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By Jonathan D. Rubin, Esq.
Kaufman Borgeest & Ryan New York, NY
Allison Angel, Esq.
Kaufman Borgeest & Ryan New York, NY
Leanora Di Uglio, CPHRM,
Corporate Director, Risk Management Health Quest Systems Lagrangeville, NY
News: A Connecticut jury recently awarded $6.5 million to the family of a 44-year-old medical malpractice victim who suffered a sodium overdose resulting in brain damage and lapse into a permanent vegetative state while admitted to a local hospital. After four days of deliberation, the jury found for the family who brought the action on patient's behalf, and deemed the hospital guilty of medical malpractice for failing to adequately monitor his sodium levels.
Background: On March 1, 2006, a 44-year-old father of three was found by his wife lying unconscious on the floor of their Connecticut home. He was rushed to the local hospital and admitted to the intensive care unit (ICU) for excessively low sodium levels, a condition not uncommon to distance runners and people who consume large quantities of alcohol. In such cases, the patient should be hooked up to an intravenous drip of saline solution to increase and stabilize the level of sodium in their blood. However, continued monitoring is imperative, as it is equally dangerous to allow the patient's sodium levels to increase too much or too quickly.
This is precisely what is claimed to have happened in this case. Prior to his hospital admission, the decedent took up drinking to cope with the loss of his job. In February 2006, he stopped drinking at the request of his wife, but he was vomiting due to alcohol withdrawal. The vomiting in turn exacerbated the levels of sodium in his blood, leading to his March 1, 2006, hospitalization. He was in a semi-comatose state by the time he reached the emergency department.
At trial, the plaintiffs conceded that the hospital formulated a proper plan of care involving the gradual and monitored administration of IV saline, but they argued that this plan was never followed. Instead, members of the ICU staff negligently permitted the patient's sodium levels to increase at a dangerous speed, which resulted in a condition known as central pontine myelinolysis (CPM). The man eventually was placed on life support and passed away roughly two weeks after his admission.
His wife and three children thereafter filed a wrongful death action. The hospital refused to settle and argued that the patient was very ill when he arrived and had little chance of surviving. The jury apparently disagreed. After four days of deliberation, the jury awarded the family $3 million for the decedent's pain and suffering and another $3 million for loss of enjoyment of life, which factored in a 30-year life expectancy. The jurors also awarded $500,000 for the wrongful death. They found the hospital guilty of medical malpractice for failing to adequately monitor the patient's sodium levels and carelessly overseeing his treatment.
What this means to you: CPM does not occur on its own; rather it is a complication secondary to some other treatment. With a proper plan of care established, as confirmed by plaintiff's counsel during trial, what went wrong that resulted in the patient's demise? If this event was reported to you as the risk manager, there would be several areas to investigate to identify the causative factors.
One such area would be communication between the physician and pharmacist. Although the physician would be responsible for ordering treatment, in this case the amount of IV saline to be given per liter per hour, was this the correct IV infusion rate based on the patient's age, weight, and other medical conditions, or was there an opportunity for a dosage miscalculation that might have been identified by a pharmacist? Pharmacists bring specific expertise and need to be an active member of the healthcare team, especially for conditions that are not commonly seen in a healthcare setting.
Other communication issues that might have impacted the treatment that would require further investigation surround the physician's orders for clinical monitoring of the patient's sodium level, execution of the orders, and the reporting of the laboratory results. Communication areas to explore would include the following:
Whenever evaluating the adequacy of a complex process, it is important to remember that the focus of the assessment should be on identifying the potential process failure points and not how well or poorly an individual healthcare practitioner performed. For example, as part of the investigation into this type of event, the risk manager should take the opportunity to review and evaluate the adequacy of the laboratory's policy for reporting panic values. Does this policy identify the what, when, who, and how lab results are to be reported when they reach the laboratory's defined abnormal and/or panic value range?
The use of an IV infusion pump to deliver the prescribed amount of IV saline solution also should be a focus of the investigation because there is a possibility that the nursing staff relied on the integrity of the IV infusion pump to provide the correct IV infusion rate with minimal oversight by staff. Any mechanical device can assist staff with providing care in a safe manner. However, if not used or monitored correctly, a mechanical device can cause significant harm.
It should come as no surprise to a risk manager that medication errors occur in all healthcare environments and that many of these medication errors involve IV infusion pumps. This step requires ongoing review and assessment of the maintenance and use of IV infusion pumps as a routine patient safety activity. When investigating this type of event, the risk manager should evaluate whether the IV pump was set to deliver the correct rate of infusion (in addition to the rate being correctly calculated), the alarms were set at a range and audible level to match the patient's condition and/or manufacturer's recommendations, and the pump has had the necessary preventive maintenance, including calibration. Even if all these tangible activities were done appropriately, it would be necessary for the risk manager to assess whether staff relied upon a mechanical device to alert staff of a problem in lieu of using their critical thinking skills and clinical assessment of the patient's condition.
Without further details, it is difficult to say what happened in this event that lead to the untimely death of the 44-year-old father of three. But, as with any untoward event, the actions or inactions of staff and the healthcare organization play a role. Whether it was staff's failure to follow a policy or failure of the hospital to provide necessary resources or infrastructure that promotes safe care, the patient, his family and the healthcare provider pay the ultimate cost.
CV08-5004962-S, Connecticut Superior Court.