Malpractice Case: How Diagnosis and Handoff Mishaps Led to Patient's Severe Stroke Outcome

Jacqueline Ross, PhD, RN; David L. FeldmanMD, MBA


June 22, 2022

It's well understood that physicians have limited time to treat patients with stroke before the disease progresses and outcomes can worsen. This case illustrates how differing opinions by remote and in-person physicians — followed by system breakdowns — can waste critical time and end in unfortunate results.

Around 3:00 PM, a man in his early 50s was unable to speak and felt dizzy. EMS was called, and he was transported to the emergency department (ED) around 3:45 PM. The ED physician saw the patient within 10 minutes and described the patient as "alert and responsive, but nonverbal." He had left facial droop and his left arm was weak. Vital signs included a heart rate of 106 beats/min and a blood pressure of 148/67 mm Hg. The ED physician's differential diagnoses included stroke, stroke mimicker, migraine, sepsis, and Bell palsy. The ED physician initiated a "code stroke" based on the patient's inability to speak.

A head CT showed no bleeding at 4:00 PM. At 4:06 PM, a teleconsult with a neurologist was done. The teleneurologist completed the exam with the assistance of the nurse. The neurologist's documentations noted low-volume, guttural labial and lingual sounds from the patient, and that the patient was "whispering to the nurse." There was no noted drift with arms or extremity weakness.

The teleneurologist gave the patient a score of less than 4, recorded dysphonia, and diagnosed stroke mimicker. The teleneurologist said that she recommended CT angiography (CTA) — documented on the consult sheet — and a callback with any abnormalities. The ED physician did not take the teleneurologist's recommendation because both the ED physician and the nurse had concerns the patient was unable to talk and the window for giving tissue plasminogen activator (tPA) was short.

About 20-25 minutes after the consult ended, the ED physician did another exam and noted that the patient was still unable to speak. The ED physician called the on-call neurologist, who ordered a CTA. At 6:35 PM, the CTA showed an occlusion of the right internal carotid artery. The on-call neurologist suggested dissection of the right internal carotid artery, and there was no aneurysm. At 6:45 PM, the patient was seen in person by a different neurologist, who documented that the patient could communicate in writing but not in speech (organic aphasia). The presumptive etiology was ischemia and tPA was ordered.

The decision to use tPA was discussed with the patient and by phone with his spouse. Because of a recent policy change at the hospital, tPA was no longer stored in the ED and was only available from the pharmacy. At 7:20 PM, the tPA order was called into the pharmacy, with the window for administration extending to 8:30 PM.

Owing to a system issue, the tPA did not arrive within the administration window. However, the patient remained within the endovascular treatment window. Because of hospital limitations, the patient had to be transferred to another hospital for the procedure.

Because of a delay in the availability of an ambulance, the patient did not make it to the second hospital in time and was now outside the endovascular window.

The stroke progressed. Now the patient has impaired speech and spasticity in his left arm and leg, requiring the use of Botox. He has difficulty with activities, such as driving or climbing stairs, due to dragging his leg.

Several experts were critical of the teleneurologist. EMS personnel who transported the patient had noted the patient was nonverbal. The experts noted even if the teleneurologist thought the patient had a dissection, it would have been beneficial to start the tPA. If the tPA had been started earlier, the neurologic injury would have been lessened. One defense expert supported the teleneurologist's decision because the teleneurologist had documented that the patient was verbal, as that relayed the patient was improving. Additionally, the teleneurologist was unaware of the CTA results.

This case settled with the teleneurologist and hospital.

Tips for Malpractice Risk Reduction: The Three Ps

  1. Prevent adverse events by ensuring that clinical systems are well-designed and functioning. As seen in this case, a delay from the pharmacy led to the inability to administer tPA. There was a recent policy change at this hospital that may have affected this outcome. The tPA was previously stored in the ED, but the policy moved it back to the pharmacy. Once this occurred, the patient required a higher level of care and, unfortunately, again encountered delays in the transfer to this facility.

  2. Preclude malpractice claims by communicating frequently with the patient and family about what is happening in the hospital. Answer their questions honestly and provide education on all options for treatment. More informed patients and families are more engaged, and this improved communication assists in establishing a trusting relationship with the healthcare team.

  3. Prevail in lawsuits by documenting the clinical rationale in the record. Clinicians should be careful to read notes before making their own notes. If there appears to be inconsistencies in what a prior clinician documented, a phone call to that physician might help prevent the conflicting documentation seen in this case. It may also improve patient care if, in fact, the inconsistent documentation reflects incorrect assumptions and/or knowledge on the part of the second physician.

The guidelines suggested in this article are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.

The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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