Legal Review & Commentary
Transcription error results in medication dose that is fatal and $140 million verdict
By Jonathan D. Rubin, Esq.
Kaufman Borgeest & Ryan
New York, NY
Laura A. Russell
Kaufman Borgeest & Ryan
Bruce Cohn, JD, MPH
Risk Management & Legal Affairs
News: A 59-year-old woman was discharged from a hospital after undergoing treatment for a clogged dialysis port. Shortly after returning home, she developed complications. Her physician directed that she be admitted to a rehabilitation facility for additional treatment. Operating from the hospital physician’s discharge summary and a physician order prepared by the hospital, staff at the rehabilitation facility gave the decedent 80 units of Levemir insulin, which was 10 times the dosage prescribed by her physician. The decedent went into full cardiopulmonary arrest, was resuscitated, but never regained consciousness and died eight days later. A jury awarded the decedent’s family $140 million in damages.
Background: A 59-year-old woman was discharged from a hospital after undergoing treatment for a clogged dialysis port. Shortly after returning home, she developed complications, and her physician directed that she be admitted to a rehabilitation facility for additional treatment. The treating physician dictated the discharge summary and medication orders, which were sent to a United States-based company for transcription. The company, in turn, subcontracted the services to two companies in India whose workers transcribed the physician’s dictation. As a result of the arrangement, information dictated by the physician went through a computer in the United States to India, where the subcontractors’ employees prepared the discharge summary and sent it back to the hospital.
Unfortunately, in this case, the subcontractors’ employees incorrectly transcribed the dosage of Levemir insulin as 80 units instead of the actual amount prescribed by the treating physician, which was only 8 units. The hospital staff then sent the decedent’s admission paperwork to the rehabilitation facility. Operating from the hospital physician’s discharge summary and a physician order prepared by the hospital, staff at the rehabilitation facility gave the decedent 80 units of Levemir insulin, which was 10 times the dosage prescribed by her physician. The decedent went into full cardiopulmonary arrest, was resuscitated, but never regained consciousness and died eight days later.
A lawsuit was filed by the decedent’s estate against the hospital, its United States-based outsource transcription vendor, and the two Indian subcontractors. The plaintiff claimed that the hospital and the transcription companies negligently transcribed the physician’s discharge summary, failed to recognize and timely correct the error, and negligently hired and failed to properly supervise and train the transcriptionist. The plaintiff also claimed that the transcription service, which transcribed admission paperwork sent from the hospital to the rehabilitation facility, incorrectly transcribed the dosage of Levemir insulin as 80 units instead of the actual amount dictated/prescribed: 8 units. The plaintiff further alleged that the hospital staff was negligent in failing to follow its own procedures and multiple national patient safety standards. Specifically, the plaintiff argued that the hospital staff improperly prepared the decedent’s admission orders from the unreviewed and unsigned transcription, which then were sent to the rehabilitation facility in the form of a doctor’s order.
According to testimony, the original discharge summary form and medication reconciliation form were not accessible by hospital staff because they were being scanned into the hospital system by the records department. As such, the nurse used the unsigned discharge summary prepared in India and wrote the medication information onto the physician admission order containing the doctor’s signature. As a result, the documentation appeared to be a valid order. However, the physician had not confirmed the information about the medication as transcribed by the Indian company. Plaintiff’s counsel presented evidence that the hospital staff did not know that the transcription work was not being performed in-house or in another country. It was also revealed during trial that the hospital saved a mere 2 cents per line of text by using the outside company. Testimony also indicated the Indian firms operated under sub-par quality standards that are one-half to one-twelfth that of the United States in terms of acceptable error rate. Shockingly, officials from the U.S. transcription company claimed that Indian subcontractors used U.S. standards, but officials from those companies testified that in fact they did not.
All of the defendants denied liability in the jury trial. One of the Indian companies reportedly reached a settlement with the plaintiff for an undisclosed sum just before the jury rendered its verdict. The jury determined that all of the defendants were negligent and awarded the plaintiff $140 million in damages.
What this means to you: $140 million is truly a shocking number. Even if the verdict is reduced on appeal or by negotiation, the hospital has a real issue with their insurance carriers and board of trustees, not to mention the exceedingly bad publicity that will go along with this news. A 59-year-old woman with a clogged dialysis port, not an uncommon scenario, is sent to a rehabilitation facility for further care, also a daily occurrence. What we have here is again the issue that has been highlighted by The Joint Commission and others: the failure to accurately communicate. Clearly, the specific facts of this case contributed to the high verdict.
The hospital chose to use a company in India for services as do many other healthcare organizations that outsource work to companies overseas. Many of these entities provide excellent clinical or administrative services up to par with U.S. standards. Many offer benefits in some cases such as overnight radiology services for which the time zone difference means that they are awake in what is the middle of the night in the United States. In this case, the testimony revealed that the overseas company did not comply with the accuracy that would be the standard in the United States and the amount of money saved was, at least to the jury’s viewpoint, de minimus, both of which likely contributed to the adverse verdict. At least the overseas company had the good sense to settle prior to trial given the inflammatory nature of the facts of the case.
So what can risk managers take from this? If you are going to outsource any service, whether it is to a domestic or international company, take steps to investigate the accuracy or standards to which the outsourced company adheres. Make certain that the “error rate” or compliance with given standards are equal to or exceed what you would want from your own employees. The hospital’s employees relied on an unsigned and un-reviewed discharge summary, which is always dangerous whether it is a summary or unsigned radiology or pathology report. One of the root causes of using the unsigned report appears to be the unavailability of the final document due to scanning. Again, technology is wonderful and can reduce errors, but documents have to be available to the providers at the point and time of care. The speed of the scanning might need to be secondary to clinical considerations.
On patient safety and clinical analysis, the amount of insulin transcribed was 10 times the prescribed dose. This difference was not picked up or questioned by the nurse who created the discharge paperwork or by anyone at the rehabilitation facility. A quick review of an electronic or paper reference might have been a clue that the dose was fairly large and at least caused the nurse to call a physician or pharmacist to verify the dosage. All providers, whether they be prescribers, dispensers, or administering clinicians, need to be aware of what orders are reasonable. They need to do the research if the answer is unclear.
JVR No. 1212200046, 2012 WL 6642470 (Ala.Cir.Ct.).