Failure to order appropriate treatment

Presentation
On December 3, a 27-year-old woman came to the office of Internist A. The patient reported abdominal pain. The patient’s history included relapsing acute thrombotic thrombocytopenic purpura (TTP). TTP is a blood disorder characterized by abnormal clotting in the small vessels and low platelet and red blood cell counts due to fragmentation of the red blood cells.

The patient had a 13-year history of the disease, with chronic renal insufficiency, hypertension, congestive heart failure, and splenectomy. She had been under the care of Internist A for four years. The patient was frequently noncompliant with the recommended treatment and was usually treated for acute TTP events as an outpatient by transfusion of fresh frozen plasma.

Her most recent treatment occurred in August, when she was admitted to a local hospital for continuous infusion of fresh frozen plasma. She improved after five days and was discharged.
 

Physician action
When the patient came to the office on December 3, she was seen by Internist B. He noted right upper quadrant tenderness. Lab studies revealed a drop in the platelet count to 11,000. Internist B recommended admission.

The patient was admitted to a local hospital at 2:30 p.m. Internist B faxed orders for lisinopril 20 mg daily; methylprednisolone 40 mg IV every eight hours; one unit of fresh frozen plasma every two hours (plasma infusion versus plasma exchange); azathioprine 100 mg; and aspirin. The patient’s admitting blood pressure was 162/118 mm Hg.

At 3:45 p.m., Internist B ordered levorphanol 2 mg IV every three hours and prochlorperazine. At 4 p.m. the patient’s blood pressure was 170/106 mm Hg.

At 6 p.m., Hematologist A assumed care of the patient. He gave telephone orders for granisetron 1 mg IV for nausea. The patient’s blood pressure was 175/105 mm Hg at 8 p.m. The nurses noted continued nausea, vomiting, and abdominal pain at 11:45 p.m.

Hematologist A called in orders for dolasetron IV, promethazine, and furosemide at 1:45 a.m. Lab studies taken at 4:30 a.m. showed worsening TPP (platelets at 5,000) and anemia (hematocrit at 24%). At 6:30 a.m., the nurses documented: “Patient received 40 mg furosemide IV and only diuresed 225 cc with 575 for total shift . . . day nurse aware and to notify MD.”

Internist A assumed the patient’s care at 7 a.m. In a handwritten admit note, he stated, “Since admission late p.m. she has received cryoprecipitate-free fresh frozen plasma every two hours. However, platelets continued to decrease to 5,000. Will begin apheresis with 1.5 plasma exchange using cryoprecipitate-free fresh frozen plasma. Will have nephrology place Quinton. Give unit single donor platelets prior to insertion of Quinton. Plan apheresis daily until counts increase.” Internist A also ordered furosemide and daily lab studies.

A nephrologist placed a Quinton catheter in the patient’s left groin. At 10:40 a.m., the nurses placed a urinary catheter noting, “only 10cc of bloody urine out at this time.”

The patient was transferred to the dialysis unit and the plasma exchange began at 12 p.m. Her blood pressure dropped and she became unresponsive. At 2:05 p.m. a code was called and an emergency department physician began ACLS procedures. The patient was intubated and stabilized.

The results of an EKG were consistent with acute myocardial infarction. A cardiologist performed an emergent cardiac catheterization at 6 p.m. No coronary artery occlusions were found.

At 6:30 p.m., the patient arrested. She could not be resuscitated and died at 6:45 p.m. No autopsy was performed, but cardiologists believed the patient’s death was due to cardiogenic shock resulting from diffuse blood clots in the small arteries of the heart, secondary to TTP.
 

Allegations
Lawsuits were filed against Internist A, Internist B, and Hematologist A. The allegations included:

  • failure to timely order plasma exchange versus plasma infusion;
  • failure to order red blood cells in the face of progressive hemolysis; and
  • ordering platelets while the patient was receiving an ACE inhibitor.

The group that employed Hematologist A and the hospital were also sued.
 

Legal implications
The plaintiff’s expert argued that the initial choice for plasma infusion was questionable given the severity of the patient’s condition. He stated the patient should have been closely monitored and more quickly moved to plasma exchange when she did not respond to infusion. Compounding the problem was the failure to give red blood cells in the face of progressive hemolysis and giving platelets in the absence of a bleeding problem.

Defense experts maintained that the initial treatment ordered by Internist B was reasonable because the patient had an established history of responding to this treatment. There was also discussion among the experts that the patient’s condition was not salvageable by the time she came to Internist B. TTP patients typically require several days of treatment to fully recover from an acute episode, but the patient died after only 24 hours of treatment.
 

Disposition
This case was taken to trial and the jury reached a verdict in favor of the defendants.
 

Risk management considerations
The outcome was a success for all the defendants; however, this case still offers opportunities for improving documentation and processes in the future.

There was a concern about a delay in the plasma infusion treatment being started following admission to the hospital. Given the severity of the patient’s condition, more specific orders and closer follow up were warranted. Physicians ordering diagnostic testing or treatments in a hospital should provide clear orders about urgency (routine, stat etc.). The ordering physician should also follow up on lab testing. Making an entry next to the lab order asking to be notified of test results when they are received, could expedite the review process. It is also helpful to indicate in the medical record any specific changes in the patient’s condition that warrant physician notification. This could provide an earlier opportunity to change or adjust the treatment plan.

 

 

These closed claim studies are based on an actual malpractice claims from TMLT. These cases illustrates how action or inaction on the part of physicians led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician’s defensibility. These studies have been modified to protect the privacy of the physicians and patients.

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