Report: Lehigh Valley Hospital gave fatal dose

FROM THE MORNING CALL

Doctors at Lehigh Valley Hospital-Cedar Crest, using faulty blood sugar testing strips, this year administered an apparent fatal double dose of insulin to a patient with extremely low blood sugar levels, a critical state Department of Health report says.

A nurse monitoring the patient's status from a remote site knew that bedside blood sugar testing strips differed significantly from more reliable laboratory tests of the patient's blood, but failed to warn doctors about the discrepancy, it says.

Doctors at the hospital ordered insulin for the patient to lower the level of blood sugar, which is the body's fuel, since too much blood sugar can lead to life-threatening conditions. But the lab test indicated that the patient's blood sugar was extremely depressed after hours of receiving insulin, so continuing to administer it was a critical error.

Additionally, the state report says there was "no documented evidence" that a doctor, a second staffer who was electronically monitoring the patient that morning from the remote site, took the routine step of providing notes on the disparate test results to the attending physician that day, Jan. 3.

Meanwhile, the patient remained on an insulin drip to lower his blood sugar levels for 10 hours, says the report, which does not identify the patient or hospital staff by name. When the malfunctioning blood sugar testing strips reported stubbornly high levels, a doctor administered an injection of additional insulin, according to the report.

The patient, who had undergone a kidney transplant and had complications including a urinary tract infection, swelling on the brain and respiratory failure, later on the morning of Jan. 3 was found in an "unresponsive coma" as a result of "prolonged hypoglycemia," or too little blood sugar. Those conditions presented "brain death criteria," the report says. The unnamed patient died Jan. 6, it says.

The state report does not identify the patient's gender, age or health condition, such as when the transplant occurred.

In a statement to The Morning Call, LVH said federal law prevents it from divulging information about the patient.

"We were extremely saddened by our patient's passing," the statement says. "All of our physicians, nurses and staff are dedicated to carrying out our mission of healing, comforting and caring for each patient. At the time it occurred, we reported the incident to the appropriate authorities and took immediate action to improve our processes and procedures."

The statement also says hospital officials have been notified that the family has hired a lawyer, so it would be "inappropriate" to comment further.

A kidney transplant patient's blood sugar levels require attention because the care needed to prevent rejection of the organ can affect those levels, said Bryan Becker, past president of the National Kidney Foundation and a transplant nephrologist.

"Early after transplant, blood glucose values may fluctuate due to stress as well as the medicines that a patient receives to prevent rejection early after transplant," he said in an email statement. "The most common cause of changes in blood glucose early after transplant is use of intravenous corticosteroids. These medicines, different than the type of steroids used by athletes at times, reduce inflammation but also have many side effects including significant changes in blood glucose values."

The state issued its findings in the report dated April 8. Under health department rules, the report remained unavailable to the public until this month.

In addition to the communication failures, the state report cites the hospital for failing to make sure the blood monitoring test strips worked properly. The strips can provide false readings if mishandled or exposed to light and moisture, it says.

The department said it undertook the investigation "on its own initiative," not through a complaint, said spokeswoman Christine Cronkright.

The Lehigh County coroner's office did not respond when asked if it investigated the death.

According to the report:

The patient was admitted to LVH on Dec. 21. Orders dated Jan. 1 indicated that the patient needed to be treated for high blood sugar with a target level of 80-110 milligrams per deciliter.

Two days later, as the first weekend night shift of the year was ending, bedside testing showed the patient's blood sugar level to be as high as 480 milligrams per deciliter, even after five hours of an insulin drip. However, more accurate blood tests taken three times that morning and analyzed in the lab showed the patient's sugar level to be far below normal, at 1-3 milligrams per deciliter.

A nurse in the Advanced Intensive Care Unit at 2024 Lehigh St., Allentown, where nurses and a doctor electronically monitor around 90-100 patients, became aware of the discrepancy between the tests when the first of the three blood tests came back at 4 a.m. Jan. 3. However, records showed "no documented evidence" that the AICU nurse notified doctors about the differences between the high bedside test results and the low lab results.

Without knowledge of the low blood sugar tests, doctors at the bedside continued to bring down the patient's levels. Between 11 p.m. Jan. 2 and 6:01 a.m. Jan. 3, doctors increased the insulin drip from 14.7 units per hour to 52.6 units per hour. More than two hours after the nurse learned of the differences in the records, a doctor at 6:06 a.m. ordered an injection of insulin, in addition to the insulin drip already being administered.

Still, bedside blood tests showed high blood sugar levels. At 9:20 a.m., more than 10 hours after doctors began lowering the patient's blood sugar, a physician ordered the insulin drip to be put on hold.

Staffers, concerned about the test strips, tried other strips and found that they too recorded high readings. By 10:30 a.m. Jan. 3, staffers were so worried that two tested their own blood sugar levels, which also registered high. At that point, the staffers determined that the test strips "malfunctioned," and the patient had to be treated for extremely low blood sugar levels.

In subsequent interviews, staffers acknowledged relying on the test strips, although they said the blood serum tests are "more accurate."

The state report casts wide blame for the death, saying the board of trustees and the medical staff were accountable for failing to provide the best quality and safe care. The director of nursing also failed to ensure that the testing was done properly, that the patient's records were accurate and that the medical supplies were in good condition, it says.

In response to the event, the hospital undertook immediate action to review procedures and re-educate staff. For instance, the blood glucose monitoring and quality control processes were revised and reinforced, the report says. The Advanced ICU staff updated rules to document critical events and reinforced the importance of communicating abnormal reports to physicians. In addition, the hospital began developing a written protocol for bedside nurses to contact the AICU physician if a critical care patient shows a sudden or unusual change in condition.

LVH's website says the AICU provides a second layer of care for critically ill patients and lowers death rates by 30 percent.

According to the website, the network "has one of the industry's most advanced electronic charting systems, which automatically captures and transmits data from bedside monitors and equipment to the AICU, miles away.

"Customizable 'events' inform our intensivists about serious changes in the patient's condition so they can act immediately to address the problem. The electronic charting system also eliminates much of the bedside paperwork, freeing caregivers to spend more time with patients."

tim.darragh@mcall.com

610 778-2259

TIMELINE

Dec. 21, 2010: Patient admitted.

Jan. 1, 2011: Physician orders patient to be treated for high blood sugar.

Jan. 2, 11 p.m.: Physician orders insulin drip to be increased.

Jan. 3.: Bedside tests show elevated blood sugar; lab tests show very low level.

Jan. 3, 4 a.m.: Nurse in the AICU becomes aware of the testing discrepancy.

6:06 a.m.: Physician orders second dose of insulin in addition to drip.

7:46 a.m.: Bedside tests still remain high.

9:20 a.m.: Insulin drip put on hold.

10:32 a.m.: Staff discovers that test strips malfunctioned; patient now treated for low blood sugar.

Morning, Jan. 3: Patient discovered unresponsive due to "prolonged hypoglycemia that met brain death criteria."

Jan. 6: Patient dies.

Source: Pennsylvania Department of Health

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