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Woman's death leads to $602,800 verdict
News: A woman who required a feeding tube went to the hospital for a colonoscopy. Because of complications experienced during the procedure, doctors inserted a central line for intravenous fluid access. Upon her discharge from the hospital, a nurse attempted to restart the woman's feeding through her feeding tube, but she mistakenly connected the feeding pump to the patient's newly inserted central catheter line, which caused some of the feeding solution to infuse into the woman's system. Within 30 minutes, the woman began experiencing respiratory distress and was rushed to the intensive care unit, where she soon died. The patient's estate sued the hospital and its nurse. A jury awarded $602,800 in favor of the plaintiff and found that the hospital should be assessed punitive damages due to its grossly negligent conduct.
Background: A 62-year-old woman was developmentally challenged, blind, deaf, and nonverbal and had a history of mitral valve prolapse, high blood pressure, recurrent respiratory infections, and a mild stroke. With no close family relationships, she lived as a ward of the state in a group home for individuals with similar needs. She struggled to become a productive member of society, although she did have a job and had learned to communicate through body language, gestures, signs, vocalizations, and mannerisms.
In 1996, the woman underwent surgery to have a gastrostomy feeding tube (G tube) inserted to aid in her nutrition. Two years later, the woman went back to the hospital for a colonoscopy, but she experienced complications during the procedure. The woman was consequently hospitalized, and doctors inserted a central line for intravenous fluid access. Throughout her subsequent hospital stay, the woman experienced trouble with her G tube feedings. On the date of her discharge, nurses discussed the proper administration of her G tube feeding solution. One nurse ultimately attempted to restart the woman's feeding through her G tube but mistakenly connected the feeding pump to the patient's central line instead. The mistake caused 15 cc to 20 cc of the solution to infuse into the woman's system via the triple lumen central venous catheter.
Within 30 minutes, the woman began suffering from respiratory distress, and her skin and mucous membranes became bluish in color, a condition known as cyanosis, suggesting that her blood did not have enough oxygen. A Code Blue was called, and the woman was intubated and rushed to the intensive care unit. The patient's condition continued to deteriorate over the next several hours, and she died later that day, less than six hours after the feeding solution had been administered.
The woman's estate — distant relatives who did not know of the woman's existence until after her death — sued the hospital and its nursing staff for gross negligence. The plaintiff claimed that the woman had endured six hours of conscious pain and suffering, which was compounded by the fact that the decedent's hands were restrained during the incident, thereby preventing the woman from being able to "see." The hospital conceded that an error had occurred, but it disputed that its actions constituted gross negligence.
The hospital tried to minimize the plaintiff's damages, claiming that the woman was largely unresponsive during most of the time between the Code Blue and her death, suggesting that she did not suffer during that time. The hospital also claimed that immediate steps were taken to avoid similar errors in the future. In response, however, the plaintiff introduced evidence of subsequent mistakes by the same nurse.
After a trial, the jury found that the defendant's actions had risen above mere simple negligence and classified them instead as gross negligence. The jury's damages award was consequently doubled, leading to an eventual judgment of $602,800, which included $250,000 in punitive damages.
What this means to you: "This is a sad, untoward outcome that could have been prevented," says Leilani Kicklighter, RN, ARM, MBA, CPRHM, LHRM, consultant/principal for The Kicklighter Group in Tamarac, FL, and past president of the American Society of Healthcare Risk Management. Significantly, this incident occurred in 1996, before the publication of the Institute of Medicine's report To Err is Human, which emphasized the prevention of medical error and the patient safety initiative. Kicklighter notes that many of the patient safety preventive goals that have been implemented as a result of the report are issues in this case scenario.
In this situation, the patient had a long-term G tube placed in the abdomen for feeding, which looks quite different from a central intravenous line. Nevertheless, this case illustrates that when a patient has more than one tube, the purpose of each tube should be labeled to prevent confusion. "This method would have probably prevented the infusion of the tube feeding into the central line in this scenario," says Kicklighter. A second preventive intervention that has been implemented since 1996 is the manner in which different tubes are connected. Kicklighter notes that if the feeding pump connectors not been compatible with the central line in-connector, this incident likely would not have happened.
Kicklighter questions the way the providers in this scenario handled the patient's situation. First, it is unclear whether the nurse who mistakenly connected the feeding pump to the central line was involved in the discussion among the nurses regarding the problems the woman had been having with her G tube. Because the problem with the G tube was known before the incident occurred, Kicklighter questions why the patient's physician did not call a consult or correct the problem with the G tube. "And if the patient had been having problems," says Kicklighter, "why did an attempt to give the tube feeding wait until the day of discharge?"
Another issue raised in this scenario is the restraint of a patient whose senses, hearing, seeing, and speaking were compromised. "It is unclear why the woman's hands, which she used to communicate, were restrained and taken from her in this case. Nowadays, the use of restraints is closely monitored and must be thoroughly documented," notes Kicklighter.
She notes in conclusion that disclosure is a requirement of The Joint Commission and in many states. "A root-cause analysis of this incident performed at the time of this unfortunate outcome might have shed more light on the situation, and addressing the issues identified in the root-cause analysis by implementing corrective action might have changed the reaction of the woman's distant relatives and might have prevented the alleged subsequent incidents involving the same nurse," Kicklighter concludes.