User login
The story:
JR is a 32-year-old woman with a medical history of juvenile diabetes mellitus and end-stage renal disease on intermittent hemodialysis for the past 2 years. She was admitted to the hospital with shortness of breath and was found to have a large right-sided pleural effusion with loculations. Antibiotics were initiated. On hospital day 2 she underwent a video-assisted thoracoscopy for drainage, lysis of adhesions, and placement of two chest tubes. After returning to the floor from the postanesthesia care unit, JR had difficulty achieving adequate pain control despite a hydromorphone patient-controlled analgesic pump. Additional "as needed" intravenous morphine was ordered for relief. Before going home, the attending internist checked in on JR and discontinued her intravenous fluids (D5 half-normal saline), but wrote to resume her long-acting insulin later that same evening.
At approximately 7:30 p.m., JR was found by the nurse barely breathing. Her pupils were pinpoint and her respiratory rate was only 5 breaths per minute. A code blue was called and a hospitalist responded. A combination of epinephrine, atropine, and naloxone led to a return of consciousness, and JR was never intubated. In fact, the code sheet reflected that after the naloxone, JR was now fully awake, crying, and complaining of right-sided pain.
JR subsequently complained of nausea and began to vomit. Prior to transferring her to the intensive care unit, the hospitalist placed a nasogastric tube and made JR nil per os. To complete JR’s transfer to the ICU, the hospitalist contacted a critical care attending to give report, and then wrote "holding" ICU admission orders.
JR remained on the regular nursing floor for another hour as the ICU prepared for her arrival. Just prior to leaving the floor, JR’s nurse gave her 13 units of glargine insulin as ordered earlier that afternoon by the attending internist.
JR underwent a standard admission assessment upon her arrival at the ICU. The hospitalist "holding admission orders" included regular blood glucose checks and regular insulin coverage on a sliding scale. At midnight, JR’s blood glucose was over 250 mg/dL, and she was administered 6 units of regular insulin. At 5 a.m., another blood glucose was obtained and was recorded as 114 mg/dL. At 7:45 a.m., the new day shift ICU nurse did a complete assessment and noted that JR was lethargic with slurred speech. The critical care consultant rounded on JR at approximately 10 a.m. and also noted a change in mental status. Thirty minutes later, JR became unresponsive to verbal or tactile stimuli. A point-of-care blood glucose was performed and found to be 10 mg/dL. JR was subsequently intubated, but she never regained consciousness again.
She lived for another 2 months before her family decided to stop her dialysis and she passed away.
Complaint:
The family was upset to learn that JR suffered irreversible brain injury from low blood sugar. JR had been a diabetic on insulin all of her life, and the family couldn’t understand how such a thing could happen under the watchful eye of doctors and nurses.
The complaint alleged that there was an egregious failure with respect to communication between the attending physician, the floor nurse, the hospitalist, and the critical care consultant. Specific to the hospitalist, the complaint alleged that the "holding admission orders" should have included intravenous fluids with dextrose and/or explicit instructions to not give the glargine insulin as ordered earlier that same day.
The complaint was also disparaging of the critical care consultant for not recognizing the hypoglycemia earlier, given the mental status changes that JR exhibited.
Scientific principles:
Hypoglycemia can produce a myriad of neurologic signs and symptoms, but usually presents with symptoms of increased epinephrine release (e.g., tremor, diaphoresis) followed by neurologic symptoms that include generalized seizures, bizarre behavior, coma, and focal deficits. In acute severe hypoglycemia, a bolus of 25-50 grams of dextrose should be administered intravenously, followed by a continuous dextrose infusion. Blood glucose concentrations should be measured hourly. Reversal of neurologic symptoms may lag behind normalization of glucose levels.
Complaint rebuttal and discussion
All the health care providers thought their actions were reasonable in this case.
At the time that the attending internist wrote to resume JR’s glargine and stop the dextrose-containing intravenous fluids, JR was awake and was planning to have a light dinner. The floor nurse who gave the glargine later that night testified that she had a valid order to administer the medication.
The hospitalist testified that he was there to respond to emergencies, and that he transferred care of JR to the critical care consultant by verbal report. The critical care consultant acknowledged the verbal handoff from the hospitalist, but doubts there was any discussion regarding JR’s diabetes and was adamant that she was not responsible for JR receiving two doses of insulin (glargine and regular insulin) via the orders of two other physicians before she even had the opportunity to see the patient. The critical care consultant also testified that JR’s mental status change was nonspecific and was reasonably due to the pain medications she was receiving.
The plaintiffs countered with the reality that JR, a 32-year-old woman, died from low blood sugar because she received insulin when she wasn’t allowed to eat or drink – all at the hands of the medical team.
Conclusion:
Much of the attention regarding safe transitions of care is focused on the hospital discharge. Yet discontinuity within hospital walls is frequently associated with medical errors, and communication problems represent the largest category for hospital sentinel events.
The Joint Commission, the World Health Organization, the Institute of Medicine and the National Quality Foundation have all published white paper recommendations regarding the need to improve medical handoffs. Most hospitalists probably see this case as a "system error," and sure enough following this event the hospital overhauled its policies and procedures as they related to ICU transfers. But in the world of medical malpractice, the "system" doesn’t face the jury in litigation.
Although the attending internist was eventually dropped from this case, the hospital, the critical care consultant, and the hospitalist all settled with the plaintiff for an undisclosed amount.
Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system.
The story:
JR is a 32-year-old woman with a medical history of juvenile diabetes mellitus and end-stage renal disease on intermittent hemodialysis for the past 2 years. She was admitted to the hospital with shortness of breath and was found to have a large right-sided pleural effusion with loculations. Antibiotics were initiated. On hospital day 2 she underwent a video-assisted thoracoscopy for drainage, lysis of adhesions, and placement of two chest tubes. After returning to the floor from the postanesthesia care unit, JR had difficulty achieving adequate pain control despite a hydromorphone patient-controlled analgesic pump. Additional "as needed" intravenous morphine was ordered for relief. Before going home, the attending internist checked in on JR and discontinued her intravenous fluids (D5 half-normal saline), but wrote to resume her long-acting insulin later that same evening.
At approximately 7:30 p.m., JR was found by the nurse barely breathing. Her pupils were pinpoint and her respiratory rate was only 5 breaths per minute. A code blue was called and a hospitalist responded. A combination of epinephrine, atropine, and naloxone led to a return of consciousness, and JR was never intubated. In fact, the code sheet reflected that after the naloxone, JR was now fully awake, crying, and complaining of right-sided pain.
JR subsequently complained of nausea and began to vomit. Prior to transferring her to the intensive care unit, the hospitalist placed a nasogastric tube and made JR nil per os. To complete JR’s transfer to the ICU, the hospitalist contacted a critical care attending to give report, and then wrote "holding" ICU admission orders.
JR remained on the regular nursing floor for another hour as the ICU prepared for her arrival. Just prior to leaving the floor, JR’s nurse gave her 13 units of glargine insulin as ordered earlier that afternoon by the attending internist.
JR underwent a standard admission assessment upon her arrival at the ICU. The hospitalist "holding admission orders" included regular blood glucose checks and regular insulin coverage on a sliding scale. At midnight, JR’s blood glucose was over 250 mg/dL, and she was administered 6 units of regular insulin. At 5 a.m., another blood glucose was obtained and was recorded as 114 mg/dL. At 7:45 a.m., the new day shift ICU nurse did a complete assessment and noted that JR was lethargic with slurred speech. The critical care consultant rounded on JR at approximately 10 a.m. and also noted a change in mental status. Thirty minutes later, JR became unresponsive to verbal or tactile stimuli. A point-of-care blood glucose was performed and found to be 10 mg/dL. JR was subsequently intubated, but she never regained consciousness again.
She lived for another 2 months before her family decided to stop her dialysis and she passed away.
Complaint:
The family was upset to learn that JR suffered irreversible brain injury from low blood sugar. JR had been a diabetic on insulin all of her life, and the family couldn’t understand how such a thing could happen under the watchful eye of doctors and nurses.
The complaint alleged that there was an egregious failure with respect to communication between the attending physician, the floor nurse, the hospitalist, and the critical care consultant. Specific to the hospitalist, the complaint alleged that the "holding admission orders" should have included intravenous fluids with dextrose and/or explicit instructions to not give the glargine insulin as ordered earlier that same day.
The complaint was also disparaging of the critical care consultant for not recognizing the hypoglycemia earlier, given the mental status changes that JR exhibited.
Scientific principles:
Hypoglycemia can produce a myriad of neurologic signs and symptoms, but usually presents with symptoms of increased epinephrine release (e.g., tremor, diaphoresis) followed by neurologic symptoms that include generalized seizures, bizarre behavior, coma, and focal deficits. In acute severe hypoglycemia, a bolus of 25-50 grams of dextrose should be administered intravenously, followed by a continuous dextrose infusion. Blood glucose concentrations should be measured hourly. Reversal of neurologic symptoms may lag behind normalization of glucose levels.
Complaint rebuttal and discussion
All the health care providers thought their actions were reasonable in this case.
At the time that the attending internist wrote to resume JR’s glargine and stop the dextrose-containing intravenous fluids, JR was awake and was planning to have a light dinner. The floor nurse who gave the glargine later that night testified that she had a valid order to administer the medication.
The hospitalist testified that he was there to respond to emergencies, and that he transferred care of JR to the critical care consultant by verbal report. The critical care consultant acknowledged the verbal handoff from the hospitalist, but doubts there was any discussion regarding JR’s diabetes and was adamant that she was not responsible for JR receiving two doses of insulin (glargine and regular insulin) via the orders of two other physicians before she even had the opportunity to see the patient. The critical care consultant also testified that JR’s mental status change was nonspecific and was reasonably due to the pain medications she was receiving.
The plaintiffs countered with the reality that JR, a 32-year-old woman, died from low blood sugar because she received insulin when she wasn’t allowed to eat or drink – all at the hands of the medical team.
Conclusion:
Much of the attention regarding safe transitions of care is focused on the hospital discharge. Yet discontinuity within hospital walls is frequently associated with medical errors, and communication problems represent the largest category for hospital sentinel events.
The Joint Commission, the World Health Organization, the Institute of Medicine and the National Quality Foundation have all published white paper recommendations regarding the need to improve medical handoffs. Most hospitalists probably see this case as a "system error," and sure enough following this event the hospital overhauled its policies and procedures as they related to ICU transfers. But in the world of medical malpractice, the "system" doesn’t face the jury in litigation.
Although the attending internist was eventually dropped from this case, the hospital, the critical care consultant, and the hospitalist all settled with the plaintiff for an undisclosed amount.
Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system.
The story:
JR is a 32-year-old woman with a medical history of juvenile diabetes mellitus and end-stage renal disease on intermittent hemodialysis for the past 2 years. She was admitted to the hospital with shortness of breath and was found to have a large right-sided pleural effusion with loculations. Antibiotics were initiated. On hospital day 2 she underwent a video-assisted thoracoscopy for drainage, lysis of adhesions, and placement of two chest tubes. After returning to the floor from the postanesthesia care unit, JR had difficulty achieving adequate pain control despite a hydromorphone patient-controlled analgesic pump. Additional "as needed" intravenous morphine was ordered for relief. Before going home, the attending internist checked in on JR and discontinued her intravenous fluids (D5 half-normal saline), but wrote to resume her long-acting insulin later that same evening.
At approximately 7:30 p.m., JR was found by the nurse barely breathing. Her pupils were pinpoint and her respiratory rate was only 5 breaths per minute. A code blue was called and a hospitalist responded. A combination of epinephrine, atropine, and naloxone led to a return of consciousness, and JR was never intubated. In fact, the code sheet reflected that after the naloxone, JR was now fully awake, crying, and complaining of right-sided pain.
JR subsequently complained of nausea and began to vomit. Prior to transferring her to the intensive care unit, the hospitalist placed a nasogastric tube and made JR nil per os. To complete JR’s transfer to the ICU, the hospitalist contacted a critical care attending to give report, and then wrote "holding" ICU admission orders.
JR remained on the regular nursing floor for another hour as the ICU prepared for her arrival. Just prior to leaving the floor, JR’s nurse gave her 13 units of glargine insulin as ordered earlier that afternoon by the attending internist.
JR underwent a standard admission assessment upon her arrival at the ICU. The hospitalist "holding admission orders" included regular blood glucose checks and regular insulin coverage on a sliding scale. At midnight, JR’s blood glucose was over 250 mg/dL, and she was administered 6 units of regular insulin. At 5 a.m., another blood glucose was obtained and was recorded as 114 mg/dL. At 7:45 a.m., the new day shift ICU nurse did a complete assessment and noted that JR was lethargic with slurred speech. The critical care consultant rounded on JR at approximately 10 a.m. and also noted a change in mental status. Thirty minutes later, JR became unresponsive to verbal or tactile stimuli. A point-of-care blood glucose was performed and found to be 10 mg/dL. JR was subsequently intubated, but she never regained consciousness again.
She lived for another 2 months before her family decided to stop her dialysis and she passed away.
Complaint:
The family was upset to learn that JR suffered irreversible brain injury from low blood sugar. JR had been a diabetic on insulin all of her life, and the family couldn’t understand how such a thing could happen under the watchful eye of doctors and nurses.
The complaint alleged that there was an egregious failure with respect to communication between the attending physician, the floor nurse, the hospitalist, and the critical care consultant. Specific to the hospitalist, the complaint alleged that the "holding admission orders" should have included intravenous fluids with dextrose and/or explicit instructions to not give the glargine insulin as ordered earlier that same day.
The complaint was also disparaging of the critical care consultant for not recognizing the hypoglycemia earlier, given the mental status changes that JR exhibited.
Scientific principles:
Hypoglycemia can produce a myriad of neurologic signs and symptoms, but usually presents with symptoms of increased epinephrine release (e.g., tremor, diaphoresis) followed by neurologic symptoms that include generalized seizures, bizarre behavior, coma, and focal deficits. In acute severe hypoglycemia, a bolus of 25-50 grams of dextrose should be administered intravenously, followed by a continuous dextrose infusion. Blood glucose concentrations should be measured hourly. Reversal of neurologic symptoms may lag behind normalization of glucose levels.
Complaint rebuttal and discussion
All the health care providers thought their actions were reasonable in this case.
At the time that the attending internist wrote to resume JR’s glargine and stop the dextrose-containing intravenous fluids, JR was awake and was planning to have a light dinner. The floor nurse who gave the glargine later that night testified that she had a valid order to administer the medication.
The hospitalist testified that he was there to respond to emergencies, and that he transferred care of JR to the critical care consultant by verbal report. The critical care consultant acknowledged the verbal handoff from the hospitalist, but doubts there was any discussion regarding JR’s diabetes and was adamant that she was not responsible for JR receiving two doses of insulin (glargine and regular insulin) via the orders of two other physicians before she even had the opportunity to see the patient. The critical care consultant also testified that JR’s mental status change was nonspecific and was reasonably due to the pain medications she was receiving.
The plaintiffs countered with the reality that JR, a 32-year-old woman, died from low blood sugar because she received insulin when she wasn’t allowed to eat or drink – all at the hands of the medical team.
Conclusion:
Much of the attention regarding safe transitions of care is focused on the hospital discharge. Yet discontinuity within hospital walls is frequently associated with medical errors, and communication problems represent the largest category for hospital sentinel events.
The Joint Commission, the World Health Organization, the Institute of Medicine and the National Quality Foundation have all published white paper recommendations regarding the need to improve medical handoffs. Most hospitalists probably see this case as a "system error," and sure enough following this event the hospital overhauled its policies and procedures as they related to ICU transfers. But in the world of medical malpractice, the "system" doesn’t face the jury in litigation.
Although the attending internist was eventually dropped from this case, the hospital, the critical care consultant, and the hospitalist all settled with the plaintiff for an undisclosed amount.
Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system.
