A 48-year-old morbidly obese woman with diabetes and sleep apnea (treated with nightly nasal CPAP), required surgery for a detached retina. Two days before surgery, during her preoperative evaluation with a locum tenens physician in her PCP’s office, she reported a 3–4 day history of phlegm-producing cough and intermittent shortness of breath. Her EKG was within normal limits with no acute changes. The physician diagnosed her with acute bronchitis and prescribed antibiotics and a bronchodilator. He also sent the patient’s pre-operative report to her surgeon, and discussed all relevant findings. Because the patient’s procedure was scheduled as day surgery, the physician did not order post-op CPAP.
During the patient’s pre-operative interview, the anesthesiologist noted the patient’s acute bronchitis and sleep apnea. No respiratory assessment was documented.
Surgery was performed without complications. Given the patient’s history of sleep apnea and the late afternoon surgery, her daughter requested that the patient be admitted overnight for observation.
6:30 p.m. Stable, alert, and oriented, the patient was transferred to the floor. The floor nurse received the patient without a report or any mention of her sleep apnea.
7:00 p.m. Shift change
8:00 p.m. The patient—one of eight the incoming nurse was responsible for—complained of eye pain and was given Demerol (PO).
8:30 p.m. The patient vomited and the nurse assumed that the pain medication had been expelled. Despite a clear order to contact the physician for uncontrolled eye pain, the nurse administered an antiemetic and another dose of Demerol (IM) without notifying the physician.
9:30 p.m. The patient again complained of inadequate pain control. The nurse contacted the physician, who ordered a different antiemetic and pain medication. After receiving both medications and being encouraged to lie down, the patient appeared comfortable and began to fall asleep.
11:45 p.m. Upon checking the patient and finding her to be lethargic with cool, moist skin, the nurse called the lab to draw her blood sugar. While waiting, the nurse gave the patient a glass of orange juice. Her blood sugar was 278 and she seemed more alert.
12:45 a.m. The patient again appeared lethargic but arousable. The nurse, concerned for her patient, asked the charge nurse to assess her. He felt the pain medications had taken effect and the patient was sleeping comfortably; the physician was not contacted.
1:15 a.m. The nurse found the patient without a pulse or respirations and called a code. The patient was resuscitated, but upon transfer to an ICU at a neighboring hospital, she was declared dead.