Case Archive
Registered Nurse - Renal Clinical Care
Ref. # 983201

A woman was receiving her hemodialysis treatment on a Baxter 1550 machine at a dialysis clinic. She had gained 4.6 kilograms since her previous treatment. In one hour and twenty minutes her blood pressure decreased from 140/70 to 110/70. The patient pushed the machine's step button, which increases the sodium in the dialysate, preventing fluid loss and stabilizing blood pressure. The staff was placed on notice to monitor the woman. Thirty minutes later she pushed the step button again. Another half-hour later her blood pressure was 98/60. The Patient Care Technician (Pct) administered an additional 200cc bolus of normal saline. Another 30 minutes later the Pct returned. The woman's blood pressure was 110/60. The Pct pressed the step button and left the room. Five minutes later the staff found the woman unresponsive. Her venous fistula needle had dislodged from her chest. According to the staff, there was a small amount of blood on the woman and under her chair. A team of firefighters and EMT's responded to the clinic's 911 call. Upon arrival they found voluminous amounts of blood on the woman and spread out over the floor to the nurse's station and out to the adjacent patient chair. The woman died at the scene. A medQuest registered nurse specializing in renal clinical care reported the clinic's dialysis staff negligently failed to monitor the patient every 5-15 minutes in light of the fact that she was not tolerating the treatment well. The duty to monitor included: assessing the fistula needle insertion sites to ascertain any dislodgment; assessing the patient's appearance; assessing and documenting the patient's blood pressure and venous pressure trends; and weighing the patient before treatment to ascertain overly large weight gain, which had in fact occurred. The deviations from the standard of care caused the woman's untimely death.

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