Nurse Case Study: ICU Charge Nurse allegedly failed to monitor a critical patient and escalate treatment

Medical malpractice claims may be asserted against any healthcare practitioner, including nurses. This case involves a registered nurse working in the Intensive Care Unit (ICU) as a Charge Nurse.

A 50-year-old male was recently in reasonably good health, although he had recently received a diagnosis of thyroid cancer. He was divorced and shared custody of his teenage son. He had a very active lifestyle and social life.
On October 19th, he underwent a total thyroidectomy and neck dissection. The surgery was uncomplicated, and he was discharged home on October 21st. On October 22nd at 12:45 a.m. the patient presented to a local medical center’s emergency department (ED). He reported that he had heard a “pop” in his neck about 40 minutes earlier, following which he developed neck swelling and began to experience difficulty breathing.
At the time of the patient’s arrival, the hospital was experiencing a high volume of patients. In fact, due to the volume of patients the hospital was using locum tenens physicians and agency staff nurses to help cover the overload.
The patient was admitted to the Intensive Care Unit (ICU) due to the risk of suffering from a post-thyroidectomy hematoma. The patient was admitted by his surgeon but requested the ICU hospitalist oversee the patient care for the night. An agency nurse (co-defendant) was assigned to the patient. The hospitalist (co-defendant) was with the patient from 1:01 a.m. until 1:21 a.m.
After assessing the patient, the hospitalist left the ICU and went to the on-call room to take a nap. Shortly after the hospitalist left, the patient’s nurse spoke to the ICU Charge Nurse (insured) relaying her concerns about the patient’s care. She felt the hospitalist should be doing more for the patient instead of taking a “wait and see” approach. Over the next 20-25 minutes the patient became increasingly anxious and short of breath.
The patient’s nurse contacted the hospitalist and let him know that the patient appeared to be decompensating, was having difficulty breathing and becoming extremely anxious. The hospitalist gave an order for intravenous lorazepam (1:36 a.m.) and monitor the patient’s response. The nurse did not feel comfortable with the order, so she again relayed her concerns to the Charge Nurse.
The Charge Nurse instructed the nurse to proceed with the lorazepam and she would contact the hospitalist and tell him to come see the patient. The Charge Nurse called the hospitalist and told him that he should come see the patient. The hospitalist voiced frustration with the call and stated that the patient was having an anxiety attack and the lorazepam would help. The Charge Nurse disagreed with the hospitalist. She told him that if he didn’t come see the patient, she would call the ED physician. According to the Charge Nurse’s deposition, the hospitalist told her that the ICU staff were incompetent and to “knock herself out” and call the ED. A few moments after the lorazepam was administered, it became readily apparent that the patient was headed toward respiratory distress.
The patient’s nurse called the Charge Nurse for assistance. The Charge Nurse instructed the ICU secretary to call the ED and get an ED doctor to come see the patient STAT. Within several minutes the anesthesiologist and surgeon were both at the patient’s bedside. The anesthesiologist was not able to intubate but bagged the patient while the surgeon evacuated the hematoma in the patient’s neck.
Once the hematoma was evacuated, the anesthesiologist was able to intubate the patient. The patient was emergently (via helicopter) transferred to a higher acuity hospital for further treatment. He ultimately suffered anoxic encephalopathy during his time in the ICU when he was in respiratory arrest.
The patient can’t use utensils, so he can’t feed herself, can’t groom or perform any of his ADLs. He is able to walk short distances with a walker but must have assistance. Because he has not being able to voluntarily move his arms, he cannot propel a wheelchair. He can’t even use a wheelchair with a joystick because that also requires voluntary upper extremity movement. He currently lives in an assistive living facility near his son and friends. He suffers from cortical blindness, has complete upper extremity loss of proprioception and loss of balance and coordination. The patient continues to make improvements, but his recovery is slow.
The patient/plaintiff filed a lawsuit against the hospital, the hospitalist and all ICU nurses that were listed on the patient's chart. The plaintiff’s experts were primary focused on the treatment and care provided in the ICU. The plaintiff experts claimed our insured, as ICU Charge Nurse:

  • Failed to assure the hospitalist was fully informed of the patient’s condition and escalate the patient’s treatment to other available providers.
  • Failed to monitor a critical patient.
  • Failed to be a patient advocate and initiate the chain of command.
Risk Management Comments
During the hospitalist’s deposition, he testified that he was never told that the patient was decompensating. In fact, he asserted that the only reason he knew of the patient’s critical condition was he heard the Code Blue being called and came to the ICU.  He stated that if he had known about the patient’s condition earlier he would have acted more urgently.
After all the testimonies, the defense experts did not have any criticism for anything our insured ICU Charge Nurse did once she became involved in the patient’s care. In fact, she followed the facility’s chain of command as well as called a Code Blue to get the patient immediate care. The experts deemed that the hospitalist’s failure to act was the direct cause of the bad patient outcome.
The plaintiff’s experts agreed that the hospitalist’s inaction put the ICU Charge Nurse in a difficult position. They agreed that the insured did all she could to get the patient emergent treatment. The defense filed a motion to dismiss our insured ICU Charge Nurse from the lawsuit based on our experts’ positive testimony.
Just prior to trial, the court granted our motion to dismiss with prejudice. Defense of the claim lasted six years, and legal fees to defend our insured nurse totaled more than $131,000. (Note: Figures represent only the payments made on behalf of our registered nurse and do not include any payments that may have been made by the registered nurse’s employer on her behalf or payments from any co-defendants. Amounts paid on behalf of the multiple co-defendants named in the case are not available.)
Risk Management Recommendations
As a nurse leader/manager:
  • Ensure that nursing practice is safe, effective, efficient, equitable, timely, and patient-centered (Institute of Medicine, 2001).
  • Act as the patient’s advocate in ensuring patient safety and the quality of care delivered.
  • Know and comply with your facility’s policies, procedures and protocols.
  • Supervise nursing staff and monitor their needs. Anticipate patient care problems before they arise.
  • Clearly articulate the nursing staffs’ roles and responsibilities within the team.
  • Communicate effectively in all areas of practice. Effective communication can manage change and address conflict. Nurse leaders/managers must be competent in making quick decisions, evaluating the quality of patient care and resolving conflicts.
As a nurse caring for patients:
  • Act as the patient’s advocate in ensuring patient safety and the quality of care delivered.
  • Because communication failures can lead to bad patient outcomes, nurses should assess and evaluate their communication skills and effectiveness.
  • Document your patient care assessments, observations, communications and actions in an objective, timely, accurate, complete, appropriate and legible manner. 
  • Invoke the chain of command policy to ensure timely attention to the needs of every patient and persist to the point of satisfactory resolution.
  •  If the organization’s current culture does not support the chain of command, explain the risks posed to patients, staff, practitioners and the organization, and initiate discussions regarding the need for a shift in organizational culture
  • Contact the risk management department or legal department regarding patient or practice safety issues, if necessary.

The information, examples and suggestions presented in this material have been developed from sources believed to be reliable, but they should not be construed as legal or other professional advice. CNA 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. Please note that Internet hyperlinks cited herein are active as of the date of publication, but may be subject to change or discontinuation. 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. Use of the term “partnership” and/or “partner” should not be construed to represent a legally binding partnership. All products and services may not be available in all states and may be subject to change without notice. CNA is a registered trademark of CNA Financial Corporation. Copyright © 2021 CNA. All rights reserved.

This publication is intended to inform Affinity Insurance Services, Inc., customers of potential liability in their practice. It reflects general principles only. It 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. This publication is published by Affinity Insurance Services, Inc., with headquarters at 1100 Virginia Drive, Suite 250, Fort Washington, PA 19034-3278. Phone: (215) 773-4600. All world rights reserved. Reproduction without permission is prohibited.

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