Presentation

On January 13, an 85-year-old woman was hospitalized for sepsis caused by a urinary tract infection, a sacral wound infection, and aspiration pneumonia. The sacral wound culture was positive for Staphylococcus aureus and E. coli. She was also noted to have an altered mental state.

The patient responded well to treatment and was discharged on oral antibiotics to a skilled nursing facility on January 16.

Physician action

The following day, January 17, she was evaluated by an internal medicine (IM) physician A. He documented a complex medical history including stroke with left-sided hemiparesis, right hip replacement, hypertension, COPD, dementia, and severely uncontrolled diabetes.

 A treatment plan was created that included metformin, antibiotics, and continuation of blood pressure medications, statins, and baby aspirin. Laboratory results showed a low glucose level of 64 mg/dL.

On January 20, the IM physician noted that the patient was hypoglycemic and exhibiting signs of dehydration and kidney failure. He ordered scheduled insulin to be discontinued while monitoring her hypoglycemia, with instructions to restart insulin once blood sugars increased.

On January 23, the patient was transferred back to the hospital for uncontrolled blood sugar. Testing revealed:

• diabetic ketoacidosis;
• metabolic acidosis;
• encephalopathy;
• altered mental state;
• hyperosmolar hyponatremia;
• acute-on-chronic renal failure;
• hyperkalemia;
• hyperphosphatemia;
• leukocytosis;
• macrocytic anemia;
• lactic acidosis;
• stage II sacral wound;
• uncontrolled type 2 diabetes;
• possible dysphagia;
• abnormal EKG with negative troponin;
• controlled hypertension; and
• COPD.
  

During her hospitalization, she was treated with IV fluids and her ketoacidosis resolved, but she remained significantly debilitated and required PEG tube feedings. She was discharged on February 1 and died on February 3 from acute respiratory failure.

Allegations

A lawsuit was filed against the IM physician alleging failure to properly treat the patient’s diabetes, resulting in ketoacidosis and, ultimately, the patient’s death.

Legal implications

TMLT consultants believed communication errors played a major role in this case. When IM physician A ordered insulin to be discontinued, the intention was for the low dose sliding scale insulin and blood sugar checks to continue. However, the nursing staff interpreted the order as stopping all insulin, including sliding-scale insulin. This caused the lack of blood sugar checks, eventually leading to ketoacidosis.

Consultants were critical of the IM physician’s instructions and noted that more detailed documentation might have prevented the misinterpretation. It was also noted that the IM physician signed off on the erroneous medication orders to the nurses.

Plaintiff experts argued that the IM physician failed to meet the standard of care for glucose monitoring, by not measuring the patient’s blood sugars before and after meals and before bed. One expert stated that taking these measurements is a universal protocol for nurses, nursing homes, hospitals, and any other facilities that care for patients with diabetes.

However, experts for both the plaintiff and defense pointed out that the patient was gravely ill with several comorbidities, such as sepsis and COPD, that contributed to her death. One defense expert stated the patient’s death was more likely caused by inadequate antibiotic treatment for sepsis during her January 13-16 hospitalization. 

The defense expert added the physician’s documentation contained errors and criticized the use of metformin, which is contraindicated in patients with renal failure.

Disposition

‍This case was settled on behalf of the IM physician.

‍Risk management considerations for adult primary care physicians

‍About communication errors

‍About documentation errors