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Risk Management Review October 2011
Failure to Monitor Patient for OSA; Physician Implicated in Death Following Surgery
Theodore Passineau, JD, HRM, RPLU, CPHRM, FASHRM
INTRODUCTION
In this Risk Management Review, we will discuss obstructive sleep apnea (OSA), an insidious condition which, if not properly recognized and treated, can result in significant healthcare-acquired injury. This interesting case from the Southwest illustrates what can happen when OSA is not addressed by the patient's treating physicians and adequately communicated to other members of the healthcare team in this case, the surgery recovery staff.
FACTS
The patient was a four-year-old male who presented to an outpatient Surgery Center for a tonsillectomy and adenoidectomy. He had a history of OSA, enlarged tonsils, and was mildly obese, however, he was otherwise healthy. The duration of the surgery was eight minutes, and it was unremarkable. Following the surgery, the patient was transferred to the Phase 1 PACU in stable condition. He was still intubated at that time. After a period in the Phase 1 unit, the patient attempted to self-extubate, and the nurse extubated him.
Shortly after the patient was extubated, he suffered a brief period of oxygen desaturation. CPAP was administered but the saturation level remained low. The anesthesiologist was summoned, and he performed a jaw thrust maneuver, which caused respirations to return to normal. The patient suffered a second episode of desaturation shortly thereafter, however, this was corrected by increasing the oxygen level and changing the patients position.
The anesthesiologist instructed the Phase 1 nurse to not administer Lortab (it is normally a standing order). After the ENT surgeon and the anesthesiologist consulted, it was agreed that the family would be instructed to not fill the Lortab prescription they had been given, but to use Tylenol instead. When the patient was transferred to Phase 2 of the PACU, the following entry was made in the record:
PO pain med held due to patients sleepiness. Will continue to monitor in Phase 2.... Phase 2 nurse aware of pain med not given. Report given.
In Phase 2, the patient appeared to be doing well although he seemed to be in pain and the family requested pain medication. After consulting with another nurse, the Phase 2 nurse administered 3 ml. of Lortab. It should be noted that when the anesthesiologist instructed the Phase 1 nurse to not administer the Lortab, he did not cross out the standing order in the chart; he simply gave a verbal order. For that reason, the standing order for 5 to 7 ml of Lortab was still present in the chart. The Phase 2 nurse understood that the Lortab had simply been withheld earlier because of the patients sleepiness.
After about an hour in Phase 2, the patient was evaluated as stable for discharge, although he was still deeply somnolent at that time. This was not considered uncommon since he had been up much earlier than usual to come in for the surgery. There are disputed facts regarding whether, prior to discharge, the Phase 2 nurse advised the anesthesiologist that she had administered the Lortab (although it is documented in the chart). It is agreed that, if he was not already aware of it, upon review of the medical record the anesthesiologist became aware of the administration of the Lortab approximately 20 minutes after the discharge. The anesthesiologist had advised the family to not fill the Lortab prescription, however, at no time did he inform them that the child had received Lortab in Phase 2.
The patient was put into his car seat and slept soundly all the way home. When they arrived home, they put him on a couch in the living room. Unfortunately, the other family members present also fell asleep in the living room and no one remained awake to monitor the patient. Some time passed before anyone realized that he was not breathing. EMS was summoned and resuscitation was attempted at the scene, followed by transportation of the patient to the hospital. Later in the day, he was declared brain dead and life support was discontinued.
Suit was subsequently commenced against the anesthesiologist, the ENT surgeon, and the surgery center. With the consent of the physicians, the case was resolved. Payment was in the high range, with allocation of 20 percent to the ENT surgeon, 40 percent to the anesthesiologist, and 40 percent to the surgery center. Expenses were in the high range.
DISCUSSION
In the U.S., obstructive sleep apnea (OSA) is estimated to be present in approximately 24 percent of adult males, 9 percent of adult females, and 2 percent of children, with 80-90 percent of cases being undiagnosed.i Certain populations are at increased risk for OSA, including people who are overweight or obese, middle aged and older men, and post-menopausal women.
OSA must always be considered as a risk factor whenever patients undergo treatment which may impair their ability to breathe. This would obviously include any procedure involving general anesthesia, but also treatment with any medication which could have a respiratory depressing effect. There are numerous reported cases of patient injury-including several deaths- resulting from treatment of patients without proper consideration of OSA. This has occurred in both the inpatient and outpatient settings.
Two factors made it difficult to defend this case. First, a definitive cause of death was never determined, either by the pathologist who performed the autopsy, or by the pediatric forensic pathologist who reviewed the case for the defense. Certain possible etiologies (such as cardiac) were ruled out; however, a clear, verifiable cause was not identified. Plaintiffs counsel asserted that the cause of death was the effect of the Lortab, exacerbated by the OSA, resulting in respiratory depression and ultimate death. Because the cause of death was not able to be determined, the defense was left without any way to rebut this assertion. What is known is that the Lortab was administered after the ENT surgeon and the anesthesiologist had agreed that is was contraindicated (as evidenced by the recommendation to the family to not fill the Lortab prescription).
A second factor which may have contributed to this tragic outcome is the occurrence of at least three hand-offs following the surgery. A hand-off is generally defined as the transfer of patient care from one person to another. This can occur as a result of a shift change, handover of a patient from EMS to ED staff, after hours coverage, or, as in this case, movement of a patient within or between units. It is the potential for miscommunication that places patients at greatest risk during the hand-off process
In this case, after the surgery was completed, the anesthesiologist delivered the patient to the PACU Phase 1 nurse (the first hand-off). It appears that the communication between the anesthesiologist and Phase 1 nurse (specifically, the order to hold the Lortab) was adequate; however, the anesthesiologist failed to strike the standing order for Lortab from the chart. Then, when the patient was transferred from Phase 1 to Phase 2 (the second hand-off), the verbal order was apparently not clearly communicated between the Phase 1 and Phase 2 nurses. This, combined with the presence of the Lortab standing order in the chart, caused the Phase 2 nurse to conclude that it was acceptable to administer the Lortab. Finally, when the patient was discharged (the third hand-off), the parents were not warned to observe the patient closely for several hours. Ideally, this warning would have been given at the time the parents took the child home. However, if the anesthesiologist was not aware of the Lortab administration at the time of discharge, it was imperative that he immediately recontact the family when he learned that this had occurred.
SUMMARY SUGGESTIONS
The following suggestions may be of assistance to physicians in preventing the interaction of OSA and medical treatment, resulting in patient injury:
1) Every patient should be evaluated for OSA, and when it is identified, OSA should be prominently noted in the patient's record;
2) If OSA is confirmed or suspected the physician must be very judicious in determining which medications may cause or exacerbate respiratory depression;
All providers must recognize the high-risk nature of hand-offs, and be especially clear in both their oral and written communication during hand-off situations;
Whenever a known OSA patient is being discharged while still under the influence of a medication with the potential for respiratory depression, discharge instructions to the patients caregivers must be very clear and well documented.
CONCLUSION
Patients with OSA will provide a challenge for their physicians, regardless of the practice setting. However, with proper identification and careful consideration of OSA, such patients can be managed safely. The physicians vigilance in these cases will result in treatment which can be both safe and efficacious.
Failure to Monitor Patient for OSA; Physician Implicated in Death Following Surgery
Theodore Passineau, JD, HRM, RPLU, CPHRM, FASHRM
INTRODUCTION
In this Risk Management Review, we will discuss obstructive sleep apnea (OSA), an insidious condition which, if not properly recognized and treated, can result in significant healthcare-acquired injury. This interesting case from the Southwest illustrates what can happen when OSA is not addressed by the patient's treating physicians and adequately communicated to other members of the healthcare team in this case, the surgery recovery staff.
FACTS
The patient was a four-year-old male who presented to an outpatient Surgery Center for a tonsillectomy and adenoidectomy. He had a history of OSA, enlarged tonsils, and was mildly obese, however, he was otherwise healthy. The duration of the surgery was eight minutes, and it was unremarkable. Following the surgery, the patient was transferred to the Phase 1 PACU in stable condition. He was still intubated at that time. After a period in the Phase 1 unit, the patient attempted to self-extubate, and the nurse extubated him.
Shortly after the patient was extubated, he suffered a brief period of oxygen desaturation. CPAP was administered but the saturation level remained low. The anesthesiologist was summoned, and he performed a jaw thrust maneuver, which caused respirations to return to normal. The patient suffered a second episode of desaturation shortly thereafter, however, this was corrected by increasing the oxygen level and changing the patients position.
The anesthesiologist instructed the Phase 1 nurse to not administer Lortab (it is normally a standing order). After the ENT surgeon and the anesthesiologist consulted, it was agreed that the family would be instructed to not fill the Lortab prescription they had been given, but to use Tylenol instead. When the patient was transferred to Phase 2 of the PACU, the following entry was made in the record:
PO pain med held due to patients sleepiness. Will continue to monitor in Phase 2.... Phase 2 nurse aware of pain med not given. Report given.
In Phase 2, the patient appeared to be doing well although he seemed to be in pain and the family requested pain medication. After consulting with another nurse, the Phase 2 nurse administered 3 ml. of Lortab. It should be noted that when the anesthesiologist instructed the Phase 1 nurse to not administer the Lortab, he did not cross out the standing order in the chart; he simply gave a verbal order. For that reason, the standing order for 5 to 7 ml of Lortab was still present in the chart. The Phase 2 nurse understood that the Lortab had simply been withheld earlier because of the patients sleepiness.
After about an hour in Phase 2, the patient was evaluated as stable for discharge, although he was still deeply somnolent at that time. This was not considered uncommon since he had been up much earlier than usual to come in for the surgery. There are disputed facts regarding whether, prior to discharge, the Phase 2 nurse advised the anesthesiologist that she had administered the Lortab (although it is documented in the chart). It is agreed that, if he was not already aware of it, upon review of the medical record the anesthesiologist became aware of the administration of the Lortab approximately 20 minutes after the discharge. The anesthesiologist had advised the family to not fill the Lortab prescription, however, at no time did he inform them that the child had received Lortab in Phase 2.
The patient was put into his car seat and slept soundly all the way home. When they arrived home, they put him on a couch in the living room. Unfortunately, the other family members present also fell asleep in the living room and no one remained awake to monitor the patient. Some time passed before anyone realized that he was not breathing. EMS was summoned and resuscitation was attempted at the scene, followed by transportation of the patient to the hospital. Later in the day, he was declared brain dead and life support was discontinued.
Suit was subsequently commenced against the anesthesiologist, the ENT surgeon, and the surgery center. With the consent of the physicians, the case was resolved. Payment was in the high range, with allocation of 20 percent to the ENT surgeon, 40 percent to the anesthesiologist, and 40 percent to the surgery center. Expenses were in the high range.
DISCUSSION
In the U.S., obstructive sleep apnea (OSA) is estimated to be present in approximately 24 percent of adult males, 9 percent of adult females, and 2 percent of children, with 80-90 percent of cases being undiagnosed.i Certain populations are at increased risk for OSA, including people who are overweight or obese, middle aged and older men, and post-menopausal women.
OSA must always be considered as a risk factor whenever patients undergo treatment which may impair their ability to breathe. This would obviously include any procedure involving general anesthesia, but also treatment with any medication which could have a respiratory depressing effect. There are numerous reported cases of patient injury-including several deaths- resulting from treatment of patients without proper consideration of OSA. This has occurred in both the inpatient and outpatient settings.
Two factors made it difficult to defend this case. First, a definitive cause of death was never determined, either by the pathologist who performed the autopsy, or by the pediatric forensic pathologist who reviewed the case for the defense. Certain possible etiologies (such as cardiac) were ruled out; however, a clear, verifiable cause was not identified. Plaintiffs counsel asserted that the cause of death was the effect of the Lortab, exacerbated by the OSA, resulting in respiratory depression and ultimate death. Because the cause of death was not able to be determined, the defense was left without any way to rebut this assertion. What is known is that the Lortab was administered after the ENT surgeon and the anesthesiologist had agreed that is was contraindicated (as evidenced by the recommendation to the family to not fill the Lortab prescription).
A second factor which may have contributed to this tragic outcome is the occurrence of at least three hand-offs following the surgery. A hand-off is generally defined as the transfer of patient care from one person to another. This can occur as a result of a shift change, handover of a patient from EMS to ED staff, after hours coverage, or, as in this case, movement of a patient within or between units. It is the potential for miscommunication that places patients at greatest risk during the hand-off process
In this case, after the surgery was completed, the anesthesiologist delivered the patient to the PACU Phase 1 nurse (the first hand-off). It appears that the communication between the anesthesiologist and Phase 1 nurse (specifically, the order to hold the Lortab) was adequate; however, the anesthesiologist failed to strike the standing order for Lortab from the chart. Then, when the patient was transferred from Phase 1 to Phase 2 (the second hand-off), the verbal order was apparently not clearly communicated between the Phase 1 and Phase 2 nurses. This, combined with the presence of the Lortab standing order in the chart, caused the Phase 2 nurse to conclude that it was acceptable to administer the Lortab. Finally, when the patient was discharged (the third hand-off), the parents were not warned to observe the patient closely for several hours. Ideally, this warning would have been given at the time the parents took the child home. However, if the anesthesiologist was not aware of the Lortab administration at the time of discharge, it was imperative that he immediately recontact the family when he learned that this had occurred.
SUMMARY SUGGESTIONS
The following suggestions may be of assistance to physicians in preventing the interaction of OSA and medical treatment, resulting in patient injury:
1) Every patient should be evaluated for OSA, and when it is identified, OSA should be prominently noted in the patient's record;
2) If OSA is confirmed or suspected the physician must be very judicious in determining which medications may cause or exacerbate respiratory depression;
All providers must recognize the high-risk nature of hand-offs, and be especially clear in both their oral and written communication during hand-off situations;
Whenever a known OSA patient is being discharged while still under the influence of a medication with the potential for respiratory depression, discharge instructions to the patients caregivers must be very clear and well documented.
CONCLUSION
Patients with OSA will provide a challenge for their physicians, regardless of the practice setting. However, with proper identification and careful consideration of OSA, such patients can be managed safely. The physicians vigilance in these cases will result in treatment which can be both safe and efficacious.
