The Verdict Is In

Claim: Negligent release of a patient from the ED, without proper psychiatric evaluation, led to permanent patient harm.

Day 1

A 23-year-old male was brought in by ambulance to the emergency department in an altered mental state. It was a Sunday around 3pm. Per the emergency medical services report, the patient’s girlfriend told paramedics that the patient smoked marijuana at a New Year’s Eve party two days earlier and had not been himself since. A psychological assessment by nursing describes the patient’s mood as apprehensive, depressed, euphoric, flat and happy. Nursing notes described the patient as having flight of thought and bizarre hallucinations. The patient did not exhibit aggressive behavior towards the staff and was not considered a danger to himself. He was otherwise described as medically stable with no complaints of pain. EP-1 started the patient on Seroquel and ordered a head CT.

Day 2

At 0100 the next day, the patient continued to exhibit signs of visual hallucinations. A nursing note describes him as grabbing at the air. The nursing staff was trying to obtain a urine sample towards progressing to medical clearance. Once medically cleared, the psychiatric emergency team could be engaged for consult.

12 hours later, a nursing note indicates the patient was on stand-by for an inpatient psychiatric bed. His urinalysis was positive for benzos and marijuana. His labs were pending evaluation by a physician. He was administered Ativan 2mg/ml and Haldol 5 mg/ml given his ongoing hallucinations.

At 1900, EP-2 documented that the patient required an extensive work-up due to the complexity of the presentation. The patient had a primary diagnosis of altered mental status and a secondary diagnosis of rhabdomyolysis. EP-2 determined the patient was medically clear for psychiatric evaluation.

Day 3

At 0700 on day 3, EP-3 documented that the patient did not meet criteria for medical clearance given an elevated lab result. The patient’s total CK had resulted as 1266 U/L. EP-3 updated the patients care plan to include further inpatient care with psychiatric evaluation and the addition of an in-room sitter.

At 0800, EP-4 placed an order for the patient to be admitted as an inpatient with the length of stay estimated to be 2-3 days. The patient was prescribed Ativan 2 mg/ml prn for anxiety; Restoril 15 mg at bedtime prn for insomnia; Tylenol 325 mg Q4 hours as needed for mild pain; morphine sulfate 2 mg/ml Q4 as needed for moderate pain.

There is no further documentation reflecting a change in the patient’s condition or status.

At 1200, there is a discharge education acknowledgment signed by the patient. His primary diagnosis at the time of discharge was rhabdomyolysis with a secondary diagnosis of drug overdose. The patient received instruction about dehydration and drug abuse. The discharge plan did not include outpatient follow-up. It was unclear from the record when the patient departed or by what mode or with whom.

Patient Care Outcome

Per a report from the local police department, within two hours of discharge, the patient was seen exiting a vehicle in front of a building construction site. A witness reported that the patient climbed up approximately four stories of scaffolding and leapt into the air. A small tree broke his fall before he landed on the concrete below.

The patient was taken to the local trauma center and underwent multiple surgeries over the course of a one month admission. In the course of that admission, it was learned that the patient was diagnosed as having bipolar disorder at age 17 that went untreated. Additionally, prior to the patient’s initial ED admission, he had been taking LSD and smoking marijuana. It remains unclear whether the patient was suicidal or suffering from psychosis when he leapt off of the building. He recovered from most of his injuries but will remain legally blind in one eye.

Four Days Post-Discharge

EP-3 created a late entry in the medical record. The note clarified that on Day 3, the date of discharge, EP-3 had spoken with the patient and his family about their desire for the patient to be able to leave the hospital. EP-3 determined that since the patient did not meet involuntary hold criteria, had exhibited improved mental status and was medically stable, the patient could choose to leave. As such, EP-3 discharged the patient. The psychiatry consult order was discontinued at this point.

Survey Questions

The patient and her husband pursued the case in State Court. The anesthesiologist and the Hospital were named defendants. Ultimately, the plaintiffs dismissed the Hospital from the litigation.

1. In your opinion, does your site have a good process in place to safely manage patients with altered mental status in a situation similar to this one?

  1. Yes
  2. No

2. How do you guess this unanticipated outcome resolved from a legal standpoint?

  1. There was a lawsuit and the EPs and the Hospital settled.
  2. There was a lawsuit and the jury found for the EPs and the Hospital.
  3. There was no lawsuit; there were no payments made.

3. In general, should healthcare providers consult with their insurance provider’s risk management team for documentation guidance after an unanticipated adverse medical outcome?

  1. Yes
  2. No

To answer these questions, click here. By participating, you could win $150 for you and an additional $150 for your site.

The Previous "Verdict Is In"

The results of the October 2017 installment of "The Verdict Is In" are as shown below. The October 2017 case can be viewed here

  1. Do you believe the patient's adverse medical outcome was preventable?
    19.23% Yes
    80.77% No
  2. Do you believe the defense experts' opinions affected the jury's deliberations?
    92.31% Yes
    7.69% No
  3. The case proceeded to trial against the anesthesiologist. How do you guess the case was resolved?
    71.79% The jury found in favor of the anesthesiologist.
    28.21% The jury found in favor of the plaintiff.

Who Won the Survey Raffle?

The winner of the raffle for the above case was Imeson Shale, MD. He practices at Lodi Memorial Hospital. Dr. Shale receives a debit card worth $150; his site also receives a debit card worth $150, which can be used for any worthy cause.