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Administering QT-Prolonging Drugs; Failure to Administer Potassium


A patient presented to the emergency room (ER) complaining of fever, nausea, vomiting, urinary tract infection (UTI), kidney infection, gallstones, pneumonia, and critically low potassium. Critically low potassium, also known as hypokalemia, can cause an abnormal heart rhythm, known as a prolonged QT interval, and lead to cardiac arrest.

 

The patient was admitted to the telemetry unit. The patient was administered potassium. The patient was also administered Azithromycin, an antibiotic that has prolonging QT intervals as a side effect. The patient’s treating nephrologist ordered that potassium be replaced pursuant to the hospital’s standing potassium replacement order.

 

Three days later, nurses ceased administering potassium to the patient. The patient underwent a surgical procedure to place a stent in the patient’s kidney to aid with a kidney stone. After the patient made positive strides toward recovery, including interacting with family members, eating food, and ambulating, the surgeon who performed the stent procedure recommended that the patient be discharged.

 

The following day, a hospitalist examined the patient, reviewed the patient’s records, and consulted with the surgeon. The hospitalist discharged the patient with a prescription for Levaquin, another antibiotic which can also prolong QT intervals, to continue the patient’s treatment for pneumonia, kidney infection, and UTI.

 

At home later that morning, the patient took the first dose of Levaquin. About an hour later, the patient’s family member discovered the patient in cardiac arrest and called 911. Paramedics arrived and shocked the patient’s heart into rhythm while in transit to the ER. An EKG performed at the ER showed that the patient had a potentially fatal prolonged QT interval. The patient’s potassium levels were also critically low.

 

The oxygen deprivation left the patient unable to speak, use upper and lower extremities, perform self-care, and control bowels and bladder. An echocardiogram performed the day following the cardiac arrest revealed Takotsubo Syndrome, a sudden and unforeseeable condition immediately preceded by an emotional or physical trigger that causes transient weakening of the left ventricle of the heart.

 

The patient filed a medical malpractice suit against the hospital and hospitalist. The complaint alleged that the failure of the hospital’s nurses to administer potassium to the patient during the last three shifts of the patient’s hospitalization, counter to the standing replacement order, led to the patient’s low potassium levels after discharge and, combined with the patient’s consumption of azithromycin and the first dose of Levaquin prescribed by the hospitalist, both QT prolonging medications, resulted in a cardiac arrhythmia called Torsades de Pointes, and ultimately the cardiac arrest. The complaint further contended that the Takotsubo Syndrome was the result, rather than the cause, of the cardiac arrest and subsequent anoxic brain injuries.

 

At trial, the Whitley Circuit Court limited the testimony of the patient’s expert doctor of pharmacy to areas within the expert’s expertise, excluding the actual cause of the patient’s cardiac event.

 

The patient sought to introduce the hospital’s incident report that had been produced at the deposition of the hospital’s pharmacist. The report repeated information contained in the patient’s medical record and explained it was clinically suspected that a combination of levofloxacin and hypokalemia led to ventricular arrhythmia. The hospital and hospitalist objected to the introduction of the report into evidence. The hospital and hospitalist argued that the purpose of the hospital’s investigation was to conduct critical examinations of patient care, which were more stringent than the applicable standard of care required by law. The trial court excluded the incident report from evidence.

 

The patient sought a jury instruction concerning the hospital’s independent negligence. The patient argued that it was clear that the hospital’s own rules and procedures were not enforced. The trial court declined to issue such an instruction.

 

After trial, the jury returned a verdict finding the hospital and hospitalist did not breach the standard of care. The patient moved for new trial. The trial court denied the motion.

 

The Court of Appeals of Kentucky affirmed. The court held that the trial court did not abuse its discretion in excluding evidence at trial or instructing the jury.

 

The trial court did not abuse its discretion in excluding evidence at trial. Regarding the patient’s expert doctor of pharmacy, the court noted that the expert was not a medical doctor. The court found that the trial court properly limited the expert doctor of pharmacy to areas within the expert’s expertise, excluding the cause of the cardiac event. The court also noted that the excluded testimony only pertained to the issue of causation, which was not reached by the jury. Additionally, the patient presented other expert evidence on the issue of causation. Consequently, the court concluded that any error or potential error in excluding the causation testimony of the patient’s expert doctor of pharmacy was harmless. Regarding the incident report, the court found that the report did not relate to the applicable standard of care or causation in a more probative than prejudicial manner and, therefore, was irrelevant, prejudicial, and otherwise inadmissible. Consequently, the court concluded that the trial court did not err in excluding the incident report.

 

The trial court did not err in declining to give an instruction concerning the hospital’s independent negligence. The court found there was no evidence to indicate that the hospital had any knowledge that its staff was not acting in accordance with its policies. There was no specific evidence that the hospital was guilty of any independent negligence. Consequently, the court concluded that the trial court did not err in declining to give an instruction concerning the hospital’s independent negligence.

 

The Court of Appeals of Kentucky affirmed the trial court’s entry of judgment on a jury verdict in favor of the hospital and hospitalist.

 

See: Kentucky Guardianship Administrators, LLC v. Baptist Healthcare System, Inc., 2019 WL 1967122 (Ky.App., May 3, 2019) (not designated for publication).

 

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