Legal Review and Commentary

Failure to monitor diabetic's blood sugar leads to brain damage, $3.9 million California settlement

By Blake J. Delaney, Buchanan Ingersoll PC, Tampa, FL

News: An adult patient, who had been diagnosed with diabetes at age 11, was admitted for surgery to repair his retina due to injuries related to diabetic retinopathy. Although the amount of pre-surgery insulin that had been administered is unclear, it seems that the man's blood sugar was not monitored during the procedure. After the surgery was completed, the man was unable to be aroused. The man subsequently suffered a seizure with resulting brain damage, causing him to require around-the-clock nursing care. The patient brought suit against the hospital, surgeon, and anesthesiologist. Although all defendants claimed to have acted non-negligently, they all settled with the patient prior to trial for a total of $3.9 million.

Background: A 29-year-old man had been diagnosed with juvenile diabetes at 11 years of age. A merchant marine on disability, the man developed diabetic retinopathy, a complication which had occurred when the diabetes damaged the blood vessels inside the light-sensitive tissue at the back of his left eye. Doctors recommended he undergo surgery to treat the condition. Prior to the procedure, the ophthalmologist instructed the patient to take half of his usual dose of insulin. The surgery was successful, and he was scheduled to undergo a follow-up procedure by the same ophthalmologist three months later.

Prior to the second surgery, the plaintiff claimed that he was not instructed to lower his insulin dose. Consequently, the man took a shot of the hormone immediately before leaving home for the operation. When he presented at the hospital for the procedure, he claimed that he wrote on a history form provided by the hospital that he had taken insulin that morning, and he included the dosage taken on the form. Never-theless, the nurse wrote on the hospital record that the man had taken no medications that morning, and she left blank a box on the history form that specifically requested information regarding insulin dosage taken, if applicable.

The patient also claimed that the defendant anesthesiologist was aware that he was undergoing surgery for diabetic retinopathy and that the plaintiff was an insulin-dependent diabetic. Apparently the man initially told the anesthesiologist that he had not taken a shot of insulin, but when the doctor asked the patient about a test that showed a high blood sugar count, the man said he took what he described as a small dose of insulin. The anesthesiologist later testified that he did not follow up with the patient by inquiring how much insulin he had taken that day because, according to the anesthesiologist, the man was a "poor historian." Instead, the doctor relied on the chart, which showed that the man had taken no insulin that day. Had the anesthesiologist known that the man had just taken insulin, extra caution during the procedure would have been required.

During the ensuing four-hour procedure, the operating physician gave the patient intravenous fluids, none of which contained glucose. The man's blood sugar was not monitored at any time during the procedure. At one point during the surgery, the anesthesiologist asked for a device to measure the patient's blood glucose level, but he was told the apparatus was in another room. Unfortunately, the anesthesiologist failed to demand that a nurse get the instrument. After the surgery, the patient was not arousable from the anesthesia, and his blood sugar was found to have dropped to a critically low level. He subsequently suffered a seizure that resulted in brain damage.

The patient was comatose for four days before he regained consciousness. He filed suit against the hospital, surgeon, and anesthesiologist for negligence. The plaintiff's intelligence level was tested multiple times and found to be within normal range. However, the man maintained that his brain damage primarily manifested itself through slurred speech and an impaired "executive" function involving his insight into his own limitations and his ability to make responsible decisions. He sought damages for his medical condition and depression resulting from his requiring 24-hour care by his mother and father. The man was able to show that the doctor's negligence had caused him to walk with a shuffle and teeter on the stairs, he needed to be reminded to eat, and his depression even caused two attempts at suicide before trial. The plaintiff claimed future medical expenses of $6 million, based on present value, and past loss of earnings of $400,000.

The operating ophthalmologist, anesthesiologist, and hospital disputed liability, causation, and the plaintiff's claimed damages. They primarily asserted that the plaintiff was not as disabled as he claimed and, at most, would require part-time monitoring by a certified nurse assistant. In fact, they argued, the man was able to live alone in his apartment. The defendants further maintained that the plaintiff would not have returned to work at the merchant marine, even if he had not been injured by the surgery. Nevertheless, prior to trial, the action settled with all defendants. The anesthesiologist paid $2.9 million, and the ophthalmologist and hospital each contributed $500,000. The total verdict of $3.9 million was placed in a trust fund to ensure the plaintiff's care for years to come.

The anesthesiologist also faced a medical board accusation filed in an administrative law court for his negligence in treating the plaintiff. After a hearing wherein the doctor admitted to the accusation of gross negligence, the Medical Board of California revoked the doctor's license. The board then stayed the revocation and placed the doctor on probation for three years and ordered him to complete hundreds of hours of medical classes. The anesthesiologist, who can still practice while on probation, also was required to pay the state of California nearly $12,000 for the cost of the case.

What this means to you: This case underscores several issues that risk managers should be made aware of. First, no physician was managing the patient's diabetes while he was hospitalized, notes Marva West Tan, RN, ARM, FASHRM, associate director of the quality initiative at the Health Services Cost Review Commission in Baltimore. Even though the patient was a severe insulin-dependent diabetic who was being treated in the hospital for a diabetes-associated complication, apparently there was no physician with experience in diabetes care, such as a diabetologist, an internist, or family physician, who assumed responsibility for managing his diabetes.

"Clearly, neither the anesthesiologist nor ophthalmologist assumed complete responsibility for diabetes management perioperatively, and attention to glycemic control was spotty and incomplete," she says.

Tan recognizes that the patient may have had a physician who was managing his diabetes on an outpatient basis, but she suggests then that the ophthalmologist should have sought consultation with this physician for inpatient diabetes management. However, in the absence of such a pre-existing physician relationship, the ophthalmologist should have sought out another clinician with diabetes expertise to consult on perioperative care for the patient. One recommendation put forth by Tan is that after the first eye procedure, the patient should have been referred back to the physician who usually managed his diabetes or offered a referral to a diabetes specialist and strongly urged to schedule a follow-up appointment.

"Involvement of a specialist with expertise and responsibility for diabetes care perioperatively may have helped to avoid or correct the problems caused by poor medication reconciliation and the lack of adequate glycemic monitoring during the second procedure," says Tan.

Tan further notes the confusion and lack of medication reconciliation regarding insulin self-administration before the second procedure. Although the anesthesiologist was aware of inconsistencies between the patient's history and the medical record documentation regarding
preoperative insulin administration and dose, he made an assumption instead of attempting to investigate further in order to clear up the inconsistencies.

The scheduled surgery was apparently not an emergency procedure, Tan says. "A timeout should have been called to address the inconsistency regarding the insulin," she says. "Transitions between care settings and practitioners, such as when a patient is admitted for a surgical procedure, are times of increased risk for important information, including medication-related details, to fall between the cracks."

It is not surprising that medication reconciliation across the continuum of care is one of the National Patient Safety Goals for 2006 from the Joint Commission on Accreditation of Healthcare Organizations.

Finally, Tan points out that the lack of attention to glycemic control during the operation compounded the other problems. It appears that the ophthalmologist was not monitoring glucose levels and that even though the anesthesiologist apparently thought about glucose monitoring at least once, he failed to follow up when a glucometer was not available immediately in the operating room. Furthermore, the nursing staff, who have a critical role in diabetes monitoring (and education for inpatients and outpatients), did not remind the physicians or follow up regarding the glucometer. "Hence, no clinician took responsibility for intraoperative diabetes management," says Tan.

Tan has seen a new emphasis on appropriate glycemic control for patients nationwide, especially with regard to intensive care unit (ICU) patients and patients undergoing cardiothoracic surgery. As part of the Institute for Healthcare Improvement's "100,000 Lives" campaign, tight glycemic control to avoid and manage sepsis are part of the patient safety bundle for ICU care. Similarly, appropriate glucose control for cardiac surgery patients is one of the measures in the newly launched voluntary national Surgical Care Improvement Project ("SCIP"). "In addition to patient safety measures recommended by these focused national patient safety programs, every diabetic patient who is hospitalized for any type of problem, diabetes-related or not, should have a physician taking responsibility for appropriate inpatient diabetes management," Tan says.