On 12/5/2011, a patient underwent knee replacement surgery. In the course of his post-operative recovery in the hospital, the patient developed a rapid heartbeat.
On 12/6/2011, he was seen by Hospitalist A in the morning. Hospitalist A attributed the patient’s rapid heart rate to his pre-existing atrial fibrillation and ordered an oral beta-blocker. The patient’s heart rate was soon restored to a more moderate level. The patient was transferred to the telemetry unit for closer monitoring at about 11:00 a.m. Hospitalist A saw the patient again the following morning, noting that the patient was on nasally-administered supplemental oxygen, that his cardiac rhythm was irregular, that he was anemic, and that he had diminished bilateral breath sounds. The hospitalist ordered chest x-rays and a blood transfusion. The hospitalist’s order for a chest x-ray read “?chf” under “Indications.”
On 12/8/2017 at 8:40 a.m., nursing notes stated that the patient was receiving 2 liters of oxygen per minute via nasal cannula and his oxygen saturation level was 94%. Hospitalist A’s chart entries made at about 10:40 a.m. indicate the patient was anemic, displayed some mental confusion, and had abdominal distention. Hospitalist A opined that the distention “(m)ay be ileus due to oral morphine SR plus PRNs But r/o bleeding.”
Hospitalist A ordered x-rays of the patient’s abdomen, which confirmed the presence of an intestinal ileus. Hospitalist A did not obtain a CT scan of the patient’s abdomen. At about 3:50 p.m., Hospitalist A directed a nasogastric tube be placed to decompress the ileus. Nursing notes from that evening indicate that the patient’s abdomen was “very distended, rounded” with hypoactive bowel sounds.
On 12/9/2017 at 2:30 a.m., a chart entry by Hospitalist B noted that the patient was “extremely uncomfortable with increased abdominal distention.” She ordered a Harris flush procedure to reduce the patient’s intestinal pressure.
On 12/9/2017 at 3:58 p.m., the patient’s oxygen monitor alarm was sounding. His oxygen saturation was 74% despite 2 liters per minute of supplemental oxygen. Nurses repositioned the patient in bed and increased the oxygen flow rate to 5 liters per minute. The indicated oxygen saturation increased to 88%. The nasal cannula was moved to the patient’s mouth and the indicated oxygen saturation increased to 91-93%. Hospitalist A was notified of the patient’s condition.
At 4:30 p.m., the attending nurse again called Hospitalist A to report that the patient was extremely short of breath with “labored” respirations and an indicated oxygen saturation “in the low to mid 80s.” Hospitalist A directed that the patient be repositioned higher in bed; the nurse informed Hospitalist A that the patient was in the highest possible position. Hospitalist A gave no new orders regarding the patient’s care.
The attending nurse’s chart entry for 5:10 p.m. states the following:
“(p)t’s condition continues to worsen. Pt unable to hold O2 sats about low to mid 80’s on 5 liters NC. Respiratory called to put on non-rebreather mask. Pt’s LOC is decreased. Pt repositioned up in bed. NG tube flushed. Pt requiring one-to-one nursing care. Follow-up call to break and relief nurse’s call to [Hospitalist A] to ask that he come to the floor to see pt, d/t pt’s deteriorating respiratory status. [Hospitalist A] still not answering the phone.”
The attending nurse placed a “Rapid Response” call to summon a physician to assess the patient at 5:20 p.m. Hospitalist A came to the patient’s room, and his notes state that the patient’s oxygen saturation improved when he was repositioned in bed, “up to the 90s and stayed above 92” per measurement by the respiratory care provider. Hospitalist A decided to continue with the current treatment on the medical floor rather than transferring the patient to the intensive care unit.
The medical record indicates that at 5:50 p.m., the patient’s oxygen saturation level is “in the 90’s but the O2 sat is variable with sat going down into the 80’s.” The patient was still receiving supplemental oxygen via the 100% non-rebreathing mask. The nursing notes for this time state that the patient’s daughter, a nurse, believed the patient should be monitored in the intensive care unit rather than on the medical floor and conveyed that desire for transfer to nursing staff, the nursing supervisor, and to Hospitalist A.
Nursing notes for 6:45 p.m. state the following:
“BP 92/63 HR 120’s. Pt minimally responsive, respirations increasingly labored. Telemetry and O2 sat monitors frequently alarming. Pt requiring RN at bedside at all times. pt hands cyanotic and remain cool to touch and forehead now appears slightly bluish in color. [Hospitalist A] aware. Family tearful, verbalizing anger w/staff regarding pt not being transferred to ICU.”
At 7:05 p.m., Hospitalist B ordered the patient to be transferred to the intensive care unit, apparently in deference to the fact that the “family, rn, supervisor want the pt moved to icu though it was discussed with all by the rounding hbs that there are not criteria for icu…” The patient was taken to the intensive care unit at about 7:35 p.m.
The intensive care nurse’s notes state that the patient arrived at the ICU unresponsive with his oxygen saturation reading in the 70% range despite being on 15 liters of supplemental oxygen per minute via non-rebreather mask. The patient’s fingers and toes were cyanotic and his body mottled.
On 12/10/2011 at 3:10 a.m., the patient died despite additional care.
The Board expressed concern that Hospitalist A practiced below the standard of care by failing to order an abdominal CT scan in a patient with an identified bowel obstruction that was not responding to care. He failed to recognize clinical indicators of early septic shock and make a timely transfer of the patient to a higher level of care. He failed to recognize and respond to the patient’s acute respiratory distress.
The Board issued a public reprimand. He was ordered to take a course in early recognition of septic shock.
Date: January 2017
Medical Error: Delay in proper treatment, Diagnostic error, Failure to order appropriate diagnostic test, Failure of communication with patient or patient relations, Failure to properly monitor patient
Significant Outcome: Death
Case Rating: 3
Link to Original Case File: Download PDF
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