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Case example: Failure to Monitor a Patient’s Changing Condition

Posted on May 2, 2014

In this case, a 36-year old woman went to the emergency room with difficulty breathing. She had a complicated medical history including asthma, pneumonia and obesity, and arrived at the ER in severe respiratory distress. Blood was drawn for lab testing, she was started on an IV, and was given oxygen through a ventilation mask. Her initial blood gases showed that she was in acute hypoxic respiratory failure. She was kept in the ER overnight without being admitted to the hospital, and continued to have an elevated heart rate and difficulty breathing despite the oxygen assistance.

Despite respiratory support, she was dangerously close to fatal hypoxemia as carbon dioxide was building in her blood stream. At 8 a.m., a new doctor came on shift and arranged to transfer her to the Intensive Care Unit (ICU). The ICU team evaluated her in the emergency department but for unknown reasons, she was never actually transferred. Two hours later, she was still in the emergency department when her condition began to rapidly deteriorate and she suffered a respiratory arrest and died.

Duffy + Partners had the medical records reviewed by a certified expert in critical care medicine, who concluded that the nurses failed to report critical changes in the plaintiff’s condition to the ER doctor and furthermore, she should have been intubated and transferred to the ICU immediately upon the realization that her condition had worsened, which would have saved her life.

If you would like to discuss a similar situation and have the firm evaluate your case, contact us today to learn more.