“Had Lorrie McCombs been monitored with pulse oximetry and capnography, she might be alive today.” This was my first thought when I recently read the article, “Widower gets $3.2 million in hospital suit against WellStar.”

A jury awarded Lorrie McCombs’ husband more than $3.2 million in a malpractice suit brought against Kennestone Hospital and WellStar Medical Group for the 2012 death of his wife, Lorrie McComb.

The ruling and the reward of more than $3.2 million should be a reminder to all hospital executives and risk managers of the perils of not following adequate patient monitoring practices.

According to the lawsuit…

According to the lawsuit:

Defendant Wellstar Medical Group, LLC’s employee and/or agent, Dr. Jinu Kamdar, knew, or in the exercise of reasonable care should have known, that Lorrie McCombs was at risk for respiratory depression.

• She was morbidly obese;
• She had a traumatic chest injury, including seven broken ribs and a possible flail segment;
• She had a traumatic abdominal injury, including contusions of the liver and mesentery;
• She was prescribed and received multiple opioid analgesics concurrently, including Morphine and Hydrocodone.

In light of these risks, the standard of care required Dr. Kamdar to initiate continuous pulse oximetry for Lorrie McCombs at the time he added the additional long-acting oral opioid, Oxycontin, in order to continuously monitor her for the risk of opioid-induced respiratory depression. In direct violation of the standard of care, Dr. Kamdar elected not to order continuous pulse oximetry, directly and proximately causing or contributing to Lorrie McCombs’ cardiopulmonary arrest on May 19, 2012 and death on August 17, 2012.

What is the standard of care that the McComb’s lawsuit is referring to?

The American Society of Anesthesiologists (ASA) sets the standards of the medical practice of anesthesiology. According to the ASA’s Standards for Basic Anesthetic Monitoring the standard is:

During all anesthetics, the patient’s oxygenation, ventilation, circulation, and temperature shall be continually evaluated.

This standard of care applies “to all anesthesia care” and consists of monitoring of four physiological functions: oxygenation, ventilation, circulation, and temperature.

In the case of Lorrie McCombs, the lawyer representing Dennis McCombs and the estate of Lorrie McCombs said that the defendant hospital and attending clinicians “were not monitoring her for signs of respiratory depression,” and noted that Lorrie McCombs had not been monitored even for her pulse. In addition, Ms. McCombs “slipped into respiratory failure after nurses failed to check on her for three or four hours”. The Lippincott Manual of Nursing Practice recommends that respiratory rate, sedation score, and oxygenation be checked periodically on an hourly, two-hourly, or four-hourly basis, and sadly and unfortunately, even this rudimentary intermittent monitoring was not conducted. Intermittent spot checks are not sufficient to detect the signs of respiratory depression.

The PPAHS position: Continuous Electronic Monitoring

In our position paper, “Patients Receiving Opioids Must Be Monitored With Continuous Electronic Monitoring,” the Physician-Patient Alliance for Health & Safety advocates for the monitoring of patients with pulse oximetry to measure oxygenation and capnography to measure the adequacy of ventilation. As stated by the ASA Standards for Basic Anesthetic Monitoring:

• The objective of monitoring with pulse oximetry is to “ensure adequate oxygen concentration in the inspired gas and the blood during all anesthetics.”
• The objective of monitoring with capnography is to “ensure adequate ventilation of the patient during all anesthetics.”

These standards represent the minimum level of care that must be provided. “These standards may be exceeded at any time based on the judgment of the responsible anesthesiologist.”

Defendant clinicians and hospital executives should heed the implications of the McCombs case. It represents the coming together of what constitutes the medical standard of care—which is established by clinicians and by societies like the ASA—and the legal standard of care, which is the standard applied by an average juror, who will have little, if any, medical training.

Had the standard of care set for by the ASA been administered, Lorrie McCombs might be alive today.

Michael Wong, JD

Website: http://www.ppahs.org/

Michael Wong, JD is the founder and Executive Director of the Physician-Patient Alliance for Health and Safety (PPAHS). He has been at the forefront in driving practical solutions that reduce healthcare costs, decrease medical errors, and improve patient health outcomes. He has been particularly active in these areas that most affect patient safety.

Article contributors include: Laurie Paletz, BSN PHN RN-BC SCRN (Manager, Stroke Program Department of Neurology, Cedars-Sinai), and Thereza B.  Ayad, RN, MSN, DNP, CNOR (Assistant Professor, University of Massachusetts Medical School-Graduate School of Nursing; Surgical Services Clinical Staff Educator, North Shoe Medical Center.

The article was reviewed by Sue Koob, Cheif Executive Officer, Preventative Cardiovascular Nurses Association.

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