Analysis of Cerebral Vascular Accidents and Case Studies
In a review of closed claims data from The Doctors Company (see Table 1), we identified 284 claims with acute cerebral vascular accident (CVA) as the final diagnosis (the injury that resulted in the claims).
The information obtained from analyzing the claims provides useful statistics and insightful risk reduction strategies that can improve patient safety.
Case summaries that correlate with the patient safety/risk management subcategories provide valuable information about the factors contributing to CVA claims.
Patient safety/risk management issue: patient assessment issues with failure to establish a differential diagnosis.
The patient was taken to the operating room and had no complications noted during the surgery. Postoperatively, she was transferred to the post-anesthesia care unit (PACU) and did well. She was then transferred to the surgical floor.
A female presented to the hospital for reversal of a jejunal bypass and conversion to gastric bypass for a diagnosis of morbid obesity. The patient had a previous bypass approximately 15 years earlier and suffered from daily diarrhea. The insured general surgeon had performed fewer than six other operations of this type.
The patient was taken to the operating room and had no complications noted during the surgery. Postoperatively, she was transferred to the postanesthesia care unit (PACU) and did well. She was then transferred to the surgical floor.
On the second postoperative day, the family told the nurses that the patient was confused and nonresponsive. The nurses attributed the patient’s condition to the pain medication and did not call the doctor. On the third postoperative day, the patient had a high temperature, was hypotensive, nonresponsive, and draining foul-smelling brown fluid from the wound site.
The insured general surgeon examined the patient, suspected a leak, and transferred the patient to the ICU but did not take the patient to the operating room until approximately 12 hours later. There was no explanation for the delay.
The patient was then transferred to the OR, and a small leak at the anastomoses was repaired. Copious foul-smelling fluid in the abdomen was irrigated with antibiotic solution, and drains were placed. She was then transferred to the ICU and placed on a ventilator. The nurses noted that the patient was not moving the left side. A CT of the brain revealed a cerebral infarct.
The patient was transferred to a larger hospital for a neurosurgery consult but expired two days later. The cause of death was determined to be multiple brain infarcts. The plaintiffs’ experts alleged that the brain infarcts were related to sepsis from the leak and that the leak should have been recognized and repaired sooner.
Patient safety/risk management issue: failure to diagnose and delayed treatment of CVA.
A male presented to the ER of the insured hospital. He stated that he had fallen and complained of pain in the left wrist. A small abrasion was noted at the left lateral eyebrow. The patient stated he had lost consciousness for a few seconds.
He was diagnosed with new onset of atrial fibrillation with syncope, comminuted Colles’ fracture, and facial abrasion. The patient was admitted with an internal medicine doctor as the attending. A cardiology consult for atrial fibrillation was done. The cardiologist recommended starting Lovenox and Coumadin. The patient was recovering well. At 9:00 PM, the nurse noted the patient was staring but responding appropriately. At 9:45 PM, the nurse noted the phone rang and the patient attempted to answer it using the urinal. At 10:35 PM, the nurse noted the patient was not oriented to name, place, or time.
The nurse notified the attending physician, who ordered “give Haldol 2 mg IM every four hours for agitation as necessary.” At 11:37 PM, the patient’s family notified the nurse that the patient was acting strangely. The nurse noted that his pupils were equal and reactive to light. At 12:10 AM, the patient was noted to be sleeping. The patient was found on his knees beside the bed at 1:00 AM. The patient complained of a slight headache, and there was a question of whether he had hit his head. The nurse called the doctor, who ordered “non-stat CT of head in the morning, get BUN and CREAT, and may restrain the patient.” During the rest of the night, the patient was noted to be sleeping.
At 8:00 AM, there was a shift change, and a new nurse noted the patient was unresponsive, with pupils unequal and sluggish. The nurse did not call the doctor because she thought the doctor would be in shortly for rounds. The doctor came in approximately 45 minutes later.
The doctor ordered a stat CT of the brain, which was read as left cerebral hemorrhage. The patient was made Do Not Resuscitate status and expired that afternoon.
The plaintiffs alleged that delayed diagnosis and delayed treatment of the CVA led to the patient’s death. Plaintiffs’ experts felt the first nurse should have gone up the chain of command to get help for the patient since he was clearly having decreased mentation. Experts also felt that when the patient was found unresponsive, the second nurse should have called the doctor immediately rather than waiting for the doctor to make rounds on the patient.
Both case studies examined in this article involved the diagnosis and treatment of an acute cerebral accident in which the care was found to be lacking.
Because CVA is relatively common, it should be included in the differential diagnosis of any patient who complains of its typical signs and symptoms: headache, confusion, numbness or paralysis of one side of the body, blurred vision, and difficulty with speech.
It is important that staff is able to recognize the common symptoms of CVA, and it is imperative that nurses relay changes in a patient’s condition to the physician. Communication and teamwork can result in a faster diagnosis, earlier treatment, and a better prognosis for the patient.
Patient Safety Tips
Consider the following patient safety strategies:
- Institute a clear chain of command. Educate and encourage staff to use it when appropriate.
- Offer education programs to all patient care staff to enhance their assessment, communication, and decision-making skills.
- Educate staff on recognizing and responding appropriately to the signs and symptoms of CVA.
- Promote team building activities and a culture of respect for all staff and physicians.
Table 1 284 Claims Identified with a Final Diagnosis of Acute Cerebral Vascular Accident*
- Diagnosis related (failure, delay, wrong) (39%)
- Improper management of medical treatment (19%)
- Improper medication management (10%)
Responsible services alleged to be liable for the injury:
- Internal medicine (13%)
- Hospitalist (12%)
- Neurology (11%)
- Emergency medicine (11%)
- Inpatient (54%)
- Outpatient (44%)
Severity of injuries:
- Death (31%)
- Permanent significant: organ damage, sensory impairment, disabling injuries (31%)
Most frequent location where the injury occurred:
- Patient’s hospital room (28%)
- Professional office (23%)
- Emergency department (15%)
Top three associated comorbidities identified with these claims:
- Hypertension (27%)
- Cardiovascular disease (17%)
- Diabetes (17%)
Major factors identified as contributing to the injury were divided into subcategories, then into individual risk management issues:
- Patient assessment (36%)
- Selection and management of therapy (17%)
- Patient factors (14%)
Under the patient assessment subcategory, the top three individual issues were:
- Failure to establish a differential diagnosis (37%)
- Failure in ordering a diagnostic test (30%)
- Inadequate assessment and failure to note clinical information (18%)
Under the selection and management of therapy subcategory, the top individual issues were:
- Failure to order medication (44%)
- Management of medical treatment (19%)
- Medication management (17%)
Under the patient factors subcategory, the top individual issues were:
- Noncompliance with medication (41%)
- Noncompliance with follow-up calls or appointments (21%)
*The percentages represent the top categories in each area.