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Emory Rehabilitation Hospital complaint alleges baclofen pump programming overdose

The complaint alleges that a patient with a history of traumatic brain injury presented to an Emory facility for a routine intrathecal baclofen pump refill, and that a Medtronic SynchroMed pump was programmed to deliver 400 micrograms per day instead of the intended 200 micrograms. According to the complaint, the alleged programming error caused baclofen toxicity, toxic encephalopathy, ICU admission, seizure activity, permanent seizure disorder, and reduced motor function.

System
Emory Healthcare
Facility
Emory Rehabilitation Hospital
Providers involved
David T. Burke, M.D. / Emory Rehabilitation Hospital / Emory Brain Health Center
Pattern
Alleged medication programming error during intrathecal baclofen pump refill
Harm
Alleged baclofen toxicity, toxic encephalopathy, permanent seizure disorder, and reduced motor function

Overview

This page concerns a public complaint alleging that an implanted baclofen pump was incorrectly programmed during a refill at an Emory Healthcare facility, causing baclofen toxicity and neurological injury.

Chronology

  1. According to the complaint, the patient suffered a traumatic brain injury in a motorcycle accident in March 2019.
  2. According to the complaint, a SynchroMed pump was implanted in August 2020 to manage chronic spasticity.
  3. According to the filing, the patient presented to the Emory Brain Health Center for a scheduled pump refill on October 24, 2023.
  4. The complaint alleges that the pump was incorrectly programmed to 400 micrograms per day instead of 200 micrograms per day.
  5. According to the complaint, the patient was found unresponsive at home the next day and was transported by EMS to the Emory University Hospital ICU.
  6. According to the complaint, the patient suffered a seizure, and neurology confirmed that the pump was set at double the intended dose.
  7. The complaint alleges that the patient was discharged with a principal diagnosis of baclofen toxicity.

Alleged failures

  • The complaint alleges that providers failed to conduct a required time-out verification before the pump-refill procedure.
  • The complaint alleges that the physician failed to ensure that the pump was refilled and programmed with the correct daily dose.
  • The complaint alleges that providers failed to properly document medication and prescription data.
  • The complaint alleges that providers failed to provide timely post-procedure monitoring or guidance after the alleged programming error.
  • The complaint alleges that corporate entities failed to properly credential and manage the healthcare providers involved.

Entities and tags

Emory Rehabilitation HospitalEmory Brain Health CenterDavid T. Burke, M.D.Medtronic SynchroMed pumpBaclofen pumpIntrathecal pumpBaclofen toxicityToxic encephalopathySeizure disorderMedication errorProgramming errorFailure to monitorInadequate documentationPhysical medicine and rehabilitationNeurologyMedication safetyDevice programming

Questions this example answers

What does the Emory Rehabilitation baclofen pump overdose allege?

The complaint alleges that a patient with a history of traumatic brain injury presented to an Emory facility for a routine intrathecal baclofen pump refill, and that a Medtronic SynchroMed pump was programmed to deliver 400 micrograms per day instead of the intended 200 micrograms. According to the complaint, the alleged programming error caused baclofen toxicity, toxic encephalopathy, ICU admission, seizure activity, permanent seizure disorder, and reduced motor function.

Who is identified in this public case example?

This public case example identifies David T. Burke, M.D., Emory Rehabilitation Hospital, and Emory Brain Health Center. It also tags the source-supported entities Emory Rehabilitation Hospital, Emory Brain Health Center, David T. Burke, M.D., Medtronic SynchroMed pump, and Baclofen pump.

What alleged failures are summarized here?

The complaint alleges that providers failed to conduct a required time-out verification before the pump-refill procedure. The complaint alleges that the physician failed to ensure that the pump was refilled and programmed with the correct daily dose. The complaint alleges that providers failed to properly document medication and prescription data.