Information: Plantico v. Froedtert Memorial Lutheran Hospital

Summary: Was the hospital liable for death of patient via OxyContin?

Disclaimer: Due to the overly sensitive and backward nature of the state I reside in, my nurse attorney Teressa Sanzio has asked me to clarify that I am not practicing law on my blog, rather, targeting these articles toward educational activities that empower good, safe nursing practice. Thank You.

(Published with permission from nursefriendly.com)

It’s that time of year again. Elbows resting on the counter and chin in your hands you watch as a fresh batch of residents floods the nursing station appearing painfully awkward as they fumble around with their newly issued phones, metal clipboards, and pagers, nervously glancing about for a place to sit, while trying to appear as if they have been doing this for years. You and your colleagues know better. For the next two months all the nurses will have the “unofficial” pleasure of making sure the orders these neophytes write make sense and don’t have the potential to kill any patients. You’ve lost count of the many near misses that have been intercepted in the past, and have no intentions of letting anything slide by you—the veteran nurse on this floor. But today has been unusually busy. You had one code blue that went to the ICU, another heart failure patient flown in shortly after that who now has a SWAN ganz catheter, two drips to manage, and hourly cardiac outputs; a fresh thoracotomy from the PACU, and an acute stroke patient who has been admitted to the floor because he is actively dying and there are no beds on the 6th floor where end of life patients (that aren’t heart patients) are usually admitted. The family is understandably in shock and requires a lot of your time and support. Upon returning to your desk you find a new report sheet with details of yet another patient who will be added to your group. It’s an LVAD patient coming in because his flow readings aren’t looking normal and the doctors think he needs to be rehydrated or transfused. Awesome.

While making rounds and checking on everyone, you notice something isn’t quite right with the patient who had the thoracotomy. She has a patient controlled analgesia pump running and you double checked (with the PACU nurse) all the settings upon her arrival to the floor. No adjustments have been made to the pump since then. “Mrs. Beatty how are you feeling right now?” you ask. “I just feel so drowsy, like my head is somewhere above my body” she responds. She says her pain level is a one. Her vital signs are okay with the exception of her respirations which are 12-14 per minute, and her oxygen saturation which is 92% on 2 liters of oxygen via nasal cannula. One of the prongs is out of her nose. While readjusting the nasal cannula you advise her: “I’m going to increase your oxygen a bit and raise the head of the bed to allow you to breathe in a little deeper” Eyes closed, she nods in agreement, and begins to snore. Mrs. Beatty’s oxygen saturation picks up a bit and rises to 96%. Her respirations are now 14-16 breaths per minute. You feel only halfway at ease, because your nurse gut is still whining, taking up space in your head. You sit down in a chair to think when the nurse iPhone alarms, signaling that it’s time to go shoot another round of cardiac outputs on the sick heart a couple of doors down. Shaking off that nagging feeling, you take one last look at Mrs. Beatty’s oxygen saturation monitor (it’s 95%) and leave the room. You’ll check on her again when you get done with the outputs and call the CT Surgery Resident, perhaps the settings on the PCA pump need to be lowered.

One of your colleagues enters the room where you are attending to the sick heart patient, who, himself is starting to worry you because his numbers don’t look good and neither does his heart rate…. “The family in 324 is asking for you, they think something has changed.” Thanking her for the advisement you make a mental note to call the heart failure team overseeing this patient and you head down the hall to the room where the stroke patient is actively dying. The daughter is waiting for you at the door, tearfully sharing that her father seems to be “struggling with his breathing” and is having a difficult time. A quick assessment reveals that the patient could be experiencing air hunger. His respirations are 18 per minute at the moment but he is indeed struggling to breathe and his body is showing signs of tension. You reassure the daughter that there are standing orders for morphine to help relax her father and make him more comfortable. After administering the morphine you sit at the bedside for a few moments to assess its effect on the patient’s breathing. His respirations slow to 12 and they are deeper, his body begins to relax. The frightened family members in the room gingerly approach the bedside once more to continue their vigil. You sense this is your cue to leave. But before you exit, you bump up the patient’s oxygen to 4 liters per minute and ask the family to call for anything else they may need.

Before getting distracted with anything else you quickly dart into an empty room to page the heart failure team and report your concerns about their patient. Relieved that they will be up to see him in the next five minutes you take a moment to decompress by leaning back into the chair, closing your eyes, taking a deep breath and begin counting to 100. Somewhere between 45 and 50 a pulse oximetry alarm goes off and you hear the sound of feet running down the hall. Reluctantly you pull yourself up out of the chair to investigate which of the nurses might need some help. As you make your way to the nurse’s station yawning and stretching you hear “Mrs Beatty wake up! Mrs. Beatty you need to breathe! Mrs. Beatty can you hear us?” A code blue sounds overhead. Grabbing her chart you run into the room and find your coworkers initiating CPR and placing a bag valve mask on her face until the code team arrives. You learn that one of the nurses came in to check on Mrs. Beatty when her pulse oximetry alarm went off and she found the patient slumped over in bed barely breathing.

The code team arrives shortly thereafter and with chart in hand you answer their questions about the patient. They inquire about the PCA pump settings and you provide them with the orders the CT Surgery Resident wrote earlier when the patient came to the floor. One of the code team nurses yells out “What? A background rate? The pump is set to a demand dose and a background dose? No wonder she coded!” That nagging voice in your head is now screaming “See? I told you to look harder! I told you something was wrong!” You’ve known that patients on this floor never have a background dose of narcotics infusing at the same time as the patient is obtaining a demand dose of the narcotic every time they press the button. It’s clear Mrs. Beatty has been overdosed. How could you have missed something so obvious? One of the code team nurses calls out for Narcan. Mrs. Beatty responds to the medication and wakes up, but her respirations are still slow. “Let’s roll everyone” says the doctor as he heads out the door, plucking the chart from your hand. He pauses, and returns to your side, putting a reassuring hand on your shoulder. “It happens to the best of us,” he says. Before you know it Mrs. Beatty is packaged up and rushed out of the room to the ICU. She dies two hours later, during shift change. Right then you don’t care to ever take another breath. You feel so sick and shocked it’s a painful struggle to get through shift report. All you want to do is be a fly on the wall, or curled up in a dark corner away from everyone and everything. The nagging voice is back, only now, with an ominous message: “This is bad……real, real, bad.”

The Real Thing

Patricia Plantico was admitted to Froedtert Memorial Lutheran Hospital for back surgery to help with chronic back pain she had been experiencing. Her physician, Dr. Maiman wrote orders for morphine to relieve postoperative pain. Patricia did not respond well to the morphine so Dr. Maiman ordered Oxycontin 80mg, to be given by mouth every twelve hours. Patricia received her first dose of the Oxycontin at midnight. About 9:25 the following morning she summoned the nurse to report feeling “shaky, nauseated, and overmedicated.” At that point she was given another 80mg tab of Oxycontin, which incidentally—was not supposed to be given for another two and one half hours. Records show Patricia’s call button was pressed sometime between one and two in the afternoon. Around two in the afternoon a nurse found Patricia unresponsive. A code was initiated, Plantico was transferred down to the intensive care unit. She was maintained on life support for a period of five days before she died.

Questions to Consider:

1. A physician writes an order for a pain medication. The dose is much larger than what you are accustomed to seeing. You know this doctor has a history for throwing charts in the nursing station when he gets questioned. What do you decide to do, and why?
For a post- operative back surgery patient such as the one above how often would you be assessing pain and/or level of consciousness? Would you be interested in objective data more than subjective, or would your impression consider both subjective and objective assessments? Why or why not?
Is the nurse primarily responsible for the decline of this patient or is the physician? Why?
Could pharmacy have had a part to play in this unfortunate scenario? How?
Do you see this situation as one that faults one or two people or the current system in place?
Take a break from the blame game and construct a pretend root cause analysis—consider all points at which the ball may have been dropped. Keep in mind that errors of this nature are rarely the result of one person’s miss…rather….it’s the system itself in need of improvement. Find solutions to the problems you identify.

Discussion

The case notes made no mention of Patricia’s age. I couldn’t find any information about whether the nurse caring for the patient was a newer nurse or a veteran, or whether there were any other mitigating factors. What this case screamed out to me was “systems error.” Did the hospital have a policy or pain protocol about dosage ranges that could be given to post- surgical patients? Was there an assessment protocol to follow to ensure proper monitoring of patients on medications like this one? (Q 2 hour pain and LOC assessments) Did the pharmacy have a safety feature in place to catch unusual doses such as the one mentioned above? Medication errors continue to be the number one cause of patient care errors and their incidence far under reported: “The contemporary epidemic of medication administration errors has proven to be impossible to quantify. According to the Institute of Medicine (IOM), medication administration errors are the most frequently identified medical error in the United States (IOM, 2000, 2007). Nevertheless, it has been estimated that less than 5% get reported(Cohen, Robinson, & Mandrack, 2003). The number of errors, however, varies with the definition, identification methodology, and method of reporting. Still, one thing is certain: this problem has the attention of health care governing boards. After reviewing numerous studies, the IOM (2007) concluded that “a typical patient would be subject to one administration medication error per day” (Treiber, 2012)

The nurse(s) involved in this case could very well have asked around as to whether or not the 80mg OxyContin was a “normal” medication dosage seen on that unit and could have been told “yes.” We could go on and on about all the different things that could have occurred, but much of it we will never know. What is important to ask is “if we looked at this case from a broader standpoint where could improvements have been implemented?” Nurses experience numerous interruptions during a patient care day and much research has demonstrated their impact on patient safety: “Interruptions of any magnitude can have dire consequences to patients. One study reported that nurses were interrupted up to 10 times per hour, or once every 6 minutes, which resulted in an overall error rate of 1.5 per hour… Nurses solve problems in real time, and it is often necessary for them to modify their planned assessments and treatments to adapt to environmental demands and changes in patient conditions. Accordingly, the nursing process is nonlinear and requires constant partitioning, interweaving, and reprioritizing of patient care. Therefore, interruptions of any magnitude may affect patient safety.”(Rochman, 2012) It has been suggested that developing simulation exercises to engage nursing students prior to introducing them to the “real nursing world” has helped to familiarize students with the realities they will be facing while trying to multitask, solve problems, and provide safe care to patients.

Holistic assessment and root cause analysis can easily combine to begin the problem solving process. For those of you who have just heard the terms “Root Cause Analysis” or have seen the three letters “RCA” but have no clue as to what they mean or whether the concept is even pertinent to your nursing practice—listen up, IT IS: “…Though there is no generally accepted definition of what a Root Cause Analysis is, a possible definition could be ‘a structured investigation that aims to identify the true cause of a problem and the actions necessary to eliminate it. A Root Cause Analysis is not conducted using a single tool or strategy, rather, a number of tools often used in combination.” (Anderson & Fagerhaugh, 2000) We nurses have been trained how to perform holistic assessments on people, why not apply it to the scenario? Start with one simple question: “How does an 80mg dose of Oxycontin make it to a patient, furthermore—how did two doses of this medication make it to this patient?” From there, you brainstorm about all the possible things that could occur or make the clinical setting “just right” for this sentinel event to happen. For instance, was there a staffing issue? Was a nurse working overtime? Was there a transcription error? Was the doctor exhausted and at the end of a four day run of shifts? You get the idea. Now, find solutions. A holistic assessment of the scenario could be used as an effective root cause analysis tool!

Most of the major sentinel events we catch wind of via the national news circuit are rarely the direct result of a nurse’s error, and the naming of the nurses involved does nothing to solve a tragedy—in fact it inflicts trauma upon the nurse and his/her family—for life. It’s imperative that we begin the shift from “blame” to “rename.” Rename the problem for what “it” is and not “who” did what. “Since it is the nurse who has the responsibility of administering medications to patients, the nurse has often assumed or been assigned blame for these errors. In reality, there is usually a chain of events leading to an error. Medication errors are seldom the result of one person, but involve the actions of everyone caught up in the system, including the designers of the system.” (Maurer, 2010) We as a profession accomplish nothing by throwing nurses out to pasture for falling victim to the human condition. Nurses demand perfection from one another—and anything less is deemed a big “F” for “failure.” We must learn to make use of learning opportunities as a means of breaking the cycle of blame and initiate a new practice of problem solving that will prevent harm to the patient (and trauma to the nurse) while introducing a just culture that is so desperately needed in the corporate healthcare setting.

Works Cited

Plantico v. Froedtert Memorial Lutheran Hospital, 647 N.W. 2d 468–WI (SUPREME COURT OF WISCONSIN July 26, 2002). Retrieved October 15, 2012

Anderson, B. &. Fagerhaug, T.(2000). Root Cause Analysis: Simplified Tools and Techniques. (A. Koudstall, Ed.) Milwaukee, Wisconsin, United States: ASQ Quality Press. Retrieved October 15, 2012

Maurer, M. (2010). Nurses‟ Perceptions of and Experiences with Medication Errors. Toledo: Proquest. Retrieved October 15, 2012

Rochman, M. A. (2012, July-September). Interprofessional Simulation on Nurse Interruptions. Journal of Nursing Care Quality, 27(3), 277-281. doi:10.1097/NCQ.0b013e31825734b4

Tammelleo, A. D. (2002, October 1). Hospital’s liability for overdose of OxyContin. Retrieved October 15, 2012, from The Free Library: http://www.thefreelibrary.com/Hospital’s liability for overdose of OxyContin.-a094159002

Treiber, L. &. (2012, June 7). Devastatingly Human: An Analysis of Registered Nurses’ Medication Error Accounts. Qualittive Health Research, 20(10), 1327-1342. doi:10.1177/1049732310372228