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Failure to diagnose hyponatremia leads to coma, death: $8.5 M settlement
By Radha V. Bachman, Esq.
Buchanan Ingersoll & Rooney PC
Ellen Barton, JD, CPCU
Principal, ERM Strategies, LLC
News: A woman who suffered from long-standing depression presented to the hospital seeking an adjustment of her antidepressant medication. During hospitalization, she suffered seizures. The hospital was unable to determine the etiology of the seizures and transferred the woman to another hospital in the area. Upon transfer, she underwent an examination and laboratory testing. The woman's attending physician consulted a neurologist who performed an examination and a CT scan. The examination produced normal results, but the admitting physician's lab results revealed that the woman was suffering from hyponatremia. Before the condition was addressed, she suffered another seizure and went into cardiac arrest, ultimately going into a coma and never regaining consciousness. The woman died five years later.
Background: A 68-year-old woman suffering from depression arrived at a small psychiatric hospital seeking an adjustment of her prescription for antidepressant medication. During this hospitalization, the woman suffered seizures. In order to properly determine the cause of the seizures, the psychiatric hospital transferred the woman to a community hospital in the local vicinity that was well equipped to conduct such a study. The transfer occurred and the woman immediately underwent examination and laboratory tests by her attending physician. Her attending physician consulted a neurologist, who also conducted an examination and ordered a CT scan. While the neurologist's examination produced normal results, the attending physician's lab results were abnormal - showing hyponatremia. Hyponatremia is an abnormally low concentration of sodium in the blood. Untreated, acute hyponatremia, the form of hyponatremia in which sodium levels fall rapidly, can lead to rapid swelling of the brain, resulting in coma and death. These are exactly the complications that occurred in the woman. Before the physicians were able to implement any protective measures, the woman suffered another seizure causing her to go into cardiac arrest. She became comatose, never regained consciousness, and died approximately five years later.
The woman's husband, the plaintiff in the case, filed suit against both hospitals, the attending physician, the neurologist, a psychiatrist who was alleged to have treated the woman, and three other physicians who were alleged to have been involved in the woman's treatment. The plaintiff alleged that the woman's condition and subsequent death were a result of the defendants' failure to timely diagnose the woman's hyponatremia and that these failures fell below the standard of care.
Prior to trial, the plaintiff dismissed most of the defendants, including the psychiatric hospital. Liability for the medical professional liability in failing to timely treat the hyponatremia was clear enough, so the second hospital and the neurologist settled with the plaintiff for $1.75 million. The claim proceeded against the woman's attending physician's estate because the physician had died.
At trial against the physician's estate, both sides' experts agreed that the seizures experienced by the woman were a result of the undiagnosed hyponatremia. Plaintiff's counsel contended that the woman's doctors never realized that she was suffering from hyponatremia because they failed to review the lab results. In addition, he argued that the woman had suffered a minor seizure the evening after being transferred and while the doctor recorded the event, hyponatremia was never noted.
The neurologist testified that he had misread the lab results but that it was not his responsibility, but that of the attending physician's, to review the results, since the neurological examination and CT scan were normal.
The receiving hospital testified that the lab results were clearly handed to the attending physician or attached to the top of the woman's chart. Hospital protocol required the attending physician to ensure that he personally received the lab results. The hospital also relied on the argument of the neurologist that the attending physician was ultimately responsible for the lab results.
Defense counsel argued that the woman existed in a permanent vegetative state and, therefore, did not experience any pain and suffering. Nevertheless, the jury awarded $8.5 million in favor of the plaintiff.
What this case means to you: This case illustrates the basis for The Joint Commission's National Patient Safety Goal 02.03.01 (formerly Goal 2C): "The organization measures, assesses and, if needed, takes action to improve the timeliness of reporting, and the timeliness of receipt of critical tests, and critical results and values by the responsible licensed caregiver." As a result of The Joint Commission's standard, many hospitals have developed policies and procedures to address the issue of "notification of test results" - especially critical values. As part of the notification process, some hospitals have created special stickers in order to draw attention to the "critical" value or inserted a "Red Flag" alert if the medical records are electronic. "Critical" values are generally defined as a value that is at such variance with normal as to represent a pathophysiologic state that is life-threatening, unless some action is taken in a short time and for which an appropriate action is possible but may be fully defined by the particular health care provider based on certain patient-specific information.
Further, most hospital policies state that it is the laboratory's responsibility to communicate these values immediately to the designated caregiver. While this appeared to have occurred in this case, regrettably, the attending physician appears to have delayed in responding to them. Most policies also provide a sometimes elaborate mechanism to assure that "responsible, licensed, health care providers receive the results in the event that the attending physician is not readily available." The notification of critical test results is a two-way responsibility. The lab clearly has responsibility for notifying the attending physician, and the attending physician has the responsibility for acting on the critical test results and notifying the patient, if necessary. It is the latter responsibility that was not appropriately exercised in this case, to the detriment of the patient.
What is additionally interesting about this case is, apparently, the neurologist received the test results in a timely manner but misread them. Thus, even though the attending physician had ultimate responsibility - the neurologist's defense in this case - the neurologist had knowledge and thus could not escape responsibility for his own negligence in misreading the results. This case illustrates that even with effective notification systems, negligence still can occur. This case highlights the need for systems that may need further implementation and expansion to include mechanisms for assuring that prompt and effective action is taken in response to "critical values."
Case No. 4159/99, Supreme Court, Ninth Judicial Circuit, Westchester County (NY).