The tab to taxpayers has totaled more than $60 million in court judgments, out-of-court settlements and resolution of medical malpractice claims. The government, for instance, has paid more than $14 million to resolve about 150 claims since 1985. In one 1998 claim, a family received $130,000 for an incident in which a Tripler patient allegedly needed corrective surgery to remove a sponge left behind during an earlier operation.

Court judgments and out-of-court settlements have added about another $47 million to the tab. But that isn't a complete accounting, given that out-of-court settlements sometimes are not disclosed publicly.

In an October statement about Tripler's overall operation, officials said the hospital provides safe, compassionate, high-quality care. They said the malpractice claims against the hospital follow national trends, with more filed for high-risk care performed commonly, such as complex maternal care and neonatal intensive care.

"We see nothing in our data that suggests our care is less safe than at other military medical centers or civilian hospitals providing comparable services," the officials said in their written response to Advertiser questions.

In addition, they said Tripler remains accredited and certified "in every way" by outside organizations that evaluate its services.

Its main accreditation was renewed by the Joint Commission on Accreditation of Healthcare Organizations in December 2004, with the commission finding Tripler in full compliance with the reviewed standards. Accreditations come up for renewal every three years, though that scheduling will become more random beginning next year.

Tripler officials declined comment on cases in litigation: "We take each claim on its merit, investigate it and take appropriate action."

In November, Tripler officials told The Advertiser they would no longer respond to requests for information, directing further inquiries to the hospital's Mainland headquarters. Since then, that Texas office has not provided most of the information sought by the newspaper.

400,000 ELIGIBLE

The Moanalua Ridge hospital gets an estimated 50,000 patient visits a month, while another 14,000-plus occur at Schofield Barracks Health Clinics, part of the Tripler system. More than 400,000 people are eligible to receive care at Tripler.

The hospital also serves as a teaching institution for more than 1,200 medical personnel each year, including students at the University of Hawai'i medical school. That arrangement allows resident physicians or other trainees to work alongside their mentors, similar to what happens at other teaching hospitals in the state and elsewhere.

The vast majority of Tripler cases never generate malpractice complaints.

Many patients typically are satisfied with their care or, if something bad happens, are satisfied with the explanation.

Shigeo Doc Kawamoto, a veteran of World War II, counts himself among the people pleased with Tripler's services. He periodically gets medical tests done at the hospital.

"They take good care of me," Kawamoto said. "They treat me well."

Some patients are reluctant to pursue claims, while active-duty members are prohibited from doing so. Military personnel — about a third of Tripler's patient pool — are barred by law from filing malpractice claims against the U.S. government for injuries linked to their military service, even if an injury stems from gross negligence by a government worker.

For those patients or families who formally seek compensation, the first step is to file a malpractice claim with the government. If that isn't resolved within six months, a lawsuit can be filed in federal court. A judge, not a jury, renders a verdict.

Among the Army's seven medical centers in the U.S., Tripler's 331 claims and 61 paid claims over the past decade were second only to the totals at William Beaumont Army Medical Center, a hospital at Fort Bliss, Texas, that has 94 licensed beds. The Army didn't respond to requests asking about Beaumont's numbers.

Tripler officials said the hospital's malpractice claim statistics can't be compared with Army medical centers elsewhere because of differences in state laws, malpractice tort reform, the aggressiveness of malpractice attorneys and other local factors unrelated to quality of care.

Three local malpractice attorneys dispute that, saying a legitimate claim will be valid anywhere, regardless of the idiosyncrasies of a particular area.

Tripler officials also said, "We cannot comment on whether people in Hawai'i file more claims than in other places."

No organization compiles state-by-state comparisons of filed malpractice claims, according to those who track other malpractice data.

RULES FOR OPENNESS

Industry executives and attorneys say medicine can be an inexact science, and mistakes happen at every hospital.

Mistakes at Tripler, however, have a greater chance of becoming public because of open-government regulations, particularly if lawsuits result. Mistakes at private institutions, especially the more egregious errors, tend to be dealt with secretly at the insistence of the hospitals and doctors, half-a-dozen plaintiff attorneys said.

"Our really slam-dunk (civilian) cases settle with confidentiality," said plaintiff attorney Rick Fried.

Even lawyers who have filed malpractice lawsuits involving Tripler say the hospital provides better care today than years ago.

"By and large, I think Tripler is a terrific public health institution," said attorney Eric Seitz, who represented a client in a recently settled lawsuit alleging substandard care at Tripler. "There are some wonderful doctors there."

Yet developments over the past year have once again raised questions about quality of care.

In the Baby Izzy case, a portable carbon dioxide tank was used instead of an oxygen tank, resulting in a "sentinel event," according to a federal patient safety alert on the mishap. Sentinel events typically refer to medical incidents that unexpectedly result in death or serious injury.

After the gas mix-up, the hospital apologized to the family and said immediate corrective action was taken.

"Providing carbon dioxide instead of oxygen is inexcusable," said Dr. Peter Lurie, deputy director of health research for Public Citizen, an advocacy group that focuses on healthcare and other consumer issues.

The incident prompted the U.S. Department of Defense in March to issue the militarywide alert advising medical institutions to take immediate steps to prevent similar mishaps.

Izzy's brain damage was so severe, he is dependent on medical devices for his survival. He will need 24-hour nursing care the rest of his life.

Shalay Peterson, Izzy's mother, said Izzy will never be able to lead a normal life or do the typical things that kids do together with their families.

"We've been robbed of all that," she said.

Izzy's parents have sued the government for malpractice, and plaintiff attorneys say a judgment, if the case goes to trial and the family wins, could be one of the highest in Tripler history. The current record is the $11.3 million award in 1997 to the family of the brain-damaged baby. With interest, the government paid about $12.5 million.

The government denied in court documents that Tripler was negligent with Izzy's care. The case is pending.

LONG'S SYMPTOMS

Tina Long was admitted last April with these symptoms: high protein levels in her urine, severe headaches, swelling, blurred vision and elevated blood pressure of 159/100 when it had been an average of 120/77 in prior months, according to Michael Archuleta, the family's attorney in Texas. All those general symptoms were noted in the autopsy report.

For pregnant women, high blood pressure and protein in the urine are the key symptoms of preeclampsia, according to Eleni Tsigas of the Preeclampsia Foundation. Preeclampsia is a rapidly progressing hypertensive condition that affects pregnant women and can be harmful to the unborn baby and mother. Severe headaches, swelling of the hands and face, and blurred vision are among other indicators.

Women who have high blood pressure during pregnancy typically are closely monitored because that condition may progress to preeclampsia, Tsigas said.

When Long was hospitalized in April, the diagnosis — made about 12 hours before she died — was to "rule out preeclampsia," according to the autopsy report. A "rule-out" diagnosis usually means the disorder is suspected but not enough evidence is available at the time to make a definitive call, doctors say.

Archuleta said Long's case was a textbook one for preeclampsia. Yet Tripler not only failed to monitor the patient adequately but didn't do the one thing that would have taken care of the problem — deliver the baby, according to Archuleta, who also is a doctor and says he has delivered about 100 babies.

The cause of Long's death was listed as probable peripartum cardiomyopathy (a weakened, damaged heart during pregnancy), with toxemia of pregnancy — another name for preeclampsia — noted as a contributing cause, according to her autopsy.

"There's a difference between warehousing a patient and treating a patient," Archuleta said. "Tina was warehoused."

Long's family filed several malpractice claims against Tripler, seeking $40 million in compensation. The claims are pending.

Tripler officials declined comment because it is an ongoing case.

The family of Romi're Dupuy, the baby whose esophagus allegedly was punctured, also filed several claims, seeking $15 million. Tripler likewise declined comment.

DEATH IN CHILDBIRTH

Another pending case that surfaced last year involved a Marine now stationed on the Mainland who in May sued the federal government on behalf of his late wife's estate, alleging that Tripler's negligent care led to her death and their newborn son's brain injury. Vincent Adams said in the lawsuit that an improperly administered epidural — a type of anesthesia procedure used for childbirth — led to complications in December 2002 during delivery and afterward that injured their son and caused the death of Jennifer Adams four months later in Florida.

Vincent Adams said in a March 2003 videotaped interview that a Tripler doctor told him a high epidural caused his wife to stop breathing.

William Copulos, Adams' attorney, said a high epidural or high spinal epidural refers to one that is administered in such a way that the anesthetic travels upward in the body. In Jennifer Adams' case, the epidural needle was inserted in her cerebral spinal fluid space instead of the epidural space, allowing the anesthetic to travel up the spinal column, anesthetizing her heart and diaphragm, Copulos said.

A Florida medical examiner determined in May 2003 that Jennifer Adams' death was due to complications from a high spinal epidural, according to the examiner's report. The Adams lawsuit is pending. The government denied in court documents that the care was negligent.

The issue of quality of care also came up in an August court ruling by U.S. District Judge Susan Oki Mollway. A woman patient who was sexually molested by a male licensed practical nurse at Tripler in 2001 subsequently sued the government, accusing Tripler of negligence.

Mollway awarded the woman and her husband $906,000, finding that Tripler's inattention to the patient and inadequate supervision of the male nurse who treated her were substantial factors in the sexual assault. The nurse pleaded guilty to sexual abuse and was sentenced in 2002 to 6 1/2 years in prison.

A first-year intern and a supervisory nurse who oversaw the care of the woman at the intensive-care unit paid little attention to the patient that night, even though the woman kept losing and regaining consciousness and a diagnosis was unclear, according to Mollway's ruling.

The government is appealing the ruling. The U.S. attorney's office, which is handling the appeal, declined comment.

QUALITY ASSURANCE

In a June interview, Navy Capt. Kevin Berry, deputy commander for clinical services at Tripler, said the hospital regularly keeps on top of quality issues and patient safety. The hospital, for instance, has a full-time safety manager whose focus is to identify issues that have patient safety implications and to develop plans to reduce or eliminate the potential to cause harm. In addition, Tripler is inspected by one dozen to three dozen external organizations, Berry said.

"There are literally thousands of layers to a medical quality assurance program," he said.

If something goes wrong and a peer-review process determines substandard care was given, those responsible are held accountable, he said.

But Tripler officials said the hospital rarely has incidents that require reporting physicians to state or national boards. They said they do not keep statistics on such reports.

Plaintiff attorney Mark Davis, who noted that his law firm over the years has won all 15 or so of its Tripler malpractice cases that went to trial, said common issues tended to surface: understaffing, poor continuity of care, lapses in record-keeping, inadequate supervision of personnel.

Tripler said it maintains staffing standards similar to or more stringent than those used by some civilian hospitals, reviews staff levels frequently and makes adjustments as needed, including periodically referring patients to other hospitals here or on the Mainland.

Most other issues raised by malpractice attorneys are conjecture, Tripler said.

Yet some of those very issues have surfaced in recent cases.

In the sexual assault case, Judge Mollway noted that the supervisory nurse had asked for more help that night, expressing concern that the intensive-care unit where the eventual assault occurred was understaffed. The nurse received no response to her request, according to the ruling.

In the Tina Long case, the patient never saw the same doctor regularly, contributing to her inconsistent or poor care, the family said. During her hospitalization in April, a physician asked Long's mother to retrieve medication for her daughter from a downstairs pharmacy because no hospital staffer was available to get it, the family said.

In the Baby Izzy case, Shalay Peterson said that when she asked for Izzy's records in preparation for a move to the Mainland, she was given a file that included documents from a different case, one of a boy who died at Tripler.

In the Adams case, the epidural was administered by a nurse anesthetist, but once the patient started having problems, the anesthesiologist should have been summoned to intervene, according to Copulos, the family's attorney. That didn't happen, he said.

Reach Rob Perez at rperez@honoluluadvertiser.com.