A tragic transition of care
The hospitalist testified that he was there to respond to emergencies, and that he transferred care of JR to the critical care consultant by verbal report. The critical care consultant acknowledged the verbal handoff from the hospitalist, but doubts there was any discussion regarding JR’s diabetes and was adamant that she was not responsible for JR receiving two doses of insulin (glargine and regular insulin) via the orders of two other physicians before she even had the opportunity to see the patient. The critical care consultant also testified that JR’s mental status change was nonspecific and was reasonably due to the pain medications she was receiving.
The plaintiffs countered with the reality that JR, a 32-year-old woman, died from low blood sugar because she received insulin when she wasn’t allowed to eat or drink – all at the hands of the medical team.
Conclusion:
Much of the attention regarding safe transitions of care is focused on the hospital discharge. Yet discontinuity within hospital walls is frequently associated with medical errors, and communication problems represent the largest category for hospital sentinel events.
The Joint Commission, the World Health Organization, the Institute of Medicine and the National Quality Foundation have all published white paper recommendations regarding the need to improve medical handoffs. Most hospitalists probably see this case as a "system error," and sure enough following this event the hospital overhauled its policies and procedures as they related to ICU transfers. But in the world of medical malpractice, the "system" doesn’t face the jury in litigation.
Although the attending internist was eventually dropped from this case, the hospital, the critical care consultant, and the hospitalist all settled with the plaintiff for an undisclosed amount.
Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system.
