On 10/19/2011 at 5:23 p.m., a 35-year-old male presented to the emergency department at a hospital with a chief complaint of abdominal pain and vomiting, which started approximately five hours before he presented to the hospital.
The patient was admitted to the hospital under the service of an intensivist and was notified of his arrival and condition at 5:35 p.m.
Between the hours of 5:50 p.m. and 7:22 p.m. the intensivist gave verbal orders of Dilaudid and ketorolac to the patient’s nurse.
At 9:20 p.m., the intensivist gave telephonic orders to the patient’s nurse, to place him on his home BIPAP mask.
On 10/20/2011, at 3:15 a.m. a rapid response was called due to an acute change in the patient’s respiratory status.
During the rapid response, an arterial blood gas (“ABG”) was drawn that revealed critical metabolic acidosis.
The intensivist never presented to the emergency room to assess the patient when he demonstrated medically dangerous/life-threatening signs at 3:15 a.m. or any time thereafter.
The intensivist never attended to the patient when his clinical situation was from an unknown cause and when a clear treatment plan had not been determined.
From 3:43 a.m. to 4:15 a.m., the critical care practitioner was contacted approximately five times with information on the patient’s medically unstable and deteriorating condition.
At 3:45 a.m., the patient became short of breath, restless, diaphoretic, and seizure episodes followed. He was then transported to an intensive care unit.
At 5:25 a.m., a second rapid response was called due to a further decline in the patient’s health. The rapid response turned into a code blue.
The patient underwent a cardiopulmonary arrest, and the code team was unable to resuscitate him.
On 10/20/2011, the patient expired at 6:25 am.
The autopsy results were consistent with acute hemorrhagic pancreatitis with diffuse pancreatic necrosis.
The Medical Board of Florida judged the intensivist’s conduct to be below the minimal standard of competence given that he failed to presented to the emergency room to assess the patient when the patient demonstrated medically dangerous/life-threatening signs on 10/20/2011 at 3:15 a.m.
The Medical Board of Florida issued a letter of concern against the critical care practitioner’s license. The Medical Board of Florida ordered that he pay a fine of $7,500 against his license and pay reimbursement costs for the case at a minimum of $4,503.10 and not to exceed $6,503.10. The Medical Board of Florida ordered that the critical care practitioner complete ten hours of continuing medical education in the area of critical care medicine and complete five hours of continuing medical education in “risk management.”
Date: December 2017
Diagnosis: Gastrointestinal Disease
Medical Error: Failure to properly monitor patient
Significant Outcome: Death
Case Rating: 4
Link to Original Case File: Download PDF
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