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Legal Review & Commentary
Failure to administer calcium after thyroidectomy: $4.7 million settlement
By Radha V. Bachman, Esq.
Buchanan Ingersoll & Rooney PC
and Ellen Barton, JD, CPCU
News: Following an elective thyroidectomy, a woman was diagnosed with hypocalcemia. Although calcium was ordered, it was never administered to the woman, despite persistent symptoms of the calcium deficiency. The woman eventually went into cardiac arrest and sustained anoxic encephalopathy, becoming comatose. She is in a vegetative state and requires nursing coverage 24 hours a day, seven days a week. The hospital claimed that the woman's calcium level was within a normal range and, therefore, the failure to administer calcium was not the cause of the woman's injury. The parties settled prior to the lawsuit being filed for $4,700,000.
Background: Following an elective thyroidectomy for removal of an enlarged thyroid, a 50- year-old woman's calcium level fell from 9.4 to 7.3. The woman eventually was diagnosed with hypocalcemia. Hypocalcemia is known to be the most common complication after total removal of the thyroid. As many as 6% of patients having a total thyroidectomy suffer this complication. Hypocalcemia is the presence of low serum calcium levels in the blood, typically less than 2.1 mmol/L or 9 mg/dl or an ionized calcium level of less than 1.1 mmol/L (4.5 mg/dL) and is an electrolyte disturbance. The common symptoms for hypocalcemia are neuromuscular irritability, muscle cramps, numbness, irritability, and confusion. Calcium was ordered for the woman but never administered, despite the fact that the calcium was taped to her hospital bed. As the evening progressed, the woman became increasingly nervous and agitated and also had difficulty swallowing. A second-year resident, who had only been at the hospital for a total of three weeks, visited the patient, but did not administer the calcium despite the fact that the calcium was provided in the patient's room.
The next morning the woman awoke groggy and complained of shortness of breath and increased swelling where to operation had taken place. The resident was called again for a consult. At the time of the consult, the woman went into respiratory failure and cardiac arrest. A code was called, and the woman was intubated. While her breathing was restored, the woman sustained anoxic encephalopathy and became comatose. The woman never recovered from the coma and now requires around-the-clock nursing care for her vegetative state.
The woman's guardian filed suit against the ENT physician who performed the thyroidectomy and the operator of the hospital, introducing head and neck surgery and neurology experts. The plaintiff alleged that the resident had failed to respond in a timely manner to the woman's shortness of breath and difficulty breathing, claiming that those symptoms were caused by the hypocalcemia, which, if low enough, could have caused the woman's breathing to be substantially reduced. Or, the plaintiff suggested, it could have been caused by a surgical-site hematoma, which could have compromised the woman's breathing passage. Despite records to the contrary, the resident claimed he responded quickly and was at the woman's bedside 11 minutes prior to the time the code was called.
The plaintiff also claimed that the administration of the calcium to the woman would have avoided the subsequent injury. The resident responded, claiming that he had properly opened the surgical site and removed clotted blood that was potentially compromising the woman's airway or lymphatic system. The defendant claimed that the woman's calcium level, at 7.3, has never been shown to cause cardiac arrest or difficulty breathing and, therefore, was not the cause of the woman's subsequent injury.
The physician who performed the thyroidectomy was removed as a defendant from the lawsuit. Ultimately, the plaintiff reached a settlement with the hospital in this case for $4,700,000.
What this means to you: Based on the facts presented here, clearly this case was one to settle. While the hospital attempted to articulate certain defenses, they were almost embarrassingly weak.
The medical literature recognizes that hypocalcemia is a well-known complication after total removal of the thyroid. However, regardless of the cause (which the hospital attempted to raise as a defense), in this case the hypocalcemia was diagnosed and appropriate treatment (calcium) was ordered. Unfortunately, it was never administered. Cardiac arrest also is clearly recognized in the medical literature as a life-threatening complication of untreated hypocalcemia. The patient went into cardiac arrest in this case, which resulted in catastrophic injuries.
The care (or more appropriately, the lack of care) provided to this patient is very troubling. After recognizing the complication, appropriate treatment was ordered but never carried out. The facts contain no explanation as to why the calcium was not given. Even more disturbing is the fact that the calcium had actually been "taped to the woman's hospital bed." There is no acceptable reason (or defense) for not administering the medication, and "taping" it to the bed only adds insult to injury.
The actions and inactions of the resident physician aggravate an untenable position. Unfortunately, the facts do not fully detail why the resident visited the patient the evening before she suffered a cardiac arrest. Was the resident called by nursing staff because the patient was exhibiting certain symptoms? Did the resident notice that the calcium was taped to the bed? What did he do, if anything? The resident's acts of omissions in not administering the calcium and/or further treating the patient are disturbing. Also, the resident's claims of being present prior to the patient's cardiac arrest the next day do very little to support a defense. If, in fact, the resident was present at the patient's bedside at the time of the patient's cardiac arrest, why were life-saving measures not taken sooner?
It is a nurse's responsibility to administer medications ordered by a physician. Why was the calcium not administered? The facts do not reveal the time lapse between the recognition of the hypocalcemia and the ordering of the calcium; however, it would appear that this was timely. What did the documentation indicate? Or, was the hospital dealing with a lack of documentation?
Based on the facts, this case provides several risk management lessons:
Periodic medication audits can prove very helpful in identifying weak spots in compliance from transcribing orders to administering them to documenting them. Such information then can serve as a basis for nursing education.
Supervision of residents is critical. A second-year resident should have been capable of recognizing the significance of the patient's symptoms and taking appropriate action. The hospital should have assessed the mechanisms that were in place to assure that the resident's actions/inactions were being reviewed and further determine what communications took place between the nursing staff, resident, and attending physician.
The attending physician bears ultimate responsibility for the care provided to his or her patient and should be involved in the event there is a complication or suspected complication. The hospital should have monitored what communication was taking place between the attending physician, nursing staff, and resident.
This case proves again what has been demonstrated by research: A significant number of claims involve "system" errors such as medication-related errors, communications errors, and documentation errors. It appears clear from the facts that the implementation and monitoring of good "systems" through consistent audits could have prevented the plaintiff's devastating injuries in this case.
Westchester County (NY) Supreme Court, Case No. 11285/05.