Failure to respond to or monitor hypokalemia
On March 20, a 39-year-old woman came to an oncology office to begin chemotherapy treatments. She had been diagnosed with multiple myeloma in January. Her history included back pain and leg weakness for two years, with minimal relief after several epidural steroid injections.
Failure to respond to or monitor hypokalemia
On March 20, a 39-year-old woman came to an oncology office to begin chemotherapy treatments. She had been diagnosed with multiple myeloma in January. Her history included back pain and leg weakness for two years, with minimal relief after several epidural steroid injections.
Presentation
On March 20, a 39-year-old woman came to an oncology office to begin chemotherapy treatments. She had been diagnosed with multiple myeloma in January. Her history included back pain and leg weakness for two years, with minimal relief after several epidural steroid injections. She recently developed “foot drop.”
In February, a chemotherapy plan consisting of bortezomib, lenalidomide, and dexamethasone (VRD) was recommended by Oncologist A to treat her multiple myeloma.
Physician action
At the first chemo appointment on March 20, lab work revealed low potassium of 2.9 — flagged as a “critical value” representing severe hypokalemia. Oncologist A prescribed oral potassium capsules for the patient at a dose of 10 mEq twice daily.
On March 25, the patient returned for a second round of chemo. She reported that she was experiencing diarrhea and was passing whole, undissolved potassium and acyclovir tablets since her first chemo treatment. This information was documented and relayed to Oncologist A. A nurse practitioner (NP) then prescribed soluble potassium for the patient to take at home.
At this appointment, the comprehensive metabolic panel (CMP) machine was not working, and the patient’s potassium level was not checked. She was administered another round of VRD chemo and sent home with a new prescription for dissolvable potassium.
According to the patient record, the NP had ordered CMP for the March 25 and August 1 treatment appointments after the patient’s first chemo treatment on March 20. These were noted as “add ons” as they were added late in the day after the lab had already created their schedule for the coming week.
The order for a CMP was not added to the laboratory order for March 25. The NP did not communicate with the lab to verify the order, nor did the lab personnel recheck the orders on March 25 before the patient was administered another round of chemotherapy.
The next morning (March 26), the patient was found unresponsive by her husband. EMS was called and she was pronounced dead at the scene. An autopsy listed the causes of death as undiagnosed dilated cardiomyopathy and multiple myeloma.
Allegations
A lawsuit was filed against Oncologist A, the NP, and the oncology practice. Allegations included failure to:
- properly monitor and respond to the patient’s hypokalemia;
- ensure that proper lab work was performed for the patient on March 25 before administering another round of chemo to the patient (Oncologist A and the NP);
- communicate to Oncologist A that the CPM machine was inoperable (the NP);
- perform an in-person assessment of the patient on March 25 (Oncologist A);
- resolve the patient’s hypokalemia; and
- investigate or rule out any heart health complications from hypokalemia.
Legal implications
Expert consultants who reviewed this case for the defense felt the providers in this case provided appropriate care when it came to the treatment plan for the patient’s multiple myeloma. One internal medicine consultant stated that the patient’s 2.9 potassium finding was moderate (not severe) in the context of the patient’s condition and current treatment.
However, this same consultant asserted that the providers were negligent in not following up on the low potassium and in continuing the chemo treatment without monitoring the patient’s lab work. This lack of follow up likely caused the patient’s cardiomyopathy to go undiagnosed and/or develop. Another defense consultant stated that the patient’s sudden cardiac death was likely caused by the failure to diagnose and treat the underlying causes of the patient’s cardiomyopathy.
Consultants for the plaintiff pointed out that the standard of care required that a CMP be performed on March 25 before proceeding with a second round of chemo. Had a CMP demonstrated that the patient was hypokalemic, she should have been admitted to a hospital for monitoring and correction of her potassium. Proceeding with a second round of chemo without determining her potassium level was below the standard of care.
Disposition
This case was settled on behalf of Oncologist A, the NP, and the oncology practice.
About diagnostic errors
About communication errors
Disclaimer
Presentation
On March 20, a 39-year-old woman came to an oncology office to begin chemotherapy treatments. She had been diagnosed with multiple myeloma in January. Her history included back pain and leg weakness for two years, with minimal relief after several epidural steroid injections. She recently developed “foot drop.”
In February, a chemotherapy plan consisting of bortezomib, lenalidomide, and dexamethasone (VRD) was recommended by Oncologist A to treat her multiple myeloma.
Physician action
At the first chemo appointment on March 20, lab work revealed low potassium of 2.9 — flagged as a “critical value” representing severe hypokalemia. Oncologist A prescribed oral potassium capsules for the patient at a dose of 10 mEq twice daily.
On March 25, the patient returned for a second round of chemo. She reported that she was experiencing diarrhea and was passing whole, undissolved potassium and acyclovir tablets since her first chemo treatment. This information was documented and relayed to Oncologist A. A nurse practitioner (NP) then prescribed soluble potassium for the patient to take at home.
At this appointment, the comprehensive metabolic panel (CMP) machine was not working, and the patient’s potassium level was not checked. She was administered another round of VRD chemo and sent home with a new prescription for dissolvable potassium.
According to the patient record, the NP had ordered CMP for the March 25 and August 1 treatment appointments after the patient’s first chemo treatment on March 20. These were noted as “add ons” as they were added late in the day after the lab had already created their schedule for the coming week.
The order for a CMP was not added to the laboratory order for March 25. The NP did not communicate with the lab to verify the order, nor did the lab personnel recheck the orders on March 25 before the patient was administered another round of chemotherapy.
The next morning (March 26), the patient was found unresponsive by her husband. EMS was called and she was pronounced dead at the scene. An autopsy listed the causes of death as undiagnosed dilated cardiomyopathy and multiple myeloma.
Allegations
A lawsuit was filed against Oncologist A, the NP, and the oncology practice. Allegations included failure to:
- properly monitor and respond to the patient’s hypokalemia;
- ensure that proper lab work was performed for the patient on March 25 before administering another round of chemo to the patient (Oncologist A and the NP);
- communicate to Oncologist A that the CPM machine was inoperable (the NP);
- perform an in-person assessment of the patient on March 25 (Oncologist A);
- resolve the patient’s hypokalemia; and
- investigate or rule out any heart health complications from hypokalemia.
Legal implications
Expert consultants who reviewed this case for the defense felt the providers in this case provided appropriate care when it came to the treatment plan for the patient’s multiple myeloma. One internal medicine consultant stated that the patient’s 2.9 potassium finding was moderate (not severe) in the context of the patient’s condition and current treatment.
However, this same consultant asserted that the providers were negligent in not following up on the low potassium and in continuing the chemo treatment without monitoring the patient’s lab work. This lack of follow up likely caused the patient’s cardiomyopathy to go undiagnosed and/or develop. Another defense consultant stated that the patient’s sudden cardiac death was likely caused by the failure to diagnose and treat the underlying causes of the patient’s cardiomyopathy.
Consultants for the plaintiff pointed out that the standard of care required that a CMP be performed on March 25 before proceeding with a second round of chemo. Had a CMP demonstrated that the patient was hypokalemic, she should have been admitted to a hospital for monitoring and correction of her potassium. Proceeding with a second round of chemo without determining her potassium level was below the standard of care.
Disposition
This case was settled on behalf of Oncologist A, the NP, and the oncology practice.
About diagnostic errors
About communication errors
Disclaimer
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