Patient's needs overlooked, resulting in amuptations!

[NW Admin]

• Hello everyone, I was forwarded this email last night and found it to be apaulling, but most believably true. Please read and then see my reponse to it in the next post.
  
  Risk Management Review – February 2009
  
  Introduction
  Some patients who present to the Emergency Department (ED) do not have medical emergencies. However, some are in critical condition at the time of their arrival. Because the medical status of an ED patient is not always readily apparent, ED teams need to differentiate between the two groups as quickly as possible. Without prompt assessment and follow through, a patient’s condition can quickly deteriorate and his or her chances of survival diminish with every passing hour. In this case from the Midwest, the patient’s status deteriorated because the staff failed to coordinate care and communicate in a timely manner.
  FACTS
  The patient was a 66-year-old male who presented to the E D at 1615 with complaints of lower right quadrant pain, dizziness, and nausea and vomiting. At 1630 he was noted to be hypotensive and tachycardic. The ED physician ordered a stat ECG, IV saline drip, and complete labs (including CBC and urine culture). The labs were drawn at 1645 and they were suggestive of sepsis. The urine culture was not taken until 1935 (there is no explanation for this delay). At 1707, the ED nursing notes reported a B/P of 74/45 and a pulse of 133, however neither the temperature nor the respiratory rate were recorded. In response to these vitals, a second liter of saline was started.
  At 1900, the blood pressure and heart rate had improved only slightly, and a third liter of saline was started. At 2020, the patient’s blood pressure and heart rate were unchanged, the respiratory rate was 28 and his temperature was 101.7. At 2100, antibiotics were administered, and a repeat CBC and blood chemistry were ordered for the morning. A critical care specialist was also summoned at that time.
  The critical care specialist (the only MedPro insured involved with this case) first saw the patient in the ED and immediately ordered him transferred to the ICU. Based on a preliminary diagnosis of septic shock, he ordered a stat CT of the abdomen, an abdominal ultrasound, further blood cultures, additional antibiotics, and a surgical consult.
  The surgeon was contacted and saw the patient at 2215. At that time, he ordered that the stat CT include the pelvis. The CT (which was reported to the surgeon at 0047) stated that there was a “5-6 mm obstructing stone in the proximal right ureter.” The surgeon did not take any action in response to this report, and ordered that nothing was to be reported to the critical care physician during the remainder of the night. The patient’s condition continued to deteriorate during the night. By 0800 his blood pressure was 65/40; however this was not reported to either the critical care specialist or the surgeon.
  The critical care physician checked on the patient at 0930 – but did not order a urologic consult until 1100. When the urologist saw the patient, she immediately ordered emergency surgery to place a stent. During the surgery, the patient suffered an MI, resulting in shocked liver syndrome, DIC, and ultimately, renal failure. The critical care physician saw the patient following surgery. At that time, he “requested” that Xigris be administered – however, while the order was recorded in the patient’s record, the critical care physician did not submit a formal order through the hospital’s medication ordering system. As a result of this failure, the Xigris was not administered.
  The patient began dialysis in the hospital, and his renal function did return. However, he suffered necrosis in all four extremities, resulting in bilateral above the wrist, and bilateral below the knee amputations.
  Suit was brought against the emergency physicians, the surgeon, the critical care physician, and the hospital. The case settled against the critical care physician in the high range, with defense costs also in the high range. The other defendants also contributed to the overall settlement, which was in the very high range.
  DISCUSSION
  This case illustrates several potential vulnerabilities in the provision of critical care medicine. These cases often require the marshalling of extensive technological resources and excellent coordination of care, including frequent and clear communication among numerous areas of expertise within the healthcare team.
  The most troubling thing about his case is the general agreement that if it had been handled properly, the patient’s catastrophic injuries could have been avoided. It appears that the correct persons were named as defendants in this case, since, in light of the patient’s condition, each of them rendered inadequate care.
  Given the patient’s vital signs when the patient presented to the ED, he should have been recognized as requiring urgent (if not emergent) care. It appears that the ED physicians did not recognize his critical condition during much of his ED stay.
  Emergency Medicine experts who testified in this case were critical of the delay in diagnosing the sepsis, and in ordering the abdominal CT, urinalysis and antibiotics. It is also noteworthy that the patient was in the ED for almost five hours before a critical care physician was called, despite the fact that vital signs were poor — and deteriorating.
  The critical care physician’s treatment of the patient started well. He transferred the patient to the ICU. He also ordered the correct testing, further antibiotics and an appropriate consult. However, experts were critical of his care for several reasons. First, he did not call in to get the CT results – which he had ordered stat. Second, he was unable to explain his delay in ordering a urology consult the following morning. And third, he didn’t follow the standard protocol for ordering Xigris – which could explain why the medication was not administered.
  The surgeon was criticized by expert reviewers for his order to not call the critical care physician with the CT results, and for his failure to act when he learned of the CT results. (Since the surgeon was not a Medical Protective insured, we cannot say authoritatively why he did not immediately and aggressively treat this known problem, or at least make the critical care physician aware of it.)
  The nursing staff can also be criticized for its failure to report the patient’s continued deterioration during the overnight period. If they did not report the patient’s status to the critical care physician because of the surgeon’s orders, given the patient’s worsening condition, they should have activated their chain of command so that a provider with sufficient authority could have intervened in a timely manner.
  It is axiomatic in the field of risk management that if a physician orders a test, he or she must review the results of that test or, alternatively, recall that the results have not arrived – and require a status update. The ED physicians appear not to have been aware that certain critical testing, such as the urinalysis, had not been performed in a timely manner. Similarly, when the critical care physician did not receive a report from the nursing staff regarding the stat CT, he should have called in to obtain the result.
  The failure of the surgeon and nursing staff to act in response to known information is hard to understand. While this might be attributed to simply an error in cognition, the inaction of the nurses, who were in the patient’s physical presence and watching him deteriorate, is especially hard to explain.
  RISK MANAGEMENT TIPS
  The following suggestions are offered for consideration when treating the critically ill patient:
  • Serious deviations in vital signs must trigger immediate investigation, which should not cease until the etiology has been identified and, if possible, corrected.
  • When a patient is in critical condition, a plan of treatment should be formulated very quickly and communicated to all who will need to be involved in the execution of the plan.
  • The results of all tests which were ordered must be reviewed, or the physician must know that the results were not reviewed. Special attention should be given to stat orders.
  • When hospitals have formal processes in place (e.g., medication ordering systems), these processes must be utilized. Reliance on informal processes increases the risk of error.
  • The hospital should have a system in place for rapid review of a physician’s orders when it appears that responses to the orders are not working to the patient’s benefit.
  CONCLUSION
  In the end, there were multiple opportunities to intervene and prevent the patient’s further “downhill slide.” However all of these opportunities were missed. Hopefully, changes in the processes of this healthcare delivery system will prevent similar tragedies in the future.
  The information provided in the above document should not be construed as medical or legal advice. Since the facts applicable to your situation may vary, or the regulations applicable in your jurisdiction may be different, please contact your attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, state or federal statutes, contract interpretation or legal questions.
  

Peggy D. Kuntz
Operations Lead - CRM
Medical Protective Company

[NW Admin]

Ugh, that's terrible, but I definately believe it. I was watching Obama talking to the state of Florida the other day about the health care system. He has some really good ideas. One being to turn health care systems all electronic instead of paper. He makes the point that every company and entity is electronic except the hospitals. That the paper system greatly contributes to these errors and delays... and expenses. I have to agree there. I hope that he can turn this crap around because I know none of us ever wants to go to the emergency room. Not even so much because we don't want to get sick, but because we don't want to deal with the hospital. People on a regular basis would rather sit at home and hope they get better. That's terrible.