Legal Considerations 7.2 Final Project I: Malpractice Case
In this malpractice case Iturralde v. Hilo Medical Center USA, the plaintiff, Arturo
Iturralde had sued Dr. Robert Ricketson and Hilo Medical Center due to the fact that the patient
was exposed to several health risks while in their care and died as a result. The plaintiff’s sister
Rosalinda Iturralde, represented her brother in this case, as well as the patient’s care giver. On
March 30, 2012, The Intermediate Court of Appeals decided in favor of the plaintiff.
The patient Arturo Iturralde needed spinal surgery, which was to be performed by Dr. Richetson
at Hilo Medical Center. Hilo Medical Center ordered the hardware kit that usually contains all of
the required instrumentation and tools from Medtronic. However, Medtronic did not have the
required instrumentation portion of the kit in stock from their Memphis facility. To fix this issue
Medtronic shipped out two separate orders from two separate facilities: one from their Memphis
facility and the other shipment from their Tulane facility. Although both shipments were
received on the same day the staff at HMC failed to complete an inventory of the required
contents in the kit, which is a standard policy and procedure for HMC. Despite the fact that a
nurse informed Dr. Ricketson that the inventory had not been completed yet, the doctor
proceeded with the surgery. During the surgical procedure, it was discovered the required
titanium implant rods were missing. HMC called their Medtronic sales representative who 2
ITURRALDE V. HILO MEDICAL CENTER USA informed Dr. Ricketson that it would take ninety minutes to personally deliver these rods. After
hearing about the ninety minute delay Dr. Ricketson decided that the length of time was too risky
for the patient and instead, he himself made a makeshift rod using the half of a surgical stainless
steel screwdriver that was included in the kit. Dr. Ricketson then implanted it into the plaintiff’s
spine. At no time was the patient or his family ever informed that this was done.
During the patient’s recovery while working with PT, the patient sustained falls which caused the
makeshift shaft to shatter. A second surgery was required to remove the shattered fragments of
the screwdriver shaft and implant the proper titanium implant rods. At this time a surgical nurse
who was present in the initial operation was aware of Dr. Ricketson’s actions and reported the
incident to her supervisors. The surgical nurse was told by her supervisor that it was the
surgeon’s responsibility to communicate the incident to the patient. Dr. Ricketson’s failed to
communicate the incident yet again to either the patient or the patient’s family. So this nurse
contacted the patient’s family, obtained the shattered shaft and presented it to an attorney with
the case. After the patient was discharged from HMC, his condition deteriorated. The titanium
rods that were implanted became dislodged and the patient has to undergo two additional
surgeries, in additional the patient also requiring permanent catheterization. After multiple
hospital stays and emergency room visits the patient, Arturo Iturralde ended up passing away
from Urosepsis a Urinary Tract Infection. 3
ITURRALDE V. HILO MEDICAL CENTER USA Medical Malpractice Component
In this malpractice case, Dr. Ricketson failed to exercise a legal duty to perform in
conformance to the set of professional standards. These set of professional healthcare standards,
prohibits any decision and or action that would put their patient at risk. In addition, Dr.
Ricketson failed to confirm whether or not all of the required equipment was present prior to
executing the surgery. This is one of the highly regarded legal duties of a surgeon that is required
before any surgery. According to HMC’s policy, the kits should have been inspected and
inventoried prior to surgery. It was Dr. Ricketson’s actions and conduct of high level of
negligence and his deviation from the standard of care that is recognized by the medical
community which is at fault in this case. The “Standard of care refers to the ordinary skill and
care that all medical practitioners such as physicians, nurses, physician assistants, medical
assistants, and phlebotomists must use, as determined by their state license or certification and
that a “reasonable” person would use in a similar circumstance. This level of expertise is that
which is commonly used by other practitioners in the same medical specialty when caring for
patients” (Fremgen, 2016, p.61). Dr. Ricketson’s malpractice and level of negligence is believed
to have been the root cause of the patient’s health complications and ultimate death three years
after his initial surgery. In addition, due to Dr. Ricketson’s negligence, the non-party stated in the
case “Hawaii Orthopedics Inc”. was also accused of negligence as a direct result of hiring Dr.
Ricketson who had a well-known past history of negligence. Apparently Dr. Ricketson had
previous been dismissed from two other health facilities also due to malpractice.
The unfortunate death of patient Arturo Iturralde should have never occurred and could
have been prevented if HMC’s administration was informed of Dr. Ricketson’s poor code of
conduct in the first place. 4
ITURRALDE V. HILO MEDICAL CENTER USA When Dr. Ricketson agreed to take on a surgical operation on Arturo Iturralde, a legal
duty of care was established between the two. “While physicians are not obligated to treat
everyone (except in the case of an emergency), once a physician accepts a patient for treatment,
he or she has entered into the physician-patient relationship (contract) and must provide a certain
standard of care. This means that the physician must provide the same knowledge, care, and skill
that a similarly trained physician would provide under the same circumstances” (Fremgen, 2016,
p.61). As a trusted physician Dr. Ricketson was expected to use the proper equipment for the
procedure. The obvious breach of duty was the implantation of the screwdriver rather than the
required titanium rods. Dr. Ricketson’s actions contributed to the worsening health conditions
and ultimate demise for the patient.
Nurse Feldmeyer decided to take matters into her own hands and tried to inform Arturo
and Rosalinda Arturo’s sister and caretaker herself. However, she failed to do so affectively, due
to a language barrier. The patient Arturo Iturralde did not speak any English, therefore could not
follow nor understand what nurse Feldmeyer’s was trying to tell him. Furthermore, HMC
deemed fit to post a security guard at Arturo’s room. What was the purpose of posting a security
guard in the first place? To me that might suggest racial profiling towards Arturo Iturralde.
Although nurse Feldmeyer’s actions had the best intensions, she did not follow proper HMC’s
protocol. Even though she did immediately report the incident to her supervisors, where are the
supervisor’s actions towards Dr. Ricketson and the actions of HMC following up with nurse
Feldmeyer’s supervisors? That’s two more additional counts of negligence. The hospital should
of have had a nurse or a social worker that could speak Arturo’s language assigned to him. 5
ITURRALDE V. HILO MEDICAL CENTER USA Accountability
It is vital that all healthcare providers and healthcare institutions maintain
professionalism and adhere to standards of care and follow the code of conduct. Lack of
accountability was evident when Dr. Ricketson failed to wait for the required titanium rods for
the surgery. The staff that was working with Dr. Ricketson that day also failed and in my eyes
should be held liable for lack of accountability too. According to (Gasior, 2017), “When
healthcare organizations hold themselves and their employees accountable, they can learn from
mistakes and continuously improve operations. A culture of accountability in healthcare
improves doctor-patient trust, reduces the misuse of resources, and helps organizations provide
better quality care”.
When we review the facts in this case, HMC extended hospital privileges to a health care
professional who had serious pending disciplinary actions in three different states for numerous
violations. The appellant court asserted claims of negligence, negligent credentialing, breach of
warranty, and strict liability against the various defendants including HMC (Itrrualde vs Hilo
Medical Center n.d.). Medtronic the vendor that supplied the surgical tool kit was not held liable.
The jury found Dr. Ricketson 65% liable and HMC 35% liable. Arturo’s estate was awarded
$307,000 in special damages and $1.7million in general damages and $170,000 in general
damages to Arturo’s sister Rosalinda. Individually Dr. Ricketson was held accountable for $3.4
million in punitive damages against. According to the circuit court they held HMC liable for only
25% of total damages by the court. 6
ITURRALDE V. HILO MEDICAL CENTER USA Ethical Issues
Throughout this malpractice case there are several ethical issues of concern, while the
patient Arturo Iturralde was under the care of Dr. Ricketson and his staff at Hilo Medical Center.
On more than one occasion Arturo Iturralde’s quality of care was compromised.
From our text we learned that anyone working in the medical field has to abide by the
Code of Ethics and the Code of Conduct. As per Fremgen (2016), the medical staffs, especially
the patient’s surgeon are required by their professional Code of Conduct to look after the best
interest of the patient’s welfare, therefore minimizing any pain or suffering through any and all
means possible. Nurses also follow a Code of Ethics to “protect patients’ privacy, respect
patients’ dignity, maintain competence in nursing, and assume responsibility and accountability
for individual nursing judgments” according to (Fremgen (2016). According to the American
Medical Association (2001), “the Code of Conduct is not a law; they are standards of conduct that
define the essentials of honorable behavior for the physician”. Bottom line this means at no time,
should Arturo Iturralde’s quality of care, been compromised.
From the very beginning when the inventory was not inspected. Then even though a nurse
informed Dr. Rickerston that the inventory had not been completed, Dr Rickerston made the
decision to move forward with the surgery once again, compromising his patient’s care.
The patient nor his family, were ever informed, so the doctor nor his staff did not have
proper consent to move forward. The fact that Dr. Rickerston proceeded to modify the procedure,
utilized a make-shift rod using the half of a surgical stainless steel screwdriver that was included
in the kit, once again put Arturo Iturralde’s quality of care in jeopardy. As soon as the nurse
notice the proper inventory was never completed, the surgery should have been cancelled and 7
ITURRALDE V. HILO MEDICAL CENTER USA rescheduled. In addition, without his patient’s well being in mind, Dr.Rickerston continued to be
negligent by ordering Arturo Iturralde out of bed for physical therapy.
All of these decisions that Dr. Rickerston made deviates from the standard of care, which
Dr. Ricketson had an ethical and moral obligation to abide by Fremgen (2016). In addition, by the
utilization of un-approved and subpar equipment Arturo Iturralde suffered additional pain and
suffering that could have been avoided. Arturo Iturralde fell numerous times, the screwdriver
snapped and he eventually underwent three additional surgeries to correct the first mistake.
Furthermore, Iturralde suffered many chronic and painful medical complications after the initial
botched surgery (Itrrualde vs Hilo Medical Center n.d.). Ethically, none of this should have ever
happened in the first place.
There are three ethical theories according the Worlds Health Organization (2018), the
Utilitarian theory, which is “whatever action brings the greatest results to the greatest number
of people is the right action. Then there’s the Deontological theory, which “suggests that there
are rights and duties to behave a certain way”. Lastly the Communitarian theory, which
“suggests the idea of common good or a shared value, ideal or goal of a community”.
Healthcare practitioners are guided in their respective fields by ethical theories. Ethical theories
help to ensure issues are resolved and that there is a provision of quality, safety and the over-all
healthcare for the patients is upheld. In this case study, the deontological theory could have
helped to provide the guidelines to provide the proper care. According to Fremgen (2016),
deontological ethics means when the ends do not justify the means and any harm suffered, even to
obtain a positive outcome is unacceptable. Therefore, when Dr. Ricketson decided to utilize 8
ITURRALDE V. HILO MEDICAL CENTER USA improper medical devices during Arturo’s surgery and failed to convey this information to his
patient, he was acting unethical. It is the surgeon’s responsibility to legally and ethically up hold all
standards of care and failing to do so is a clear ethical breach.
Shared-Decision Making Model
Shared decisions, as opposed to clinicians making decisions on behalf of patients, is the
current acceptable standard of care. Shared decision making (SDM) is defined as, where
clinicians and patients share the best available information when faced with the task of making
difficult decisions, and where patients are supported to consider all of their options, to achieve
the best possible outcome . This is a patient centered care model along with ethical clinicians
help patients determine their own care. An example of is the informed consent for procedures.
Every aspect of the procedure, outcomes and any and all complications with the patient are
disclosed, according to Fremgen (2016). If Arturo was given the opportunity to decide for
himself, the outcome could have been different.
According to Fremgen (2016), all healthcare providers are bound by their duty to help
their patients achieve the best possible outcome, do no harm and quality of care. Due to the lack
of inventory of the surgery kit, and missing equipment, no good outcome could be had by
proceeding with the surgery. Due to the lack of consent and open lines of provider/patient
communication, no good outcome could be had. Since Arturo couldn’t consent to having a
screwdriver implanted in his back, no good outcome could be had. Based upon the professional,
ethical and legal misconduct implemented by Dr. Ricketson which lead to poor standard of care,
and ultimately and sadly resulted in Arturo Iturralde ‘s death. 9
ITURRALDE V. HILO MEDICAL CENTER USA Recommendations
My recommendations start from the very beginning with the physician credentialing
process. According to the American Academy Family Physicians (2018), the physician
credentialing process is utilized to evaluate physician’s qualifications which include a doctor’s
education, training, licensing, and residency as well as any specialty certifications. Hospitals and
facilities will even use outside organizations that will manage their physician credentialing
process for them or hire a credentialing manager to keep the process in house. In addition, proper
protocol must be adhered to at all times, meaning the inventory should have been reviewed prior
to surgery and verified with Medtronic in the first place. All that was needed was a phone call to
confirm the two shipments.
A nurse who could properly translate for Arturo and his family should have been assigned
to his case from the very beginning and be present during all of the patient conversation, in
addition to a Social Worker from HMA. From HMC’s perspective an entire team of
Administrators who should have been following up on nurse Feldmeyers concerns and interview
her supervisors as well. The supervisors should have also reported nurse Feldmeyers concerns.
Once again standard operating procedures.
As for Dr. Ricketson he should have confirmed the inventory was complete with his
surgical staff before starting the surgery. He should have never proceeded without the proper
instruments. He should have informed Arturo and his family for proper consent. He should have
never made a make-shift rod in the first place. He also should have never ordered Arturo up right
after the surgery. He should have monitored his patient more carefully and shown a general
interest for his well being and provided constant quality of care throughout the entire process. 10
ITURRALDE V. HILO MEDICAL CENTER USA Standard Operating Procedures have been put in place not only to protect the patients but
the staff as well as, per Rao & Radhakrishnan & Andrade (2011). There are SOPs written and
implemented for every hospital department. When SOPs are written and proper protocol is
executed the patient’s safety is assured. Had Dr. Ricketson, his staff and HMC followed
standard operating protocol, policies and procedures Arturo Iturralde might still be alive today. 11
ITURRALDE V. HILO MEDICAL CENTER USA References:
Fremgen, B.F. (2016). Medical law and ethics (5th ed.). Boston, MA: Pearson.
Iturralde vs Hilo Medical Center (n.d.)
Retrieved from: .
Gasior, M. (2017, June 26). Creating a Culture of Accountability in Healthcare.
Retrieved from - healthcare/
The World’s Health Organization. (2018). Three Ethical Theories.
American Academy Family Physicians. (2018). Hospital Credentialing and Privileging FAQs
Rao, T. S. S., Radhakrishnan, R., & Andrade, C. (2011). Standard operating procedures for
clinical practice. Indian Journal of Psychiatry, 53(1), 1–3.
Retrieved from: 12
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- Fall '18
- Ethics , Physician, Rosalinda Iturralde, Dr. Robert Ricketson, HILO MEDICAL CENTER USA