A 21-year-old woman with a history of multiple birth defects, was scheduled for hip surgery. She was non-verbal (but could communicate with facial expressions, and to a limited extent, via a computer translator) and dependent on family members for all aspects of daily living. She also suffered mild diabetes insipidus (DI), otherwise known as “water diabetes.” DI is a rare disease in which the kidneys produce abnormally large volumes of diluted urine. This patient’s DI was managed at home by her mother with careful attention to her fluid intake. Three years prior to this surgery, she had undergone a similar orthopedic procedure and had an extended admission due to hypernatremia.

Two weeks prior to surgery, at the pre-op appointment, the patient’s mother reminded the surgeon—and the resident assisting him—of her daughter’s DI and her previous post-op complication. They acknowledged her concern, and the attending told her to “make sure” that the anesthesiologist understood. The mother spoke with the anesthesiologist later that day.

Upon admission, the patient’s DI was documented by the nurse practitioner on the anesthesia assessment form. Pre-op serum sodium was in the normal range (normal = 135-148). Because of the patient’s DI, the anesthesiologist closely monitored her electrolytes during surgery.

Halfway through the procedure, the resident surgeon was called to another case. He was replaced by an orthopedic fellow, who did not know the patient, and the surgery was completed successfully. Immediately after the surgery, the attending surgeon left for vacation. The fellow wrote the post-op orders but—unfamiliar with the patient’s medical history—did not include serial labs or adequate fluid intake. The PACU nurse did not pay particular attention to the patient’s electrolytes or fluid balance. The patient was transferred to the floor, where the nurse was unaware of her DI.

The next day, the mother told the nurse on duty that her daughter had DI, and gave her a worksheet of what her hour-by-hour fluid intake should be. This nurse made note of it, but did not follow up on it, assuming the physician’s orders covered the patient’s needs. The patient was visited by the orthopedic resident each post-op day.

Four days post-op, she became somnolent and experienced seizure-like activity. Not understanding DI, the nurses had not made it known when the patient was becoming more withdrawn. When she slipped into a coma and developed aspiration pneumonia, a chart review indicated that her sodium levels had gone unchecked for three days; upon testing, it was 185. She was transferred to the MICU where, over several days, her electrolyte and fluid imbalance was corrected. An MRI showed brain damage (including changes of osmotic demyelinating syndrome of the pons, thalamus, cerebellum, and basal ganglia). She is no longer able to communicate in any fashion with her family and now lives in a long-term nursing home.

1. This non-verbal patient, with a complex medical condition, was treated as routine.

   A complicated patient with potentially lethal chronic conditions requires extra planning and coordination with other providers to ensure the best possible outcome. Under the stress that surgery and hospitalization represent, comorbidities can fall dangerously out of control. On the plus side, these patients are often accompanied by a highly involved family member who can help identify symptoms when the patient cannot.

2. The lead surgeon scheduled a vacation immediately following this elective surgery, with no written or oral instructions to manage the DI.

   Ideally, an elective surgery can be scheduled when the surgeon will be around for post-op care; but reliable care should not be dependent on the presence of one practitioner. A review of a patient’s complicating clinical issues with a covering physician can lead to a monitoring plan that reassures the exiting physician.

3. No plan was made for monitoring the DI post-op, neither by the resident who knew the patient and made rounds, nor the fellow who dictated the post-op orders.

   Mandatory consults for certain serious conditions can provide needed expertise. Care plans should go with the patient across care sites and feature prominent clinical risk issues; electronic order entry and medical record systems can be implemented with decision support that flags concerns and prompts recommended actions.

4. Exclusive focus on the hip surgery led providers to look past the diabetes insipidus.

   The chief complaint is, appropriately, what providers focus on. Often, however, patients, family members, and/or PCPs have a different “main concern,” which could be a variety of side issues and health risks (e.g., allergy, suspended medication, dangerous chronic disease) that pose a danger to the patient’s health. Attending to the main concern may be key to a successful outcome. Along with a two-minute chart review or checklist during hand-offs, use of a specialized area of the chart for “main concern” can provide a helpful warning for subsequent providers.

5. Fragmented care and isolated decision-making increased the risk that providers would lose track of the patient’s diabetes control.

   Multiple providers and disciplines must maintain awareness and ensure monitoring of serious clinical risks before, during, and after treatment. Team training emphasizes techniques for clear communication, such as pre-and-post-op “huddles” to share and confirm plans. It also seeks to improve coordination during a crisis, teach subordinates to voice concerns and challenge potentially harmful decisions, and enable all team members to see the whole picture of a patient’s care needs.

6. The patient’s mother felt “closed out” of conversations with the nurses about her fluid intake and output.

   Patients and families usually crave more information, not less. The most significant factor to a family or patient can appear to be overlooked by providers. To integrate families in the care of patients, leadership must set the expectation and foster an atmosphere of sharing. Care processes that works for patients require developing a mechanism to capture and utilize input from patients and families at critical care junctures.

7. This patient’s care was characterized by assumptions: the attending surgeon assumed that the mother would tell the anesthesiologist about the DI or that the covering physicians would consider it in the post-op care; the floor nurse assumed that the fellow’s post-op order addressed anything the mother was worried about, etc.

   Most areas for improvement across settings of highly committed providers are in how the care experience is structured at critical junctures—such as transitions from primary care to surgery to post-op, or transitions among providers (including attending-to-resident). The goals are to keep providers aware of complicating factors that increase risk to the patient, and to ensure appropriate monitoring and timely response. The tools to reach these goals might include mandatory consults for certain conditions, problem lists and care plans that go with the patient from site to site, or communication protocols, such as pre-and-post-op huddles.

8. This event compounded the deficits the patient already had, and changed her ability to communicate with her mother and to recognize other people.

   The surgeon was responsible for appropriate post-op care, which included monitoring a potentially harmful pre-existing condition. The lack of monitoring led to permanent damage. Although the parents’ previous plans had been to care for their daughter at home until they were in their 70s, this now proved impossible. The question remaining for the legal case was how much compensation the patient should receive. Because the two sides were close, but unable to reach agreement on their own, they turned to mediation to help settle the case.