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Whose Patient Is She?

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Whose Patient Is She?

By Jennie Wright, RN

Related to: Diagnosis, Documentation, Emergency Medicine, Other Specialties


Description

After undergoing a breast biopsy, a 50-year-old female patient developed flu-like symptoms, persistent hypotension, irreversible organ damage, and died.

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Key Lessons

  • Patient assessment includes evaluation and documentation of recent surgical incisions.

  • The presumed diagnoses should be reevaluated when incoming data may change the initial conclusion.

  • To prevent treatment delays and errors, clinical responsibility for inpatients boarding in the ED should be clear.

  • Patients/family members are sensitive to confusion and lack of staff accountability, inferring substandard care.

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Clinical Sequence

A 50-year-old woman underwent a breast biopsy on a Friday. Over the weekend she developed flu-like symptoms (nausea, diarrhea, headache, and fever). On Sunday, she called her breast surgeon, who referred her to her primary care physician (PCP).

 

At 9:00 a.m., Monday, she presented to the PCP’s office and was noted to be hypotensive and unstable. The PCP accompanied her to the Emergency Department (ED).

 

At 11:00 a.m., she was assessed and treated by an ED attending. After initial blood work, the patient was started on IV fluids. Laboratory results revealed elevated liver and renal function tests. A physical exam was performed; no assessment of the breast biopsy site was documented.

 

At 12:30 p.m., the ED attending diagnosed possible hepatitis, and transferred care of patient to the inpatient medical service. In order to minimize the patient’s wait, he bypassed the ED resident and dealt directly with the inpatient medical service. At 3:00 p.m., the ED attending signed the patient out to an oncoming ED physician, indicating that the patient was now under the care of the inpatient medical service.

 

At 5:00 p.m., a first-year medical resident arrived reviewed the patient’s medical record. When a low dose of Dopamine failed to improve the blood pressure and urine output, the medical team decided to transfer the patient to the Medical Intensive Care Unite (MICU). A lack of MICU beds forced the patient to remain in the ED. According to hospital policy, the patient was again under the care of the ED until transfer.

 

At 10:00 p.m., upon admission to the MICU, the patient was noted to be febrile and remained hypotensive; no assessment of the breast biopsy site was documented. The MICU resident diagnosed sepsis, and a decision was made to place a central line to rapidly administer fluids and medications. The patient arrested during line placement and remained unconscious.

 

The next day (Tuesday), a Renal consult noted concern regarding the appearance of the breast biopsy site; a surgical consult (obtained at 5:00 p.m.) supported a diagnosis of infection. Without ever regaining consciousness, the patient died a week later of sepsis and toxic shock syndrome, triggered by an infection of the breast.

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Allegation

The patient’s estate sued two ED attendings, a MICU attending, and a MICU resident.

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Disposition

This case was settled for more than $1 million.

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Analysis

  1. Continued hypotension and low urine output in response to a fluid challenge is inconsistent with a diagnosis of hepatitis. A focused reevaluation of this patient’s condition would have encouraged providers to think about less “common” conditions. Failure to reassess clinical indicators and laboratory findings can contribute to a narrow diagnostic focus. Reassessment (at regular intervals) should include: physical examination, incoming diagnostic test results, vital signs, and clinical status (including level of consciousness, pain and urine output).

  2. Lack of assessment of the patient’s breast biopsy site during her ED stay and early MICU hours obscured the precipitating cause of her illness. Patients presenting with complaints of/or exhibiting fever should undergo an assessment of recent surgical incision sites. Reassessment of the surgical site should occur at regular intervals, and this reassessment should be appropriately documented.

  3. The patient’s family contended that “little or nothing was done in the ED.” In their eyes, no one was managing the patient’s care during her 10-hour ED stay. Her brother acknowledged that teams of physicians visited the patient; however, his perception was that she was uncared for. Providers who identify themselves and establish a rapport with both the patient and family develop a communication pattern that enhances the patient and family’s knowledge of the quality of care being provided.

  4. Delay in acceptance of the patient by the medical service and then a delay in transfer to the MICU created a situation where the patient was “boarding” in the ED but not acknowledged by the ED to be under their care. This resulted in failure to identify clinical findings that might have led to a prompt diagnosis of sepsis and rapid treatment with antibiotics. Clarifying the responsibility for the monitoring and treatment of patients “between” services lessens the potential that their care will suffer due to incorrect assumptions or lack of awareness.

  5. This case lacked documentation of physician oversight between 12:30 p.m. (Monday) and 5:00 p.m.—when the Dopamine was ordered—furthering the illusion that the ED was responsible for the patient but was failing to supervise her care. A critical element of patient safety is direct provider-to-provider communication during handoffs, with both providers acknowledging when care has been transferred. Institutional infrastructure should be developed to encourage confirmation of hand offs and assumption of care. Clarification as to which service is ultimately responsible for the care of patients “boarding” on their unit is necessary to prevent similar occurrences.

  6. The plaintiff alleged that the standard of care was breached by a failure to obtain a surgical consult and provide antibiotic therapy in a timely manner. Expert testimony was divided as to whether a surgical consult and rapid antibiotic therapy would have made a difference in the outcome, but lack of documentation of assessment of the breast biopsy site in either the ED or MICU made defending against such an allegation difficult. Documentation of all the elements that were assessed, and ongoing notation of rationale for treatment, is essential to the successful defense of a claim.

  7. A focus group sponsored by the defense to assess the merits of this case prompted comments such as “everyone was passing the buck.” The ED care was described as passive, suboptimal, inconsistent, and untimely. This case had many elements that can lead to a claim…and payment: multiple providers, confusion about which service is responsible for providing care, limited documentation, and a catastrophic outcome.

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March 31, 2006
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