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News: A 4-day-old infant had an aortic coarctation, a narrowing of the aorta, which is a relatively common and easily curable heart defect. While preparing for surgery to correct the condition, the doctor ordered the nurse to give the infant pre-surgery medication. The nurse then gave the infant that dosage of the medication. A few hours later, the nurses, allegedly with no order from the doctor, lowered the dosage of medication by half. This decrease caused the infant to go into cardiac arrest. It took doctors 33 minutes to get the infant’s heart beating. As a result, the infant has, among other things, a permanent brain injury and brain dysfunction that will require her to be cared for during the remainder of her life.
The plaintiff argued that the nurses, treating physician, and hospital where the incident occurred were negligent for administering an incorrect dosage of medication. The defense was that the hospital and its staff provided reasonable and appropriate care that comported with applicable standards of care and practice. The jury found the hospital staff was negligent and ordered the hospital to pay $17.8 million in damages to the plaintiff. The claims against the doctor had been resolved on unknown terms prior to trial.
Background: In 2008, the plaintiff was born with a genetic and entirely treatable heart problem called an aortic coarctation, which forces one’s heart to pump harder in order to pump blood through the narrow gap in the aorta. Four days later, the infant was scheduled to have the surgery that her physicians believed was very routine and would enable the infant to live an entirely normal life. In preparation for the surgery, and to help her condition, the plaintiff’s physician ordered she be given Prostglandin (PG). The nurses followed the physician’s order and administered PG at a dose of 0.025 mcg/kg/min and at a rate of 1.0 ml per hour. This dose was the one the physician believed would keep the patient stable prior to surgery.
Later that night, the nurses cut the plaintiff’s dose of PG to 0.0125 mcg/kg/min at a flow rate of 0.5 ml per hour, which was half the dose the doctor ordered. No physician’s order requesting this drop in dosage could be found. The decrease of PG caused a pulmonary edema and constricted ductus arteriosus and coarctation, as well as cardiac arrest. Due to the constricted ducts, the resuscitation was difficult and lasted for 33 minutes before physicians were able to get oxygen back to the plaintiff’s brain.
The lack of oxygen to the plaintiff’s brain caused a hypoxic-ischemic brain injury. The plaintiff now suffers from significant intellectual disability, cognitive impairment, and motor skill impairment. At the time of trial, the plaintiff was 7 years old, but she had the cognitive and motor skills of a child half her age. The plaintiff is also physically disfigured and will require around-the-clock medical care for the remainder of life.
The plaintiff sued the hospital and its nurses as well as the treating physician for her injuries and the associated expenses. The plaintiff alleged that the dosage of PG being lowered without a physician’s order was negligent and failed to follow the rights and rules of medication administration that require the “right dose” be administered, and that the treating physician failed to maintain control over the case. Having a physician’s order to lower dosage is standard operating procedure. Additionally, the PG being lowered led to pulmonary edema and coarctation, which complicated the resuscitation and caused it to last 33 minutes. The plaintiff argued that this time period caused the brain damage and other injuries, and the plaintiff sought to hold the hospital liable through the work of its staff.
The defense denied any negligence on its part and contended its treatment of the plaintiff was appropriate and comported with applicable standards of care. The defense also argued that there was an insufficient causal relationship between the plaintiff’s injuries and the conduct of the hospital and its staff. The claims against the doctor had been satisfied prior to trial on unknown terms.
The jury found the hospital liable for its nursing staff negligently allowing the dose of PG to be lowered without proper authorization from a physician. The jury also found this negligence to be the cause of the plaintiff’s physical and mental abnormalities, which will require extensive and continuing medical treatment. Accordingly, on March 31, 2015, the jury ordered the hospital to pay $17.8 million in damages to the plaintiff. Most of the damages, $12.2 million, are for future medical and health-related expenses. The remainder includes $2.5 million for current and past medical expenses, $2.1 million for lost future wages and earning capacity, and roughly $1 million for pain and suffering. The plaintiff’s attorney declared this verdict to be the largest medical malpractice jury award in the history of the state of Colorado.
What this means to you: The primary cause of liability from this case came from the PG being lowered without a written record of the physician’s order and the injuries that resulted. Injuries alone will not cause physicians or the hospitals for which they are working to face liability. Rather, the injuries must be related to a negligent act. Medicine is an uncertain practice in which a fairly routine procedure can become life-threatening or life-altering for the patient in an instant. A primary lesson to take from this case is not to become too comfortable or relaxed about meeting hospital and medical standards even when dealing with routine operations. In this matter, the negligence was significantly premised on lack of paperwork. Had the physicians and nurses kept prompt records or had the hospital staff remained hypervigilant in the face of this routine matter, the dosage would not have been lowered without adequate and liability-shielding paperwork. So, in addition to shelter from liability, remaining vigilant during routine procedures also can prevent an infant or other patient from suffering great hardship.
Another potential lesson here is the need to maintain and enforce the chain of command that most hospitals use. Regardless of whether hospitals and physicians practice the utmost standard of due care, a simple mistake or misunderstanding on the nurses’ part can lead to massive liability that affiliates the practicing physician and the hospital alike. That is not to say the nurses or hospital staff are to blame for this case. Rather, physicians and hospital administrators should work with all hospital staff to ensure guidelines are enforced and followed. Additionally, despite the pace at the hospital and burden of the physician being hectic at times, the physician who is giving orders must take the time to ensure his or her order is understood. The physician also should consider the nurse or hospital staff member might be equally mentally occupied at that moment. It is also essential that support staff understands the importance of, and feels enabled to seek, clarification regarding following the physician’s orders. Ensuring a well-oiled chain of command that is alert and has open lines of communication will better serve the interests of the physician, hospital, hospital staff, and, most importantly, the patient.
That said, it is unusual and ill-advised for a nurse to alter a patient’s medication dose without first consulting the patient’s physician or the hospital pharmacist and obtaining a proper order. Because all neonatal medication administration involves a high degree of risk, regardless of the particular medication being administered, the pharmacists oversee doses of medication released to the pediatric and neonatal units. Hospital clinical pharmacists frequently will recommend changing a medication dosage they think is too risky for the patient.
Also, if a nurse is not comfortable giving a certain dose of medication to a patient, he or she should consult with the hospital’s pharmacist. In these situations, the hospital pharmacist can give the nurse the order to change the patient’s medication dose. However, this process requires documentation at every step and for the pharmacist to have consulted with the physician before ordering the dosage change.
The significant amount of damages allotted for future medical expenses is illustrative of a lesson: The treatment of infants is a delicate practice, and an error can have long-term dire and costly consequences. A simple clerical error when dealing with an infant can be the foundation of negligence that holds a member or entity of the medical community liable for a lifetime of medical expenses. The necessity of following best practice guidelines and having all administrative considerations in order is amplified when dealing with an infant.
Case No. 2013CV72 (Colo. Dist. Ct. March 31, 2015).