Case Study with Risk Management Strategies
Presented by NSO and CNA
Case study: Failure to invoke the chain of command for a patient with neurological changes.
Medical malpractice claims may be asserted against any healthcare provider, including nurses. Two insured registered nurses (RNs) were involved in this case. Both had over ten years of critical care experience and were working in a cardiac intensive care unit at the time of this incident.
Summary
A 40-year-old male with a history of hypertension, hypercholesterolemia, and a documented aspirin allergy presented to the emergency department with acute-onset chest pain. The initial cardiac evaluation included a transthoracic echocardiogram and cardiac biomarkers which were both unremarkable. A subsequent electrocardiogram (EKG) revealed nonspecific ST-segment abnormalities suggestive of myocardial ischemia. A cardiac catheterization was performed revealing a 70 percent stenosis of the left anterior descending artery. A percutaneous coronary intervention (PCI) with stent placement was scheduled. However, due to the requirement for dual antiplatelet therapy (DAPT) with aspirin for the PCI procedure, the patient was admitted to the cardiac care unit for aspirin desensitization. The desensitization protocol, initiated at 3:00 p.m., consisted of sequential doses of aspirin administered at 30-minute intervals over a four-hour period. No hypersensitivity reactions were noted, and the patient remained stable.
RN #1 began her shift at
7:00 p.m. Due to an unscheduled staff absence, the cardiac care unit (CCU) was operating below the standard 1:1 nurse-to-patient ratio for high-acuity patient assignments. RN #1 was assigned two high-acuity patients: the subject of this case and a second patient recently admitted for post-interventional care. She was informed that she would be relieved at 2:00 a.m. by RN #2.
At 7:30 p.m., RN #1 conducted an initial assessment of the patient and documented that the patient was stable with normal vital signs of 112/76. At
8:30 p.m., the patient complained of a headache. RN #1 administered acetaminophen and notified the on-call cardiac care unit (CCU) resident. Approximately one hour later, the resident evaluated the patient, who described the headache as “the worst of his life,” rating the pain at 9/10. The patient denied any history of migraines or prior similar symptoms. Despite the severity of the symptoms, no neuroimaging studies (e.g., CT or MRI) were ordered, and a comprehensive neurological examination was not documented. The resident prescribed intravenous morphine (1 mg), which was administered by
RN #1 at 10:30 p.m.
One hour later, the patient reported no pain relief and had two episodes of emesis. Blood pressure at that time was elevated to 170/88, significantly above his baseline systolic range in the 110s. RN #1 contacted the resident again to report the persistence of symptoms as well as the elevated blood pressure. The resident ordered a second dose of morphine and an antiemetic, attributing the neurological symptoms to a presumed migraine and the elevated blood pressure as a response to pain. The resident did not return to reassess the patient following this update. The second dose of morphine and antiemetic were administered as ordered by RN #1. The patient’s condition remained unchanged through 2:00 a.m., at which time RN #1 transferred care to RN #2. During the handoff, RN #1 provided a verbal report that included information about the patient’s persistent headache, limited response to analgesia medications and intermittent episodes of hypertension. RN #1 shared her concerns regarding her limited ability to assess and manage this patient due to involvement in the resuscitation of her other assigned patient.
At 2:30 a.m. RN #2 conducted an initial assessment, noting ecchymosis on the patient’s extremities and a blood pressure of 160/90. The patient continued to report headaches, but RN #2 did not contact the resident, as she knew that the resident was aware of the patient’s condition. She interpreted the ecchymosis as an expected side effect of aspirin therapy and did not view it as concerning.
At 6:00 a.m., the patient again reported a severe headache, despite having received the two prior doses of morphine. RN #2 administered acetaminophen and provided non-pharmacologic comfort measures, including a cold compress, and reassurance that the attending cardiologist would evaluate him soon. No further nursing interventions were initiated. Over the following three hours, RN #2 observed that the patient was sleeping and, to avoid waking him, only reviewed and documented vital signs that she obtained from the monitor without conducting an assessment. The patient’s blood pressure remained elevated but was in the same range as the prior readings that had been previously reported to the resident. Therefore, RN #2 did not feel that an additional report was warranted.
At 9:30 a.m. the immunologist overseeing the aspirin desensitization protocol was at the bedside reviewing the healthcare information records. He did not wake the patient based upon the nurses’ notes indicating that the patient had tolerated the protocol well and the fact that the patient had been unable to sleep during the night due to a migraine. Consequently, the patient’s neurological status was not evaluated at that time, and it remains unclear whether he was neurologically intact. Assuming that the patient was stable, RN #2 did not communicate with the immunologist, as there had been no adverse reactions related to the aspirin.
At 10:15 a.m., the cardiologist came in to evaluate the patient and found him unresponsive with dried blood on his lips. The systolic blood pressure was in the 240s. A stat head CT was performed which revealed a large cerebellar hemorrhage with brainstem compression. Emergency neurosurgery was performed, including external ventricular drain placement and suboccipital craniotomy. Despite interventions, the patient’s condition deteriorated, and he expired two days later. The autopsy listed the cause of death as a large cerebellar parenchymal hemorrhage in the setting of hypertension and aspirin desensitization.
Risk Management Comments
Six months following the patient’s death, his spouse filed a wrongful death lawsuit against the involved healthcare providers, including the two registered nurses. The global assertion was a failure to diagnose and respond appropriately to signs of a cerebral hemorrhage, resulting in a missed opportunity for timely intervention. The following assertions were made regarding the nursing care:
- RN #1 failed to escalate her concerns when the resident was unresponsive to the patient’s ongoing clinical symptoms and failed to conduct serial neurological assessments.
- RN #2 was similarly criticized for not performing ongoing neurological assessments and for failing to recognize that persistent headache and new-onset ecchymosis in a patient receiving aspirin therapy warranted immediate physician evaluation. Her assumption that the resident was already informed was viewed by the plaintiff’s nursing experts as a lapse in clinical judgment and a deviation from the standard of care.
Both nurses were criticized by the plaintiff’s nursing experts for failing to invoke the hospital’s chain of command when the resident failed to acknowledge that further assessment and testing were indicated. The patient’s symptoms—including severe headache, vomiting, and elevated blood pressure—were identified by the plaintiff’s experts as red flags for a possible intracranial event, particularly in a patient without a history of migraines.
The nurses’ defense team faced the following challenges due to gaps in nursing documentation and finger-pointing among the codefendants, including but not limited to the following:
- The attending cardiologist testified that the patient had not been assessed by nursing staff for over three hours prior to being found unresponsive. This was corroborated by gaps in the nursing documentation and noted in the cardiologist’s progress note regarding the event.
- Documentation during the critical overnight period was limited primarily to blood pressure readings, with no recorded neurological assessments despite ongoing symptoms and administration of analgesics. The nurses admitted in their deposition testimonies that they did not conduct/document neurological assessments as required per CCU policy.
- The decision by RN #2 to not to wake the patient for assessments was cited as a missed opportunity to identify an active cerebral hemorrhage.
The defense team was unable to secure expert nursing testimony to support the care provided by the two RNs. The experts opined that the nurses failed to advocate for the patient by not contacting the attending physician directly or escalating concerns through the chain of command. The patient’s report of experiencing “the worst headache of his life,” in the context of recent aspirin administration, was identified as a critical warning sign that should have prompted immediate diagnostic imaging. The absence of such interventions was viewed as a significant breach of the standard of care. Additionally, nursing experts noted that staffing shortages contributed to the nurses’ inability to provide continuous monitoring and opined that this should have been communicated to the nursing supervisor to ensure appropriate patient oversight.
Resolution:
The case was settled prior to trial. Based upon the above-referenced professional liability exposures and diminished potential for a successful defense verdict, a settlement was negotiated in mediation on behalf of the insured RNs.
Total Incurred: Greater than $300,000 was paid in total on behalf of both nurses.
(Note: Amounts paid on behalf of other co-defendant(s) named in the case are not available.)
Risk Management Recommendations for Nurses:
- Conduct comprehensive nursing assessments to identify early signs of changes in the patient’s condition, considering comorbidities and new onset of pain or neurological changes.
- Promptly report changes in the patient’s status to the appropriate provider. Document all communications, provider responses, and actions taken in the patient’s healthcare information record.
- Ensure timely and accurate communication of critical patient information. Consider using an evidence-based tool for reporting critical patient information or during “hand-offs” to other members of the healthcare team. The Agency for Healthcare Research and Quality (AHRQ) offers several tools for effective communication, including:
- Team Strategies and Tools to enhance Performance and Patient Safety (TeamSTEPPS)
- Illness severity, Patient summary, Action List, Situation awareness & contingency planning and Synthesis by receiver (I-PASS)
- Situation, Background, Assessment and Recommendations (SBAR).
- Be conversant with the organizational policies, including the process for accessing additional staff to ensure safe patient care.
- Invoke the organization’s chain of command when leadership support is needed to advocate for patients requiring close monitoring, diagnostic studies or emergent care.
- Routinely engage in continuing education for your nursing specialty to ensure competency.
- Follow documentation standards established by professional nursing organizations and your employer’s policies. Document contemporaneously, factually, and thoroughly and include objective, descriptive details pertaining to the timing of events. Ensure all timing devices are synchronized. Objective and concise documentation is critical for both continuity of patient care, as well as for the defense of a potential malpractice claim. A complete healthcare information record is the best legal defense.
Disclaimer
The information, examples and suggestions presented in this material have been developed from sources believed to be reliable as of the date they are cited, but they should not be construed as legal or other professional advice. CNA, Aon, Affinity Insurance Services, Inc., NSO, or HPSO accepts no responsibility for the accuracy or completeness of this material and recommends the consultation with competent legal counsel and/or other professional advisors before applying this material in any particular factual situations. This material is for illustrative purposes and is not intended to constitute a contract. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. All products and services may not be available in all states and may be subject to change without notice. Certain coverages may be provided by a surplus lines insurer. Surplus lines insurers do not generally participate in state guaranty funds, and insureds are therefore not protected by such funds. The claims examples are hypothetical situations based on actual matters. Settlement amounts are approximations. Certain facts and identifying characteristics were changed to protect confidentiality and privacy. Any references to non-CNA, non-Aon, AIS, NSO, and HPSO websites are provided solely for convenience, and CNA, Aon, AIS, NSO and HPSO disclaim any responsibility with respect to such websites. “CNA” is a registered trademark of CNA Financial Corporation. Certain CNA Financial Corporation subsidiaries use the “CNA” trademark in connection with insurance underwriting and claims activities. This material is not for further distribution without the express consent of CNA. Copyright © 2026 CNA. All rights reserved.
Nurses Service Organization is a registered trade name of Affinity Insurance Services, Inc., a licensed producer in all states (TX 13695); (AR 100106022); in CA, MN, AIS Affinity Insurance Agency, Inc. (CA 0795465); in OK, AIS Affinity Insurance Services, Inc.; in CA, Aon Affinity Insurance Services, Inc., (CA 0G94493), Aon Direct Insurance Administrators and Berkely Insurance Agency and in NY, AIS Affinity Insurance Agency.
Resources
- Phillips J, Malliaris AP, Bakerjian D. Nursing and Patient Safety. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2021.
- ANA Nursing Resources Hub.Creating a Culture of Safety in Nursing | ANA, Safety Strategties Every Nurse Leader Needs to Know September 12, 2023
- Smith, P. (2023, January 19). Chain of command: What nurses need to know. Washington State Nurses Association. https://www.wsna.org/news/2023/chain-of-command-what-nurses-need-to-know
- Agency for Healthcare Research and Quality. (2023, May). Tool: Handoff. https://www.ahrq.gov/teamstepps-program/curriculum/communication/tools/handoff.html
This publication is intended to inform Affinity Insurance Services, Inc., customers of potential liability in their practice. This information is provided for general informational purposes only and is not intended to provide individualized guidance. All descriptions, summaries or highlights of coverage are for general informational purposes only and do not amend, alter or modify the actual terms or conditions of any insurance policy. Coverage is governed only by the terms and conditions of the relevant policy. Any references to non-Aon, AIS, NSO, HPSO websites are provided solely for convenience, and Aon, AIS, NSO and HPSO disclaims any responsibility with respect to such websites. This information is not intended to offer legal advice or to establish appropriate or acceptable standards of professional conduct. Readers should consult with a lawyer if they have specific concerns. Neither Affinity Insurance Services, Inc., NSO, nor CNA assumes any liability for how this information is applied in practice or for the accuracy of this information.
Nurses Service Organization is a registered trade name of Affinity Insurance Services, Inc., a licensed producer in all states (TX 13695); (AR 100106022); in CA, MN, AIS Affinity Insurance Agency, Inc. (CA 0795465); in OK, AIS Affinity Insurance Services, Inc.; in CA, Aon Affinity Insurance Services, Inc., (CA 0G94493), Aon Direct Insurance Administrators and Berkely Insurance Agency and in NY, AIS Affinity Insurance Agency.