HospitalInspections.org

Based on record review and interview, it was determined that for 1 of 5 patients (Pt. #1) treated for overdose, the Hospital failed to ensure the medical staff provided quality medical care to the patient in a timely manner.

Findings include:

1. The clinical record for Pt. #1 was reviewed and included that this patient was a 26 year old male, who arrived in the ED on 9/4/12 at 1:37 AM and was immediately triaged (1:37 AM) with a complaint of intentional aspirin overdose. Pt. #1 had ingested 3 bottles of aspirin at approximately 10:00 PM, before coming to the Hospital. Pt. #1's vital signs at 1:37 AM were, temperature 98.4 F, pulse 100, respirations 19, blood pressure 137/84 mmHg, oxygen saturation 96%. Medication administration notes dated 9/4/12 at 1:46 AM, stated 2 (two) 50 gram doses of charcoal (charcoal with sorbitol and charcoal oral suspension) were administered.

On 9/4/12 at 2:13 AM, an ED Resident Physician (E #1) wrote notes, "... Patient with 1 prior suicide attempt of Aspirin [ASA] overdose. Patient reports feeling lightheaded. No vomiting [or] abdominal pain. Patient's parents estimate he took [from 3 Aspirin (ASA) bottles]: thirty-nine 500 mg tabs ASA, five hundred 81 mg tabs ASA, two hundred 81 mg tabs ASA, and three 30 mg tabs Zyprexa." E #1's note stated, "... Salicylate level 71." [Normal Salicylate level is 0 - 30 mg/dL.]

2. Laboratory result reports dated 9/4/12 stated Salicylate levels were drawn at 1:58 AM - 71.0 mg/dL, 4:08 AM - 93.9 mg/dL, and 7:00 AM - 126.4 mg/dL. Physician orders for Salicylate levels were general lab orders for every 2 hours, not stat. The Salicylate level drawn at 4:08 AM (93.9 mg/dL) was reported by the Laboratory as a critical value to E #1 in the ED at 5:01 AM.

3. An ED note stated that Pt. #1 transferred to MICU at 4:12 AM. Laboratory blood tests (VRE & MRSA) were drawn for Pt. #1 in MICU at 4:30 AM, which indicated that Pt. #1 was in MICU when the 93.9 mg/dL Salicylate level was reported to ED. Progress notes at 5:00 AM included, "Patient became very agitated [CNS disturbance]. Security called and at beside. Patient too agitated for soft restraints. Leathers applied..."

4. The Poison Help line protocol entitled, "Acute Salicylate Poisoning" was reviewed and included, "Hemodialysis: Indications are... CNS [Central Nervous System] disturbances ... Salicylate level approaching 100 mg/dl."

5. On 11/20/12 at 1:55 PM, an interview was conducted with the MICU Resident Physician (E #12) who assumed care of Pt. #1 when Pt. #1 arrived in MICU. E #12 stated that Pt. #1 was "breathless" and agitated upon arrival. E #12 stated that he received the second Salicylate level (93.9 mg/dL) from E #1, after 5:01 AM. E #12 stated that he anticipated that Pt. #1 needed dialysis and wanted to place a central line for dialysis access, but had to wait for Pt. #1 to calm down to perform the procedure safely. {Pt. #1's clinical record included the placement of a right central femoral line to be used for dialysis, but does not include the time the line was placed.} E #12 stated that a femoral line was able to be inserted after Pt. #1 calmed down, at approximately 6:00 AM, and was done on an emergent basis, not routine. E #12 did not write an order for dialysis and relied on the Nephrology Fellow (E #14) to write the order. Pt. #1's hemodialysis (HD) order did not include a time of the order.

6. An interview was conducted with the Director of In-Patient Dialysis Unit (E #15) on 11/20/12 at 1:35 PM. E #15 stated that she had discussed Pt. #1's case with the Renal Fellow (E #14). {E #14 was on vacation at the time of the survey.} E #15 stated that E #14 saw Pt. #1 at approximately 6:00 AM and wrote Pt. #1's dialysis order at approximately 6:45 AM.

7. The MICU Attending Physician's (E #3's) progress note dated 9/4/12 included, "...Upon arrival in MICU renal [was] called for emergent hemodialysis... At the time I saw Patient (approximately 7:15 AM) he was mumbling and delirious but somewhat redirectable to questions... Exam limited due to mental status... At the end of rounds [time not included] hemodialysis machine arrived and was being set-up for HD. "

8. On 11/20/12 at 9:30 AM, a combined interview was conducted with the RN (E #10) who set up Pt. #1's dialysis machine and the Dialysis Technician (E #11) who provided dialysis treatment for Pt. #1. E #10 stated that he received orders for Pt. #1's dialysis at 7:10 AM or 7:15 AM. It took approximately 45 minutes to take the machine to Pt #1's room and set up the machine. The machine was ready at approximately 8:00 AM, but Pt. #1 was being intubated and an additional IV line was being started. E #11 took over for E #10 and was able to start dialysis at 8:35 AM. The dialysis filter clotted after about 45 minutes and before the dialysis could be restarted, Pt. #1's [systolic] blood pressure dropped to the 70s.

9. A Cardiopulmonary Resuscitation report dated 9/4/12 stated the time of Pt. #1's arrest at 9:43 AM. An Internal Medical Resident's (E# 13) note dated 9/4/12 at 2:57 PM, included, "A cardiac arrest was called at approximately 9:43 AM. CPR (Cardiopulmonary Resuscitation) was begun... After the 13th round (each round is approximately 2 minutes) of CPR the patient's family was brought into the room and informed that the resuscitation was unsuccessful and agreed with stopping CPR. Time of death was 10:09 AM."

10. On 11/20/12 at 9:00 AM, an interview was conducted with the Associate Chief Medical Officer for ICU and ED (E #2). E #2 stated that he had been involved in 2 committees (Root Cause Analysis and an Ad Hoc Group) to review Pt. #1's case. The findings were that the guidelines were followed, but E #2 stated the guidelines may be too conservative and that a second Salicylate level should be drawn after 1 hour, instead of waiting 2 hours.

11. On 11/20/12 at approximately 10:00 AM, an interview was conducted with the Director of Quality Strategies (E #9), who participated in the Root Cause Analysis. (Approximately 15 staff participated in the Root Cause Analysis.) E #9 stated that Pt #1's dialysis treatment was set up and delivered sequentially - 5:01 AM, high Salicylate level identified; 6:00 AM, catheter access being placed and being assessed by Renal; 7:15 dialysis machine being prepped; 8:00 AM, dialysis machine ready, but patient being intubated; and 8:35 AM, started dialysis. Some of these activities could be done concurrently and the event presents opportunities for improvement.