Legal Review & Commentary: Hospital's negligent administration of sodium results in brain damage: $5M verdict
Legal Review & Commentary
Hospital's negligent administration of sodium results in brain damage: $5M verdict
By Radha V. Bachman, Esq. Suzanne Gruszka, RN, MAS, CLNC, LHRM
Buchanan, Ingersoll & Rooney PC Administrator, Clinical Support Services
Tampa, FL Health Central
Ocoee, FL
News: A woman presented at the emergency department (ED) complaining of dehydration. She was noticeably confused and had difficulty keeping her balance. The staff determined that she suffered from chronic low sodium. A physician ordered the woman be administered 125 cc sodium every hour. A nurse administered a liter of sodium in less than an hour, causing the woman's serum sodium to increase by 23 mEqs. The woman developed pontine myelinolysis as a result. The woman brought a suit against the hospital, alleging medical malpractice in the negligent administration of such a high dose of sodium. A jury awarded the woman $5 million in damages.
Background: A 57-year-old woman was taken to the ED by her daughter. She complained of dehydration resulting from being placed on a diuretic for her high blood pressure. When she reached the ED, the woman was confused and had difficulty keeping her balance. The staff determined that she had chronic low sodium. The attending physician ordered the woman be administered 125 cc sodium every hour. However, a nurse administered a liter of sodium in less than an hour, causing the woman's serum sodium to increase by 23 mEqs. The woman began showing signs of neurological problems after receiving such a high amount of sodium. An MRI was performed, which confirmed that the woman had developed central pontine myelinolysis, nerve damage of a layer of cells that covers the brain stem.
The woman sued the hospital alleging medical malpractice. Plaintiff's counsel contended that the standard of care with respect to the administration of sodium is not to exceed 10 mEqs to 12 mEqs in 24 hours. He alleged that the hospital was negligent for its nurse administering such a high amount of sodium. He argued that the administration of the negligent amount of sodium caused the dangerously sharp rise in the woman's sodium level, ultimately leading to myelinolysis.
Plaintiff's counsel further alleged that the doctors failed to monitor the woman's sodium level or to properly respond when they knew that the dangerously high amount of sodium had been administered. Counsel also contended that the physicians should have halted the administration of the sodium as soon as they were aware of the sudden and significant increase in the woman's sodium level.
Defendants' counsel alleged that the physicians acted in accordance with the standard of care in treating the woman, as they decreased the level of saline administered to the woman every time they noticed her sodium level had increased.
Counsel for the hospital admitted that the hos- pital failed to meet the standard of care by administering such a high dose of sodium in such a short period of time. However, the hospital's counsel contested the assertion that the increased amount of sodium was the cause of the woman's brain damage. They contended that a mistake in the woman's medication administration records was responsible for the nurse administering such a high amount of sodium. They further contended that the amount of sodium the woman received in the first hour could not have caused a 23 mEq increase in her sodium, and that something outside of the hospital's negligence caused the woman's brain damage.
The woman sought between $2 million and $5 million in damages for future life care, as she would require specialized treatment for the remainder of her life, as well as damages for past and future lost wages and past and future pain and suffering.
The jury found the hospital fully liable for the negligence that caused the woman's brain damage and awarded the woman $5,003,000 in damages.
What this means to you: This woman presented with a very serious, life-threatening condition, which required prompt assessment, diagnosis, and treatment. The clinical presentation of significant hyponatremia is relatively uncommon and nonspecific in presentation. A physician must consider the diagnosis in patients presenting with vague symptoms or with altered mental status. A severe outcome can occur if a patient's sodium is replaced too fast or too slow.
The treatment protocol for patients with either acute or chronic hyponatremia is sodium replacement. The goal is to provide safe and effective sodium replacement without incident. The therapeutic goal in an acute situation is to increase the serum sodium level rapidly by raising the serum sodium level by 4 mEqs/L to 6 mEqs/L over the first one to two hours. In a chronic presentation of hyponatremia, the goal is to raise the sodium level more slowly, not to exceed a rise of 10 mEqs/L to 12mEqs/L in the first 24 hours.
Regardless of the type or therapeutic approach, if the patient presents with severe symptoms, which include severe confusion, coma, seizures, etc., the patient should receive hypertonic saline, but only enough to raise the sodium by 4 mEqs/L to 6 mEqs/L in the first one to two hours. The serum sodium must be monitored closely and corrected no faster than 10 mEqs/L-12 mEqs/L in the first 24 hours. Correcting serum sodium rapidly significantly increases the risk of the patient developing central pontine myelinolysis.
Central pontine myelinolysis is brain cell dysfunction caused by the destruction of the myelin sheath that covers the nerve cells in the brainstem. The symptoms include confusion, difficulty swallowing, double vision, muscle spasms in the face arms and legs, speech changes, etc. There is no cure for this condition. The treatment is focused on relieving the symptoms. The most common cause of central pontine myelinolysis is a rapid change in the body's sodium levels. The most common occurrence is when a person is being treated for hyponatremia and the levels rise too fast. The prognosis is long-lasting and usually results in a long-term disability. Patients who have central pontine myelinolysis experience difficulty interacting with others, inability to work or care for themselves, and suffer from permanent nervous system damage.
The woman in this case was to receive a dose of 125 cc sodium every hour. The nurse administered 1 liter of sodium in less than an hour. It is not clear what the exact dose was that the woman was to receive; however, the dose administered raised her sodium by 23 mEqs, which is far higher than the recommended rise of 4 mEqs/L to 6 mEqs/L over one to two hours. The woman's rise in sodium further exceeds the total recommended rise of 10 mEqs to 12 mEqs/L in a 24-hour period, and even after 48 hours, the level should not rise by more than 18 mEqs/L.
It appears that an untoward medical error occurred, which may have been due to several factors, including: the illegible handwriting of the physician who ordered the sodium replacement therapy; the lack of communication between the nurse and the physician confirming the prescribed therapy; and perhaps a knowledge deficit on how to administer sodium replacement, especially if hypertonic (3%) solution was used.
This woman presented with an extremely serious condition that warranted rapid diagnosis and treatment, followed by close monitoring of her condition and her blood levels. It appears that close monitoring of this woman did not occur. There was a duty to the patient by both the physician and nurse to administer the sodium replacement therapy in a safe manner. Infusing the sodium in such a rapid manner, causing the sharp increase in her sodium level, demonstrates a lack of close monitoring of this woman. It is unclear how often the physician monitored the woman's sodium level in less than one hour, but it is unlikely that more than one set of labs were drawn between the commencement of the therapy and the conclusion. It also is not clear why the sodium replacement infusion was not put on an intravenous infusion pump that would better regulate the flow of the infusion and provide a more accurate administration of volume and dose.
The woman had an MRI, which confirmed the development of central pontine myelinolysis, a condition that does not develop on its own, but rather is a complication from treatment.
This case is an example of medical negligence. Given the jury findings in this case, it is evident that the gravity of this woman's presenting condition and her subsequent treatment did not meet the standard of care for the treatment of hyponatremia. The Joint Commission issued a Sentinel Event Alert on Nov. 19, 1999, regarding high-alert medications and patient safety. The Alert focuses on the use of high-alert medications that have the potential to do great harm to patients. One of the medications that The Joint Commission focuses on is sodium chloride solutions of greater concentration than 0.9%. It states that storing higher concentrations of sodium chloride solution on nursing units poses a high risk for a potential medication error. The Alert also recommends a double-check system where administration of this medication in higher concentrations than 0.9% requires a two-nurse check system. Hospitals need to ensure that they have developed strict policies on the procuring, storing, handling, and administering of concentrated medication such as sodium. A double-check system and the use of an intravenous infusion pump may have prevented this unfortunate outcome.
Reference
Case No. GD-07-019180, Court of Common Pleas of Pennsylvania, Fifth Judicial District, Allegheny County.
A woman presented at the emergency department (ED) complaining of dehydration. She was noticeably confused and had difficulty keeping her balance. The staff determined that she suffered from chronic low sodium. A physician ordered the woman be administered 125 cc sodium every hour. A nurse administered a liter of sodium in less than an hour, causing the woman's serum sodium to increase by 23 mEqs.Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.