Case Study
Misplaced and Misread: Patient’s Death Follows Multiple Mix-ups
Description
A patient with prostate cancer sustained a cardiac arrest and brain damage following insertion of an ureteral stent.
Key Lessons
- Patient service systems can help heighten vigilance for patients who may not be able to advocate for themselves.
- Patients can tolerate unavoidable delays better when given routine updates as to reasons for the delay.
- A patient/family conference following an adverse event may contribute to averting litigation.
Clinical Sequence
Over Easter weekend, a 70-year-old semi-retired sportswriter with metastatic prostate cancer had a ureteral stent placed to relieve obstruction. The staff urologist who performed the procedure signed off at its conclusion.
The patient had significant pain following the procedure and was admitted overnight for observation. The resident on duty consulted by phone with the urologist. Subsequently, two radiology residents reviewed the post-procedure KUB (kidneys, ureter, bladder X-ray) to check the placement of the stent and (mistakenly) judged it to be properly placed. The next afternoon, a radiology fellow confirmed the residents’ (incorrect) judgment and the patient was discharged home.
On Monday morning, after two days of pain, the patient went to the hospital Emergency Department (ED). A repeat KUB suggested that the stent was not in proper position, and an abdominal CT scan was ordered to check the placement. Before the test was performed, the patient was assigned to a bed in the inpatient unit, but was kept in the ED to await his CT. During a nine-hour wait, the patient’s wife repeatedly complained to the ED staff that her husband was in severe pain. The patient received analgesics in response. No explanation was given to the patient or his wife for the delay.
At 6:00 p.m., the ED resident who had ordered the CT checked on the status of this patient. He discovered that the patient had been removed from the CT schedule because another patient with the same name had received a scan and been discharged. He informed the patient that this name mix up was the cause of the delay and scheduled an immediate CT scan.
The scan showed that the stent had perforated the patient’s ureter. A percutaneous nephrostomy was performed urgently under conscious sedation and a drain placed. Despite the sedation, the patient’s pain made positioning difficult, and he needed to be restrained. Near the conclusion of the procedure, the patient suffered a respiratory and then a cardiac arrest. He sustained severe brain damage.
At the request of the family, a conference was convened several days later to review the event. The radiology and urology residents presented their part of his care, but could not agree on the chain of responsibility.
The patient died four months later. Although his prognosis had been poor prior to the perforation, his death was attributed to the complications related to his conscious sedation.
Claim Sequence
Suit was brought against the hospital, six physicians, and a nurse. Two prominent complaints expressed by the patient’s wife in her deposition were that 1) her husband was kept waiting while in extreme pain and 2) that her family received no explanation of what had occurred during the family conference after the event.
Disposition
The suit was settled in the high range (>$500,000).
Analysis
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With the patient’s report of pain, the urology resident alerted the attending, observed the patient overnight, and reviewed the KUB before discharging him.
Patients can provide early warning of problems when they are instructed how to collaborate in their care by reporting unexpected side effects of treatment. -
Better systems for following up on patient care in the ED were needed to avoid “losing” this patient. Repeated requests for pain control medications were cues to staff to re-evaluate this patient’s status.
Physician and nursing staff are responsible for tracking orders written for patients. Older patients are traditionally less assertive about getting their needs met in a medical setting. Patient service systems may need to provide flags to alert staff to heighten vigilance for patients who may not be able to advocate for themselves. -
Plaintiffs in professional liability cases often cite feelings of abandonment by their providers as a factor in their claim. In this case, the patient’s long wait for the diagnostic procedure while in “significant pain” was a prominent point in the plaintiff’s complaint.
Patients can tolerate unavoidable delays better when the hospital staff or provider routinely updates the patient as to reasons for the delay. -
The “same name” delay in obtaining diagnostic services in the ED pointed to the need for changes both in staffing systems and in physician follow-up, but the excuse didn’t appease the patient’s dissatisfaction.
Reprobating the hospital system in front of the patient may only serve to undermine the credibility of care providers. Instead, a response that objectively analyzes what went wrong may help to assuage frustrations. -
The family in this case requested a meeting to help them understand what had occurred, but it may not have helped.
A patient/family conference following an adverse event may contribute to averting a claim when it is well planned and carried out using good communication methods. To help both sides benefit from such a meeting, consider:- involving your risk manager,
- selecting a single spokesperson from the care team,
- reviewing and reaching consensus among the care team about the chain of events,
- allowing time for the patient/family to express their concerns,
- acknowledging and apologizing for the patient or family’s distress without pointing fingers or affixing blame, and
- offering emotional support.
A helpful guide for handling the aftermath of an adverse medical event is available here.
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