Case Study
Poor Nurse Monitoring of Self-administered Insulin Led to Coma
Description
A 37-year-old woman with insulin-dependent diabetes mellitus and multiple co-morbidities, was admitted for severe headache, nausea, and elevated BP; she was allowed to check her own blood sugars (BS) every four hours and adjust her insulin as needed. She slept through a BS check, was found unconscious with a high BS, and after a week-long coma never returned to baseline neurological.
Key Lessons
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Physician orders allowing patients to check/deliver certain aspects of their medical care while in the hospital should still be supervised by a medical professional to see that these tasks are done on time, done accurately, and that non-compliance is managed appropriately.
Clinical Sequence
A 37-year-old wife and mother was admitted to the diabetic unit of the hospital with complaints of a severe headache, nausea and elevated BP (173/103). Her past medical history included Type I diabetes mellitus (since age 14), hypertension, renal insufficiency, and several other co-morbidities. Physician orders included IV fluids, insulin, finger stick blood sugar (BS) checks with an insulin sliding scale, Labetalol, etc. The following day her endocrinologist ordered ‘when patient eating, discontinue sliding scale, let patient choose her own insulin dosage.’
Over the next day or so the patient’s BP and BS varied and her medications were again adjusted. Orders were written by her nephrologist for the IV fluids to be discontinued, and BS to be checked every four hours (“wake patient at night – start now”). The plan was for the patient to be discharged home the next day if stable.
The following day she did not go home as planned due to a rising creatinine level (Cr = 3.6, up from 2.7; nl range 0.5 – 1.1 mg/dl), along with the need for continued medication adjustments, and her history of asymptomatic hypoglycemia and hypertension. Her physician noted that the “patient is very aggressive with her insulin dosage, BS = 59 this am and 197 at 11pm – have asked the patient to be careful about lowering her BS below 120. Patient is willing to stay to stabilize her BP and renal function.”
During her continued stay her renal function continued to decline (Cr = 4.1), developing edema in her lower extremities (4+) and lower back, with crackles noted in her lungs and a weight gain of approximately 20 pounds since admission. Orders for daily weights and strict I&O were written. Her BS also continued to fluctuate, frequently below the desired 120 (e.g, RN note: “4-11pm: BS = 42 at 4:45pm – patient ate dinner and BS rose to 103; the patient checked her own BS and administered insulin but not always consistent with orders for every 4 hours”).
One week after admission, the patient was taken to the OR for creation of an AV fistula in preparation for upcoming hemodialysis. That night, when the patient checked her BS it was 128 at 10:00 p.m.). She gave herself 2 units of Humalog and 8 units of Lantus. At 4:15 a.m., the nurse wrote “will continue to monitor closely.” Despite this, the nurse did not document any BS check between 10:00 p.m. and 6:00 a.m. At 5:40 a.m., the patient was found unresponsive; her BS was 30 (ref 70-110). She had decerebrate posturing, was intubated, and transferred to the MICU.
Post event, the nurse admitted that she didn’t wake the patient up in the middle of the night to make sure she checked her BS (but was aware of orders to check BS every 4 hours). Progress notes in the MICU state that the patient’s hypoglycemia was most likely due to her overly aggressive treatment of her BS before she went to sleep, which was compounded by her poor clearance of insulin secondary to renal insufficiency. After multiple tests (e.g., head CT, brain MRI; EEG; CXR), the impression was that the patient likely suffered an ischemic brain injury (with cortical and subcortical involvement) from hypoglycemia of unknown duration.
Approximately one week later she was able to open her eyes and move her extremities spontaneously, and was transferred back to the diabetic unit. Within two months, with improved symptoms, the patient was discharged to rehab.
Later that year, the patient underwent both a kidney and pancreas transplant. Over the next several years her neurologic function improved but she was still considered disabled, especially with regards to her emotional/social health. She spends most of her time watching TV and shows no interest in interacting with her husband or children; she also does little socializing with friends.
Disposition
The case was settled for more than $1 million.
Claim Sequence
The plaintiff sued the hospital and the nurse, alleging failure to monitor the patient’s BS every four hours per physician order, resulting in ischemic brain injury.
Analysis
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The providers shifted the responsibility for monitoring blood sugar to the patient, without adequate monitoring.
Part of a health care professional’s role is to help patients learn how to manage their own illnesses. Allowing patients to take on these types of responsibilities in the hospital gives them time to gain a better understanding of their medical condition and how best to adjust/manage their treatment, while remaining in a “safe” environment. The nurse is required to monitor the patient’s compliance and ability to manage her own illness. This should include documentation of the entire process, including patient education. The nurse is also responsible for notifying the patient’s physician when the patient does not adhere to the prescribed orders or parameters. -
The nurse, having taken care of this patient previously, knew she was capable of performing the tasks of checking her BS and administering her own insulin, but did not consider contrary information about this patient, including asymptomatic hypoglycemic events and the effects of recent surgery.
Yet when the patient is familiar, some assumptions may need to be re-evaluated. Rather than relying on a patient’s past ability, providers should also consider patient attributes that work against them. A patient’s history of previous asymptomatic hypoglycemic events, whether due to aggressive insulin dosing or poor oral intake, is a key consideration in how vigilant the monitoring should be. Also, recent surgery may make system regulation even more difficult. -
Despite physician orders, the nurse did not confirm BS checks overnight, and let the patient sleep through one of them. Deviating from the specific orders can be tempting for the comfort of a patient. Providers need to continue their vigilance in following a patient’s care plan, even when the patient is well known to them. This is especially true when the patient has a history of non-adherence or asymptomatic responses to alarming conditions.
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The nurse’s failure to follow the physician orders to ensure BS checks every four hours on the night before the patient died led to the need to settle the case before trial. An effective defense is unlikely in the presence of a direct violation of documented physician orders that might have prevented an adverse event. When all four of the legal requirements for medical negligence are met, including a duty of care, a breach in the standard, harm, and a connection between the harm and the clinician’s actions, then a settlement is most likely.
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