Exempt from public disclosure pursuant to offline a. § 13 cf. PAA. § 13 first paragraph. 1
Businesses in the specialist shall immediately notify about serious incidents to the Board of Health (Special Health Services Act § 3-3 a). With serious incident meant death or serious injury to the patient where the outcome is unexpected in relation to foreseeable risk. Investigation unit, which processes the alerts, is a division of the State Board of Health. In some of the cases will be performed on-site inspections. Here at home published reports of cases in which it is done on-site inspections and any other matters that starts with notice. Information on patients and others who are subject to confidentiality is taken away. In most cases are also health and hospital anonymous. Requests for access to the document by the FOIA should be addressed to the State Board of Health, see link to post journal on the front.
Decision on warning
Norwegian Board of Health has decided to issue a warning pursuant Health Personnel § 56 first paragraph. We have determined that you have violated the acceptability requirements of the same Act § 4 on your checks to a named patient by emergency contact.
Norwegian Board of Health has concluded that your record keeping is contrary with the requirements of the journal’s content in the Health § 40.
you can appeal the decision within three – 3 – weeks of receiving this letter.
Procedural process
Norwegian Board of Health received by letter dated XXXXXX from the County of XXXXXX sent a supervision about your business as a doctor. Audit case concerns your checks to a named patient by emergency contact the XXXXXX.
We oriented you by letter dated XXXXXX that we would consider giving you a warning. You said you case by letter dated XXXXXX, but we have not received any statement from you after we sent our letter of XXXXXX.
The subject matter
You are educated in XXXXXX and received authorization as a doctor in Norway the XXXXXX, HPR no. XXXXXX. At the time of the incident were you duty doctor at XXXXXX emergency.
Norwegian Board has considered the matter on the basis of the documents you’ve got submitted earlier in the proceedings. Below is a discussion of the factors that has been important for our assessment.
Audit The case was initiated on the basis of complaints from relatives on the health care patient XXXXXX, born XXXXXX (hereinafter the patient), got ahead of his death XXXXXX.
the patient was the XXXXXX admitted to hospital XXXXXX stroke. Previously she had diabetes mellitus, hypertension, cardiomyopathy and angina pectoris.
The XXXXXX patient was transferred to XXXXXX XXXXXX for rehabilitation after stroke. The XXXXXX contacted a nurse at XXXXXX emergency, when the patient had a temperature of XXXXXX, was pale, clammy and hot skin, and had a blood sugar of 30. Furthermore, it was measured one CRP 227 and urinary test shows that knocked out positive for nitrite and glucose . From nursing journal is the lead of the days, the XXXXXX and XXXXXX:
“ XXXXXX ”
Please also find attached your journal notes from the event:
“Dia 2, metformin and metoprolol. Glucose 30.5 – has
Do not fast acting. (kl.15.21)
temp 38.3, CRP 227, ustix: 250mg / dl glucose, nitrite pos. 30.5 “ (kl.15: 59)
Excerpts from your statements to the case
statement of XXXXXX to the County informs you that you were informed the XXXXXX (XXXXXX) kl. 3:21 p.m. on the patient. It was informed that the inquiry involved a patient with type 2 diabetes mellitus and that she was controlled with Metformin. It shall be emphasized that the patient had rapid-acting insulin available from previous ordinations.
Furthermore, you pronounce the patient was described as awake and slightly warm. It lacked information about her vital parameters. On this basis asked to healthcare by XXXXXX to check these first. You were so informed at. 3:57 p.m. that the patient had a rectal temperature of 38.3 degrees, CRP 227 and urine showed glucosuria (sugar in urine), amount of 250 mg / dl (13.9 mmol) and nitrite positive, not mentioned ketone (ketones urine). The patient had further normal blood pressure, and respiration was described as straightforward.
You write that you did not get more information regarding the patient’s diabetes, when there were no more measurements available. You stated that you reviewed the patient who does not septic and that her blood sugar increase was a result of a urinary tract infection. Since she was awake and had difficulty swallowing, you chose to start with the described Ciproxin dose and encouraged staff to check your blood sugar regularly and closely and monitor her condition would change with regard to sepsis and diabetes. In addition, you asked them to call the attending physician the following day.
You were not contacted later that day for a reassessment of the patient and / or your treatment advice. You acknowledge that your medical record is sparse and inadequate, and that you may be better to record the telephone consultations.
Finally, you pronounce that you are not sure if you would have reacted differently today. You emphasize in this context that the patient had continuous supervision of qualified
personnel, where one must assume that they have the knowledge to assess whether the situation is stable or not.
By letter dated XXXXXX received Norwegian Board statement from you. You want to deepen the preparation in County Department of transmittal to the State Board of Health, which according to you are perceived as incorrect. When you got a call from the nurse got only information that the patient had elevated blood sugar and that she was somewhat warm. You point out that there were no further details. When the nurse later called back with supplementary information, the patient was awake, in its habituelle condition and sitting in his chair. In this context, emphasizes that all such conversations as you guide your healthcare provider or patient, quit resistant with: “Please contact the deterioration, uncertainty or desire for reassessment. Do not be afraid to come back / contact again. “
If you had known that the patient was somnolent or bad contactable, you would never have let the patient lie on the nursing home. In this context, states that neither you (that kept even at. 11:00 p.m.) or your colleague who had night duty, were called from the nursing home again. You note that you have a large guard district with XXXXXX in different municipalities. In addition, you must relate yourselves to as many community nursing stations. You handle many patients by phone to save the patient the long journey. Urinary tract infections, temperature and diabetes are often represented in these discussions / consultations.
Finally, sorry you faced patient survivors that you decided to wait. Retrospectively, when you read that the patient only slept, you would have summoned the patient with an acute ambulance with suspected ketoacidosis due to hyperglycemia.
Legal basis for the assessment
patient Dealing
the information in supervision by the case to consider whether you have acted contrary to the requirement of sound management in the Health § 4.
the Health § 4 first and second paragraph reads:
Health personnel shall conduct their work in accordance with the requirements to professional responsibility and diligent care that can be expected based on their qualifications, the nature of work and the situation in general.
Health professionals should abide by their professional qualifications, and shall obtain assistance or refer patients further where necessary and possible.
If patient needs dictate, the profession shall be by collaboration and cooperation with other qualified personnel. Health professionals have an obligation to participate in developing individual plans, when a patient or user is entitled to such a plan for patient and user Rights Act § 2-5.
Journal routing
we will also consider whether your journaling is in line with the Health § 40; see. journal Regulations § 8 about journaling.
the Health § 40 first paragraph reads
the records shall be kept in accordance with good professional conduct and shall contain relevant and necessary information about the patient and the health care, as well as the information necessary to fulfill the notification or disclosure laid down in the Act or pursuant to law. Records shall be easy to understand for other qualified healthcare provider.
The contents of the Health § 40 is further emphasized in the journal Regulation § 8.
Norwegian Board of Health review
the central subject of assessment is about your monitoring of the patient by telephone the XXXXXX was professionally acceptable, ref. the Health § 4.
the Health § 4 is a central provision. The provision requires professional responsibility and diligent care and to health professionals’ professional practice. What is justifiable is determined by an assessment of each case, and how health workers ideally should have behaved. In the specific assessment of whether your dealings were proper, take the State Board of Health based on what is considered good practice. The Emphasis is placed on current policies in the field, ref. Norwegian electronic medical handbook (NEL) and Casualty Handbook. Not any deviation from “good practices” considered unjustifiable. There must be a relatively clear deviations from good practice before the action is indefensible.
At the justifiability assessment takes further as to whether healthcare adapts to their professional skills and obtain assistance when necessary.
Good practice in assessing patients in emergency
emergency work specifically requires treatment responsible doctor. The doctor must have sufficient medical expertise, be able to cope with varying and sometimes high workload, prioritize and communicate with employees and cooperative healthcare in an efficient and appropriate manner.
The doctor must have good ability to separating the serious from the less serious. Emergency work belongs to the general medical field, and it is important to stay abreast of current professional guidelines. For emergency physicians comprised many decisions to reduce the likelihood that it is a serious condition due to the patients’ ailments or reduce the likelihood of serious incident occurring. This is particularly important in the treatment of acute illness. The crucial when assessing whether it is acted properly, will most often be the following: What is the probability, given the patient’s symptoms, the existence of a serious illness / condition or that it could develop into something serious? What is the risk of the patient by ignoring this or not to implement “necessary” measures? What has the doctor done to reduce the risk?
As far as possible, the emergency doctor doing research and record a history that is sufficient to consider follow-up and treatment needs in the short term, such as whether the patient should be hospitalized as emergency care in hospital. Casualty doctor should then organize health care or communicate to others who can ensure their organization, such as EMCC. When emergency services must therefore be made as to severity.
By assessments of matters relating to doctors in emergency one must question whether the emergency physician evaluated the situation on a sufficiently thorough manner, the doctor provisioned that the patient was observed occasionally or provided information to the patient in terms reconfigure pace worsen. It must be considered whether the doctor had sufficient grounds to conclude that the situation was reasonable “clarified”, and the initiation of therapy was adequate to clinical and presumed diagnosis.
Good practice in assessment and treatment of hyperglycemia in patients with diabetes
High blood sugar in patients with type 2 diabetes can cause typical symptoms such as thirst, increased urination, night urination, increased appetite, weight loss (at significant and prolonged hyperglycemia) blurry vision, paresthesia, skin infections (bacteria or fungi), and urinary tract infections. Exceptionally, glucose levels become so high that the patient becomes dizzy or develop a coma.
Diabetic ketoacidosis is a serious, life-threatening complication of diabetes and is characterized by hyperglycemia, ketosis and acidosis. Diabetic ketoacidosis primarily affects patients with type 1 diabetes, but may occur with type 2 diabetes, and can be triggered by infections. Hyperosmolar hyperglycemia is a differential diagnosis of diabetic ketoacidosis is a life-threatening endocrine emergency that occurs in all age groups, but most frequently in elderly patients with type 2 diabetes symptoms of hyperosmolar hyperglycemic state is pronounced dehydration, significant hyperglycemia with mild or no ketosis and often some degree of neurological disorder. This condition can partly be triggered by infections. Both of these conditions are serious and potentially fatal and requires emergency treatment and hospitalization.
When blood glucose & gt; 13.9 mmol / liter and ketostiks above or equal 3+ have patient-threatening ketoacidosis. By stupor / coma, blood glucose & gt; 34 and negative or weakly positive ketostiks patient has non-nonhyperinsulinaemic hyperosmolar coma. On suspicion of these severe conditions, the patient should be admitted at the fastest possible transport to a medical ward for treatment and monitoring.
Good practice in the treatment of upper urinary tract infection
pyelitis in adults often acute symptoms with chilliness and fever, but in early stages fever may be absent. Other symptoms may include nausea and vomiting and pain in the flank and abdomen. One can also find bank tenderness in kidney lodges. Lower urinary tract symptoms may be present in approximately 1/3 of patients signs of simultaneous involvement of the bladder. Pain in the lumbar region occur. CRP is generally elevated. On urinary test shows one can find leukocytes, protein and positive nitrite. Most mild to moderate cases can be treated at home with antibiotics. If the fever persists within 72 hours of starting treatment, or if nausea / vomiting increases, patients should be evaluated hospitalized suspected urosepsis. The treatment in adults is either Trimethoprim-sulfamethoxazole tablets 160/800 mg (2 tablets) x 2 for 7-10 days or possibly Ciprofloxacin 500 mg x 2 for 7-10 days.
Assessing your patient follow-up
Norwegian Board assumes that you, the doctor on duty in the emergency room were contacted by a nurse at XXXXXX XXXXXX by telephone in the afternoon XXXXXX. You received information that the patient had type 2 diabetes and that she had a blood glucose of 30.5. You notified the nurse to measure CRP, temperature and take urinary test shows. The nurse called back and gave the message that CRP was 227, rectal temperature 38.3 and urinary test shows gave impact on sugar and nitrites. This information appears in both your and the nurse’s medical records.
Your telephone note is very brief and say nothing about the patient’s general condition or state of consciousness, or whether such information was requested. The memo says either nothing about the kind of advice that is given in terms of observation and monitoring of the patient. Nurse’s medical record discloses that the patient was pale, clammy and warm. She slept in her wheelchair. According to the nurse, you were asked whether it was necessary treatment for high blood sugar, you thought it was not. You prescribed antibiotic treatment for suspected urinary tract infection without examining the patient. You did not consider whether there was a need for hospitalization or other treatment.
When blood is measured to over 30 in a diabetic patient, one that physicians should consider whether there may be threatening ketoacidosis. In case of impact on ketones in the urine, other diagnoses considered. Hyperosmolar hyperglycemia is a differential diagnosis that one has to consider in the elderly, although it is rare. In this case it was demonstrated a high CRP and impact on urinstiks indicating that a urinary tract infection had caused the high blood sugar. This does not preclude a more serious complication could develop, as these can be triggered by infections.
You started treatment with Ciproxin for urinary tract infection, which is in line with the guidelines. Given that the clinical situation was stable and the patient was not septic, this could be justifiable if she was secured close supervision of competent health and blood glucose was measured frequently and regularly. It does not appear that the nurse on XXXXXX XXXXXX has been clear and unambiguous information from you about what kind of follow-up was required. It emerges nor whether you requested the information needed to assess the patient’s condition good enough.
Norwegian Board believes that a blood sugar of over 30 simultaneous signs of a severe urinary tract infection dictates that you should have taken up a more thorough medical history and examined the patient himself, to make sure that the patient was in a state indicating that she could be treated and observed at the nursing home, or whether she should be hospitalized. On the basis of subject matter, it appears unclear whether the urine was checked for ketones or if you have requested this. Moreover, you should by a blood sugar of over 30 consider treatment with rapid-acting insulin, regardless of whether urinary tract infection were treated properly. If you then had found that the patient could be treated in nursing, you should ensured close monitoring and frequent measurements of blood sugar throughout the afternoon / evening at the nursing home, and made clear agreements with the responsible nurse around when you should be contacted again.
although you in your statement writes that in all conversations with healthcare concludes with: “Please contact the deterioration, uncertainty or desire for reassessment. Do not be afraid to come back / contact again “, we find it not well done to the documentation that such clear messages or appointments is provided in communication with the nursing home.
Your monitoring of the patient by telephone the XXXXXX was professionally irresponsible, ref. the Health § 4.
journaling
What is assessed is on about your record keeping is in line with the requirements of journal content, ref. the Health § 40; see. journal Regulations § 8.
Norwegian Board notes that a patient has multiple functions. It will serve as a tool, and should also give patients and including the regulatory authority the opportunity to gain insight into the treatment is performed. It is also central in which the patient switching processes, so that new processes should be able to get an overview of the health care that have been given. The record shall include information on contact cause, exploration, discovery, clinical assessments and diagnostic considerations, besides plan for further treatment.
Journal note will contain no medical history, description of the patient’s condition, your assessments and treatment advice or advice given regarding monitoring of the patient to staff at XXXXXX XXXXXX. Norwegian Board realizes that it may be that you have a broader knowledge of the patient’s health status than that which appears in the current Journal. We consider, however, that your extremely sparse information in the phone log / journal note does not contain sufficient evidence of the health care provided, and nor will it be easy to understand for other co-operating personnel.
After the State Board of Health assessment journal memorandum of XXXXXX so deficient that it does not meet the requirements that the regulations stipulate. Norwegian Board of Health finds that you have violated the recordkeeping obligations in the Health § 40; see. Journal Regulations § 8.
Assessment of whether you should be given a warning
Norwegian Board of Health finds that you have violated the Health §§ 4 and 40.
violations of Health Personnel provisions we can give warning pursuant to the Health § 56 first and third paragraphs which read:
the board can issue a warning to healthcare professionals who intentionally or negligently violates obligations under this Act or regulations issued pursuant to it, if the breach of duty is liable to endanger the safety of health and care services, to inflict patients and users with a substantial load or to substantially undermine confidence in healthcare or health and care services.
Warning are individual decisions under the Public Administration.
To give warning is firstly a condition that you have acted negligently. In this assessment, the Norwegian Board of Health to decide whether you can be blamed. In the assessment, we could focus on whether you had alternatives of action in the current situation, we believe that you had. Norwegian Board of Health finds that you could made a thorough medical history of the patient and recorded the information / findings. You could add the patient and examined herself, either by traveling out or requisitioned ambulance transport to you. You could checked whether there was ketones in the urine.
Furthermore, you could possibly have decreed fast-acting insulin to bring down the high blood sugar. You could have conveyed clear messages about close monitoring of patients to staff at XXXXXX XXXXXX and clear messages that you should be contacted if the patient’s condition has not improved or deteriorated. You could alternatively referred the patient be urgently to hospital. We also find that you could have resulted journal according to the requirements of the law.
Norwegian Board finds on this basis that you acted negligently.
The second condition that must be met is that actions are likely to endanger the safety of health care services, apply patients or users an
significant burden or to substantially undermine confidence in healthcare or health and care services. It does not matter whether the actions in the present case actually received such consequences.
Norwegian Board has considered whether your negligent actions are likely to cause patients considerable load. In our assessment is deficient / insufficient medical history / physical examination and failure to ensure close monitoring of patients or refer patients to emergency medical care hospitalization, likely to cause patients considerable strain by serious disease is not detected and / or treated in time.
the main conditions to give you a warning pursuant to the Health § 56 first paragraph are fulfilled. The Board shall make a judgment on whether you should be given a warning. Such assessments are based on the purpose of giving warning, which is responding to serious violations of the Health. The reaction will help to promote quality in health, patient safety and help prevent future breach of duty.
The case comes to treating a patient for a limited period. Norwegian Board looks however serious your inadequate monitoring of the patient. We expect that GPs have a good knowledge of evaluation and treatment of hyperglycemia in diabetic patients, as it is common in general practice and can develop into a serious, life-threatening situation for patients. We consider that the incident caused a significant health risk to the patient. Norwegian Board of Health finds an overall assessment that the violations of the Health is so severe that you should be given a warning.
Resolution
Norwegian Board provides pursuant Health Personnel § 56 first paragraph a warning for violation of the Act §§ 4 and 40.
We will send information about the decision to Supervisory för care och care (IVO) in Sweden and National Board of Health in Denmark, see attached copy.
you have the right to appeal this decision to the State board for Health Personnel, ref. the Health § 68. the deadline for appeals is three – 3 – weeks of receiving this letter. Read the attached information sheet with further information about the rules for appeal.
This should be sent to the Norwegian Board of Health. You must complain before eventually traveling litigation concerning the validity of the decision,. Administration § 27 b and the Health § 71.
Sincerely,
XXXXXX
XXXXXX
XXXXXX XXXXXX
The letter is approved electronically and sent therefore without signature
Attachments :
notification of the right to appeal administrative decisions
A copy of the message to the Supervisory för care och care (IVO) and National Board of Health
Cc:
County of XXXXXX
> XXXXXX
Legal officer: XXXXXX
Health Academic coordinator: XXXXXX
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