Neglecting Lithium Monitoring Leads to Home Health Patient Death

This case study highlights the severe consequences of neglecting lithium monitoring in home health care, leading to a patient's prolonged suffering and eventual demise.

ByExpert Institute


Published on February 6, 2024

Nurse assisting elderly patient

Case Overview

This case study involves a 61-year-old patient with a history of bipolar disorder, managed with lithium for many years. After her psychiatrist’s practice closed, her primary care physician (PCP) assumed responsibility for her care but neglected to monitor her lithium levels for three years. Eventually, the patient presented symptoms consistent with lithium toxicity, including memory impairment, which was overlooked by her PCP.

Six months later, she experienced thyroid abnormalities and weight loss. Despite an MRI ruling out organic brain disease, her lithium levels remained unchecked. The patient was evaluated by a home health nurse during several general wellness visits and medication reconciliations. During the last visit, the nurse conducted a cognitive assessment where the patient drew an abnormal clock with all numbers on one side. No further recommendations were made by the nurse.

Shortly after this visit, the patient was found unresponsive at home and diagnosed with lithium toxicity at the emergency department (ED). Over the next three months, she suffered prolonged lithium toxicity symptoms, including renal deficits and respiratory distress. Despite control over her lithium levels, her pulmonary condition worsened leading to her demise.

Questions to the expert and their responses


How much experience do you have evaluating patients in their homes as part of wellness checks?

I have over six years’ experience evaluating patients in their homes as part of wellness checks.


During medication reconciliation, what are common tasks performed?

Medication reconciliation typically involves reviewing hospital discharge documents, collecting and examining prescription and over-the-counter medications in the home, and notifying the physician of any discrepancies. If reliable information cannot be obtained directly from the patient, we can also contact their pharmacist.


If a patient has an abnormality with a cognitive test, what recommendations/protocols may a nurse follow up with?

Protocols vary; however, nurses know an abnormal cognitive test requires action such as a call to their supervisor or clinical director and/or the provider. The power of attorney or next of kin should also be informed to ensure follow-through on testing and treatment.


Have you ever reviewed a similar case? If yes, please elaborate.

I have reviewed similar cases in my professional capacity, where the standard of care for monitoring lithium levels was not met, leading to severe health consequences for the patient.

About the expert

This expert is a certified family nurse practitioner with extensive experience in home care and wound care nursing. They hold both BSN and MSN degrees from Chamberlain University, and are licensed as a registered nurse and advanced practice nurse in multiple states. Currently, they serve as a triage registered nurse for a home health care service and as a nurse practitioner for a wound care clinic, demonstrating their ongoing commitment to patient care in both home and clinical settings.

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