Legal Review & Commentary: Failure to refer, diagnose, and properly chart care leads to fatal cardiac arrest: $1.5M verdict
Legal Review & Commentary
Failure to refer, diagnose, and properly chart care leads to fatal cardiac arrest: $1.5M verdict
By Radha V. Bachman, Esq. Lynn Rosenblatt, CRRN, LHRM
Buchanan Ingersoll & Rooney PC HealthSouth Sea Pines Rehabilitation Hospital
Tampa, Florida Melbourne, FL
News: A 59-year-old woman was admitted to the observation area of a local hospital. The woman was thought to have had an allergic reaction to cholesterol medication she was taking, and the staff recommended she remain under observation for 23 hours. The next morning, the woman experienced chest pains and the nurse administered meperidine and nitroglycerine. The nurse did not inform the attending physician of the administration. The woman was discharged and died the same day. A jury returned a verdict in favor of the woman's estate in the amount of $1.5 million.
Background: A 59-year-old disabled woman presented to the hospital with complaints of chest pain and was admitted to the observation area. Based on discussions with the woman, the hospital staff determined that the woman was probably suffering from an allergic reaction to her cholesterol medication and suggested she remain in the observation area for 23 hours. The next morning, the woman experienced approximately 20 minutes of chest pain. She summoned the attending nurse, who administered meperidine and nitroglycerine. Following the administration of the medication, the attending nurse failed to inform the attending physician of the events, including the chest pain and medication administration. About 45 minutes later, the attending physician consulted with the woman, who told him that she had been experiencing chest pain. Nevertheless, the physician dis- charged the woman without further investigation or inquiry. The woman was driven home by her husband. Upon returning from work, the woman's husband found the woman face down on their bed and nonresponsive. Emergency personnel were called, but the woman was pronounced dead upon arrival to the hospital. The cause of death was listed in her chart as cardiac arrest.
The husband, on behalf of the woman's estate, sued the attending physician and the hospital, as well as the woman's primary care physician, physician residents, and the attending physician's practice group. The lawsuit alleged malpractice, failure to diagnose, and failure to refer.
The plaintiff argued that the attending physician was liable for negligence because of his failure to order an EKG, draw cardiac enzymes, place the woman on oxygen, put her on a monitored bed, or refer her to a cardiologist when she reported the chest pain. These actions, the plaintiff argued, fell below the standard of care as he failed to take any precautionary measures and, instead, discharged the woman prematurely.
The plaintiff further argued that the nurse was negligent in failing to notify the attending physician of the woman's bouts of chest pain and the administration of medication. With regard to the claim against the primary care physician, the plaintiff alleged that the woman had notified her primary care physician of her chest pain and that the primary care physician failed to investigate further or refer the woman to the appropriate specialist.
The defense used the woman's abuse of a fentanyl patch for back pain as the main contributor to her death. Counsel also contended that the woman did not die from cardiac arrest but rather from a fatty liver as was stated on the woman's death certificate. Plaintiff's counsel vehemently denied this allegation by eliciting the testimony of the county coroner, who said that drug overdose was ruled out as cause of death and that the death certificate should have read that the woman died of heart disease and not a fatty liver.
The jury returned a verdict in favor of the woman's estate in the amount of $1.5 million.
What this means to you: The plaintiff argued that the attending physician was liable for negligence because of his failure to order an EKG, draw cardiac enzymes, place the woman on oxygen, put her on a monitored bed, or refer her to a cardiologist when she reported the chest pain. This paragraph says it all.
Clearly, today's standard of cardiac care includes the above plus an admission to an observation bed while the tests are being completed. The narrative does not go into detail about the nature of her disability other than to allude to her chronic back problems and narcotic dependency. There is some circumstantial evidence that she did indeed have a cardiac disease history, or at least symptoms that would lead one to suspect a cardiac problem.
The patient was supposedly on an observation unit overnight for what was advanced as an allergic reaction to her cholesterol medication. This seems unlikely in the sense that her chief complaint was chest pain. Cardiac observation is intended to be specific to patients experiencing symptoms suggestive of the active development of a heart attack. It is unclear what occurred overnight, as the patient apparently continued with intermittent chest pain, which is not a symptom of narcotic overdose. It is however a symptom of ischemic heart disease, and obviously the nurse thought that was a distinct possibly as she administered nitroglycerine.
It is unclear who gave the order for the two drugs, but clearly the nurse was outside her scope of practice if she acted without an order, and she was derelict in her duty for not having informed the physician responsible for this patient's care. There also is a question if the nurse accurately observed the patient's response to these medications. The nurse's observations may have reinforced the woman's claim of continuing chest pain, and the physician may have taken her more seriously and reconsidered his plan to discharge her.
Once it was established by the coroner that the woman did indeed have cardiac disease, it was also clear that her primary care physician also had failed in her treatment. It is presumed that since a judgment was found against him that the patient had been seeing him regularly. Ischemic heart disease can be diagnosed and treated effectively with proper testing and medication. The primary physician failed his patient if he was not following her as dictated by acceptable standards of care as promoted by organizations such as the American Heart Association and the American College of Cardiology.
A multitude of factors are responsible for the development of ischemic heart disease. This patient was on a cholesterol-lowering medication. There also is the theory that hypertension is a risk factor in the development of ischemic heart disease. The woman presented with most of the symptoms for ischemic heart disease, including elevated cholesterol, known stress for which she was receiving treatment, and a relatively inactive lifestyle given her chronic pain and narcotic usage. The allergic reaction to her cholesterol medications was most likely a misdiagnosis. Her true presentation was her chest pain, and that was ignored.
The nurse accurately medicated her with the nitroglycerin but may have contributed to her demise with the meperidine, which together with her fentanyl could have put her in a stupor so that she was unaware of the gripping pain she was experiencing as she sustained a fatal myocardial infarction.
This patient got lost in the system. Emergency departments are busy places where coordination of care is essential to assure that diagnostic warning signs are not missed. Nurses act under authority of the ED physician, who in turn consults with specialists, orders appropriate tests, and monitors the patient's responses through the observation of other licensed staff. None of that happened in this case.
Without a doubt, the jury was on target and realized that the blame was not only attributed to the ED physicians and nurse, but also the primary physician who had failed to meet the most basic standard of care given her history.
Reference
Westmoreland (PA) County Court of Common Pleas, 2007-CI-01255.
A 59-year-old woman was admitted to the observation area of a local hospital. The woman was thought to have had an allergic reaction to cholesterol medication she was taking, and the staff recommended she remain under observation for 23 hours. The next morning, the woman experienced chest pains and the nurse administered meperidine and nitroglycerine. The nurse did not inform the attending physician of the administration. The woman was discharged and died the same day.Subscribe Now for Access
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