Legal Review and Commentary: Ignored order leads to patient’s death
News: Following routine prostate surgery, the patient had recovered and was transported to a floor unit. Once on the unit, the patient was left under the care of a nurse’s aide, who failed to appropriately monitor him. Three hours later, a code blue was called and the patient died. Prior to trial, the hospital settled with the decedent’s family for $750,000.
Background: The patient was admitted to the hospital for routine prostate surgery. Following successful surgery, the attending physician left instructions with the recovery room staff that the patient be checked every hour; and if his heart rate exceeded 120 beats per minute, the physician should be called. The decedent was started on morphine sulfate via continuous drip IV and the physician departed. Shortly thereafter, the patient was transferred from the recovery room to the unit. The patient was doing well and spoke with his wife, who left the hospital shortly afterward.
The patient’s medical records showed that at 8 p.m., a new syringe of morphine sulfate was inserted into the Baxter pump. When the plaintiff’s attorney first obtained the patient’s medical record, only one nurse had signed the patient’s chart indicating that the entire syringe of morphine sulfate had been used; when records were obtained later, another nurse had cosigned the entry. For the next two hours and 40 minutes, no hospital personnel monitored the decedent except a nurse’s aide. At 9 p.m., the nurse’s aide noted that the patient’s heart rate was 128 beats per minute; however, the attending physician was not notified. At around, 10:30 p.m., the nurse’s aide again checked on the patient, this time to find him totally nonresponsive. At 10:54 p.m., a code blue was called, but the patient failed to respond and died.
The patient was survived by his wife and three emancipated adult children, who brought suit against the hospital. The plaintiff’s claimed that the hospital staff failed to follow the physician’s orders and appropriately monitor the patient. The plaintiff maintained that this failure resulted in the patient’s death from either an adverse reaction to the morphine sulfate or a morphine overdose.
The defendant hospital countered that the decedent’s death was not caused by an overdose or adverse reaction to morphine sulfate and that its staff had not been negligent. However, prior to trial, the hospital settled for $750,000 with the patient’s family.
What this means to you: "Even though it doesn’t appear that the discharge from the PACU [perianesthesia care unit] was inappropriate in this scenario, the first thing a risk manager might consider is to revisit the criteria for discharging a patient from the PACU postoperatively and who can discharge on what criteria in order to verify that practice and policy match. Further, the use of enough analgesic [morphine] to require a replacement at 8 p.m. is troublesome, even in a postoperative patient. If this were a PCA [patient-controlled analgesia] unit, the patient administers the doses, but they are controlled to prevent an overdose. If the morphine was administered in a continuous pump, that is rather unusual, especially after routine surgery. Either way, the nurses should have been alert to the fact that the patient was self-administering the drug [with a PCA] with such frequency, or that the continuous drip rate was apparently rather fast, or still yet questioned why morphine was given continuously, or brought the rate of self usage to the doctor’s attention," notes Leilani Kicklighter, RN, ARM, MBA, CPHRM, CHt, director of risk management services at Miami Jewish Home and Hospital for the Aged, also in Miami.
"Controlled substances require the signatures of two licensed registered nurses; failure to do so at the time of the change out of the morphine is troubling. It could have been a simple failure to sign, or something else. In this case, the two copies of the medical record — one with one signature and one with two — is a red flag, especially when considering the time frame within which the attorney obtained the first copy and the longer time frame when he got the second copy. While medical records can be amended after the fact, in this instance, the appearance of the second signature at a later date is certainly suspect. It is a nursing standard of practice that a nurse not give a drug with which they are not familiar, meaning that they know the indications, usual dosage, usual route, intended effect, untoward effect, contraindications, and complications. The nurse has a responsibility to question or verify the order with the ordering physician if the order or dose is unusual. The pharmacist is the fail-safe step in the process in those instances of an unusual dose, drug or route, or contraindication. Based on the facts in this scenario, one wonders if the nurse or the pharmacist questioned the continuous morphine drip," observes Kicklighter.
"The post-op orders were for the patient’s heart rate [vital signs] be monitored every hour and the surgeon be called if the rate exceeded 120/minute. Even a nurses’ aide can take blood pressures, check a pulse, and count a heartbeat. For this not to be done for more than two hours is of concern as is the further failure to contact the surgeon when the rate was found to be elevated over the designated threshold. Even with an order to check the patient’s heart rate every hour, it was 1½ hours between the 9 p.m. and 10:30 p.m. check when the patient was found unresponsive, and yet another 24 minutes before a code was called. Failure to carry out a doctor’s order is a deviation from accepted standards," adds Kicklighter.
"The risk manager in this situation might investigate the communication system and practices when transferring a patient from the PACU to a unit if the unit is understaffed or does not have the proper staff to carry out post-op monitoring orders and procedures. In this scenario, if that were the situation on the unit, maybe the patient should have remained longer in the PACU? In addition, since a CNA is capable of taking a patient’s vital signs, the risk manager might investigate why that was not done in this situation and if it is a common occurrence on this unit," concludes Kicklighter.
Reference
- Phyllis Furman as successor in interest to the estate of Arthur Furman, deceased, Carrie Furman, David Furman, and Stephen Furman v. San Pedro Peninsula Hospital, Los Angeles County (CA), Superior Court, Case No. NC-025 673.
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