Nurse Case Study: Failure to maintain appropriate professional education

This case study involves a registered nurse working in an operating room setting, who treated a 70-year-old male who presented for a cystoscopy and transurethral resection of the prostate procedure due to urinary retention and benign prostate hyperplasia.

Indemnity Settlement Payment: Greater than $250,000

Legal Expenses: More than $25,000

(Monetary amounts represent only the payments made on behalf of the insured registered nurse and does not reflect payments made on behalf of any other parties involved in the claim.)

A 70 year-old male presented for a cystoscopy and transurethral resection of the prostate (TURP) procedure due to urinary retention and benign prostate hyperplasia (BPH).  The urologist was assisted by a circulating nurse, a surgical technician, two laser sales technicians, an anesthesiologist and certified registered nurse anesthetist (CRNA).  The patient underwent general anesthesia at 9:10 a.m. the surgery started at 9:42 a.m. for the resection of the prostate.
At 10:00 a.m., our insured registered nurse (defendant) entered the operating room to relieve the circulating nurse for a break. As the circulating room nurse left the room, the urologist requested our insured, “connect the pump”. Although she had never performed this in a TURP procedure before, she had performed similar procedures for gynecological cases in which she would connect the pump to the inflow tubing.
She left the room to get the tubing and connected the inflow tubing to the pump. After she set up the inflow tubing to the pump, she left the room again to obtain additional supplies. Upon returning, she sat down to document in the perioperative record. At 10:15 a.m. when the assigned circulating nurse returned, she gave him a report and left the room to relieve other staff.
From 10:15-10:40 a.m., the procedure seemed to be proceeding as expected. However, at approximately 10:45 a.m., the circulating nurse noticed that fluid was dripping from somewhere around the operative field. On his investigation, he saw that fluid was dripping near the pump. It was at this point he realized that the tubing that was in the pump was the inflow tubing. At approximately the same time, the CRNA indicated that he was having trouble ventilating the patient and called for the anesthesiologist to return to the room.
The patient’s vital signs and respiration were documented as normal until 10:45 a.m. when the patient became difficult ventilate. Ultimately the anesthesia team called a code at 10:50 a.m. and during the code the patient’s stomach was noted to be significantly distended. One of the sales representatives was instructed to get additional nursing staff. As she left, she found our insured standing outside the room and informed her that she was needed in the operating room. Upon entering the room, the insured noticed the scrub technician performing chest compressions.
After a half an hour of attempted resuscitation, the patient was pronounced dead at 11:25 a.m.
The postmortem report indicated that the patient suffered respiratory compromise from reduced lung expansion as a result of fluid overload. The report further indicates that 21,000 milliliters of saline had infused through the irrigation and that only 12,000 milliliters were circulated out during the procedure. The report stated the abdominal cavity contained over one liter of clear fluid and the bilateral chest cavities each contained at least one liter of clear fluid. The lungs appeared shrunken and collapsed in the chest cavities and the soft tissues of the pelvic cavity appeared edematous. An additional finding was that the patient had 50 percent stenosis in the left anterior coronary artery and the circumflex coronary artery.
Approximately six months after the incident, the patient’s son (plaintiff and Administrator of the patient’s estate) filed a lawsuit against the hospital, the urologist, the urologist’s practice, the anesthesiologist and CRNA.

  • Failure to maintain appropriate professional information, education and clinical training needed to remain current regarding clinical practice
  • Failure to inspect/monitor equipment
  • Improper equipment use
  • Failure to communicate with the practitioner to clarify orders
Plaintiff experts claimed:
  • There was total lack of training for all responsible persons within the operating suite. An example of the lack of training was reflected when the relief nurse connected the pump to the inflow tubing which forced the fluid into the patient’s body at a high rate.
  • This action by the nurse went unnoticed by the urologist, who is the ‘captain of the ship’, the procedure and the necessary equipment and technology.
  • There should have never been a circumstance, as here, where a nurse was forced to make an assumption on the proper use of an instrument and thus the urologist failed in his responsibilities.
Two years after the incident occurred, one of the co-defendants filed a motion with the court to add our insured registered nurse as a named defendant in the lawsuit. The co-defendant claimed her actions alone caused the injury to the patient.   
Risk Management Comments
Our insured had been a registered nurse with over 30 years’ experience working in an operating room (15 of the last 30 years as a certified operating room nurse). She had been employed by the hospital her entire career, working in various surgical care areas. During her interview with defense counsel, she confessed to have had little to no instructional indoctrination and training in urology procedures or equipment. She reported that her position was as the coordinator for general and minor vascular surgeries and she was only filling in for breaks.
Two years after the incident occurred, one of the co-defendants filed a motion with the court to add our insured registered nurse as a named defendant in the lawsuit.
The co-defendant claimed her actions alone caused the injury to the patient.   
The defense counsel felt the strengths of case were that urologist was in complete control over the rate of flow of the irrigant fluid into and out of the resectoscope during the procedure. The surgeon should have known the rate or amount of fluid going in and should have investigated the situation. However, during his deposition he stated that that he had no complaints with the rate or amount of fluid going into the patient.
The obvious weakness is the fact that our insured connected the pump to the inflow instead of the outflow. She knew this was unusual for a TURP procedure, but did not clarify her understanding of what the surgeon asked of her.
The claim took three years to resolve and because our nurse was added to the lawsuit eighteen months after the original filing, the majority of her legal expenses were paid by her employer.
Risk Management Recommendations
  • Know the Nurse Practice Act and read it at least annually to ensure you understand the legal scope of practice in your state.
  • Maintain competencies (including experience, training, and skills) consistent with the needs of assigned patients, patient care units and equipment. All competencies should be verified by a staff member proficient in training area(s).
  • Speak up, ask for assistance and voice concerns when assigned and area where your competencies are not consistent with patient needs.
  • Clarify all orders if there is any doubt or uncertainty.
  • Document findings contemporaneously in the health record. Try not to make late entries unless it is appropriately labeled and is necessary for a safe continued patient care.

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