Legal Review & Commentary

Alleged failure to diagnose, monitor: Case settled

News: A woman presented at two hospital emergency departments (ED) complaining of a number of respiratory symptoms. She was not admitted and was sent home with a prescription. A couple of days later, the woman saw her primary care physician with more severe symptoms. The primary care physician sent her to the ED. The on-call physician admitted the woman and placed her on respiratory therapy with high IV doses of three drugs. The physician noticed signs of overmedication but did not adjust the dosage amounts. After a number of administrations of drugs over the next few hours, the woman was found unresponsive and was later pronounced dead. A settlement was reached between the hospital and her family for $950,000. The physician settled for $225,000.

Background: A 27-year-old female developed an upper respiratory infection and sought treatment at two local hospitals' EDs. She claimed symptoms of asthma exacerbation, shortness of breath, wheezing and dry, nonproductive cough. She was not admitted either time and was sent home with prescriptions for antibiotics and prednisone, a drug that fights inflammation.

A couple of days later, the woman visited her primary care physician's office with similar but more severe symptoms and was evaluated by a nurse practitioner. Her primary care physician sent her to the ED to be evaluated for admission.

After being evaluated in the ED, a physician admitted the woman to the telemetry unit and ordered administration of seven central nervous system (CNS) depressant medications in high dosage amounts. The physician also ordered the woman to undergo respiratory therapy but failed to include an order for her peak flows and FEVs to be monitored. Monitoring of those items would have indicated an improvement or worsening of respiratory symptoms. Records for the first two mornings indicated that the woman was getting adequate levels of medication. However, the physician was concerned about the woman being overmedicated and was informed by a floor nurse that the woman might have been self-medicating. The physician adjusted the frequency of the drug administration but not the dosage. He also ordered that she be moved to an unmonitored medical floor that day. The progress note for the day was left unfinished by the physician.

After being transferred, the woman continued to receive medications that caused either direct or indirect depression of the CNS. The evening of the transfer, the woman received breathing therapy from a licensed respiratory therapist who noted diminished breath sounds with expiratory wheezing, labored respirations, and slight tachypnea. Three hours later, the woman was given additional drugs and was not checked on for 80 minutes. A nurse found the woman unresponsive in her bed, and the woman was ultimately pronounced dead. The autopsy concluded that the cause of death was asthma, due to lack of any other anatomic finding, and a clean toxicology screen.

A suit was filed against the physician and the hospital that claimed that the medical staff at the hospital failed to properly administer IV medications to the woman and that the nursing staff had failed to properly assess and monitor the patient. The respiratory therapist did not notify the physician of her findings following treatment. The plaintiff further contended that the use of CNS depressant medications should have been done with extreme caution, and that the physician had failed to meet the standard of care when he ordered that such high dosages of the medications be administered.

The defense denied that the care and treatment of the woman was below the standard of care or that it failed to meet accepted standards for adequate medical care.

The hospital settled with the plaintiff for $950,000, and the physician settled for $225,000.

What this means to you: Here we have a young woman who is seeking care for persistent respiratory symptoms who ended up dead from what appears to be a drug overdose. This is a classic case of failure to rescue, defined as "failure to recognize and act upon declines in patients." What was the rapid response process in this organization? Why did staff fail to recognize the decline in this patient's respiratory status, so they could respond and reverse the situation in a timely manner?

Significant emphasis has been placed on medication safety and prevention of medication errors through the National Patient Safety Goals. One element of this goal is medication reconciliation.

In this case, the woman had been to two emergency departments (ED) and to her primary care physician and was given prescriptions. We have no information to indicate whether the drugs ordered by either of the previous ED physicians were reviewed and whether the patient was advised to continue or stop taking any previously ordered medications by her primary care physician or ED staff. Whether the drugs she had been taking on an outpatient basis interacted with the drugs she was given in the hospital is unknown but should be a part of the root-cause analysis performed by the hospital. The risk manager should review the process of requesting all drugs a patient has in their possession, so they can be identified and put in a safe place while the patient is hospitalized.

In addition to conducting a root-cause analysis, this case should be sent to the medical staff for a peer review to determine whether the CNS depressants were indicated and whether the high doses and rate of administration of the IV medications were appropriate in view of the other signs and symptoms and test results. The incomplete order for respiratory therapy should be addressed as well.

Depending on whether the order for medications goes directly from the physician to the pharmacy or the nurse reviews and sends it to the pharmacy, the nurses and the pharmacist each had an opportunity to question the indication, dosage, and frequency of the drugs ordered. Central nervous system drugs may be indicated in certain situations with respiratory distress, but one should have questioned why seven such drugs were ordered and administered. With seven CNS depressant drugs being administered, the respiratory system should be closely monitored. A telemetry unit would seem to be an inappropriate unit to place a patient who was complaining and exhibiting respiratory symptoms and who was receiving seven CNS drugs in high doses at a rapid infusion rate. While she was ordered to have respiratory therapy treatments, those are intermittent, and a therapist may not have recognized the respiratory depression in a timely manner.

The risk manager should conduct a root-cause analysis and facilitate a disclosure meeting with family as a part of the untoward event investigation. The credentials and delineation of privileges of the admitting physician should be reviewed to verify his training and background. The autopsy showed this patient had asthma with no other comorbidities. We have no information to determine the cause of death. Was it the CNS drugs that caused the death? Were those the correct drugs for asthma? Was asthma considered a diagnosis, or was it ruled out?

The culture of our health care system is that, in order to protect themselves from medical errors, patients should question all medications, treatments, and results, and have a family member or friend be at the their bedside to act as their advocate and monitor their drugs. It is a sad state of affairs when society feels that protection is necessary when obtaining care from health professionals.

Communication was an issue in this case in that both the physician and the respiratory therapist failed to make proper reports. A red flag should have been raised in this case. The risk manager should provide inservice sessions to all nursing and pharmacy staff to reinforce their responsibility to question a physician when they see multiple drugs, high doses, or high rates of administration. Furthermore, as a part of the root-cause analysis and the corrective action, critical thinking skills and physical assessment educational sessions should be required for all nurses. Administering CNS depressant drugs without monitoring and evaluating the patient would unmistakably be practicing below the acceptable standard of nursing care.


• Anonymous parties, Superior Court, San Diego (CA) County.