Medical Errors and Malpractice in Pennsylvania
Systematic Failures in Medicine Are Preventable — and When They Harm Patients, They May Be Actionable
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Lupetin & Unatin, LLC represents Pennsylvania patients harmed by preventable medical errors.
There is a persistent myth in medicine — one that doctors and hospitals sometimes invoke in their defense — that medicine is an art, not a science. The suggestion is that outcomes are unpredictable, that mistakes are inevitable, and that holding physicians accountable for errors is somehow unfair given the complexity of what they do.
That argument has been dismantled by decades of patient safety research. The most dangerous medical errors are not the product of complexity. They are the product of system failures — failures to follow established protocols, use available checklists, and apply the same disciplined approach to patient care that pilots, engineers, and surgeons in other fields have used to make dangerous work safer.
When a patient is harmed because a physician or hospital abandoned a known, proven system of care, that harm may constitute medical malpractice under Pennsylvania law.
The B-17 and the Birth of the Medical Checklist
In 1935, Boeing’s prototype for the U.S. Army’s next long-range bomber crashed moments after takeoff, killing the pilot and two crew members. Investigation revealed the cause: the aircraft had become so complex that the pilot — an experienced test pilot — forgot to release a single locking mechanism while managing four engines, retractable landing gear, wing flaps, and multiple other controls simultaneously.
A group of Army test pilots devised a solution that was brilliant in its simplicity: a pre-flight checklist. With that checklist in hand, those same pilots flew the Boeing aircraft — which became the legendary B-17 — nearly two million miles without a single accident. The Army ordered 13,000 of them. The B-17 contributed to Allied victory in World War II.
The lesson: when tasks become complex enough that human memory alone cannot be trusted to catch every critical step, a systematic checklist is not an optional nicety. It is a safety requirement.
Medicine took decades to absorb this lesson. But the data, when it arrived, was impossible to ignore.
The Evidence: Checklists Save Lives in Medicine
In 2001, Dr. Peter Pronovost at Johns Hopkins Hospital created a simple five-step checklist for central line insertion — a common ICU procedure that was causing thousands of preventable infections each year. The checklist items were not new or experimental: wash hands, clean the patient’s skin with antiseptic, use a sterile drape, wear sterile equipment, remove the line as soon as it was no longer needed.
In a Michigan hospital system study, implementing Pronovost’s checklist reduced the central line infection rate to essentially zero — preventing an estimated 1,500 deaths and saving $175 million in healthcare costs over 18 months. The checklist was not rocket science. The results were extraordinary.
In 2009, the New England Journal of Medicine published results from a WHO-sponsored study of a surgical safety checklist implemented across eight hospitals in eight cities worldwide. The checklist contained nineteen items — none involving new technology or novel techniques. It required surgical team members to verify patient identity, confirm the procedure and surgical site, introduce themselves by name and role, confirm antibiotics had been given, and review anticipated critical events.
The results were striking: death rates fell by nearly half, and major surgical complications dropped by more than a third. At every hospital, in every city, the checklist worked.
When Hospitals and Physicians Abandon These Systems
The tragedy is not that these tools don’t exist. It is that they are not always used — and patients pay the price.
Today, the standard of care in Pennsylvania and nationally requires hospitals and physicians to implement evidence-based safety protocols in a wide range of clinical settings. These include:
- Surgical time-out protocols before every procedure to confirm patient identity, site, and procedure
- Hand hygiene compliance to prevent hospital-acquired infections
- Medication reconciliation checklists to prevent dangerous drug interactions and dosing errors
- Sepsis screening protocols in emergency departments to catch life-threatening infections early
- Obstetric safety checklists to reduce complications during labor and delivery
- Pressure ulcer prevention protocols for hospitalized patients
When a hospital fails to implement these protocols, or when a physician bypasses them, and a patient is harmed as a result, the failure is not a reflection of medicine’s inherent complexity. It is a reflection of institutional negligence — a breach of the standard of care that Pennsylvania law holds providers accountable for.
“Medicine Is an Art” as a Legal Defense
In malpractice litigation, defendants sometimes argue that the harm resulted from an acceptable exercise of clinical judgment — that medicine’s uncertainty makes accountability unfair. Pennsylvania courts have consistently rejected this argument when the evidence shows that the physician or hospital departed from a known, established protocol without clinical justification.
The standard of care in Pennsylvania is not perfection. Physicians are not liable for every bad outcome. But when a patient is harmed because a provider failed to follow a systematically validated practice — one that exists precisely to prevent that kind of harm — the “medicine is an art” defense does not hold.
The B-17 pilots did not argue that flying was too complex for a checklist. They used the checklist, and lives were saved. The standard of care demands the same discipline from the physicians and hospitals responsible for our lives.
Common Malpractice Cases Involving System Failures
At Lupetin & Unatin, we regularly investigate cases in which a failure to follow established protocols caused serious, preventable harm. Common patterns include:
- Surgical errors from failure to complete pre-procedure verification — wrong site, wrong patient, wrong procedure
- Sepsis deaths caused by emergency departments that lacked or ignored early recognition protocols
- Hospital-acquired infections from central line or catheter insertion without sterile technique
- Medication errors from failure to reconcile drug lists across care transitions
- Birth injuries caused by failure to follow obstetric emergency protocols
In each of these cases, the harm was not caused by the unavoidable complexity of medicine. It was caused by the failure to do something that was known, required, and achievable.
About Lupetin & Unatin, LLC
Lupetin & Unatin is a boutique medical malpractice and catastrophic injury firm based in Pittsburgh, Pennsylvania. We represent patients and families harmed by preventable medical negligence throughout Pennsylvania. Our attorneys are Fellows of the American College of Trial Lawyers, recognized by Super Lawyers and Best Lawyers in America, and have recovered millions of dollars for our clients.
We accept cases on a contingency fee basis. You pay nothing unless we recover for you.
Contact Us for a Free, Confidential Case Evaluation
If you or a family member were harmed by a preventable medical error in a Pennsylvania hospital or medical practice, contact us today. We will review your records, consult with medical experts, and give you an honest assessment of your case.