Dr. M didn’t understand it, but was determined to find a cause. He reviewed the patient’s records, he looked at the clindamycin vial, he replayed exactly what had happened … and then he thought to check the written protocols for the intraocular injection, and his stomach dropped. The instructions called for the clindamycin to be diluted with saline prior to injection – something that Dr. M had not done.

He paused outside the exam room, and took a deep breath. Then he walked in, and explained to the patient and her husband what had happened. In the chart, he noted what happened during the visit, including that he had discussed with the patient and her husband “the matter of concentration of clindamycin injected into the left eye.” The dazed patient and her equally stunned husband left the office, and Dr. M sunk into a chair. He felt terrible about the error, and it would haunt him for months to come.

Subsequently, Mrs. F had a total of seven surgical procedures (by other physicians) to attempt to correct the vision loss in her left eye, but they were unsuccessful. Mrs. F was left with almost no vision in her left eye.

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Dr. M was not surprised when he received notification that he was being sued for medical malpractice. He had expected it ever since he confessed the error to the patient, and it was almost a relief when it finally happened. The physician met with the defense attorney provided by his insurance company, and explained the whole situation.

 “I see,” said the attorney, thoughtfully. “This sounds like a situation where a settlement might be the best option.” The case was settled, but only after the process of discovery had begun, and after Dr. M acknowledged responsibility for the error during a deposition. The settlement was for the maximum limit on his medical insurance policy.