Nurse Case Study: Alleged failure to assess and monitor teen patient’s pulmonary status

A male patient in his mid-teens arrived at his pediatrician at 5:11 p.m. with complaints of difficulty breathing.

A male patient in his mid-teens arrived at his pediatrician at 5:11 p.m. with complaints of difficulty breathing. He had a long history of asthma, but over the last 24-hours his symptoms worsened. He stayed home from school and admitted to having six nebulizer treatments without much improvement. The mother drove the patient to the pediatrician’s office because she wanted to get a referral to a pulmonary specialist. While at the pediatrician’s office, the patient was given albuterol and observed for a few minutes. The pediatrician noted that the patient needed to be transferred to the emergency department (ED):

“The patient is having fair oxygen exchange and needs ED treatment management. While he is holding conversations, he needs frequent bronchodilators and IV steroids. Will hold oral steroids as patient is going to the ED for treatment and admission. Will call the report to the ED so they can anticipate the patient’s arrival.”  (There is no record of the pediatrician calling the ED.)

The patient was transferred to the ED by his mother. On arrival (6:10 p.m.) the triage nurse noted his respiratory effort was labored with retractions and bilateral wheezing. Vital signs were noted to be BP 115/66, HR 120, RR 22, and PO 96% on room air. The patient was taken to a room and was immediately seen by an ED practitioner at approximately 6:20 p.m. The ED practitioner noted:

“Audible wheezing, non-productive cough, and trouble breathing, all other systems negative. Give Albuterol Atrovent inhaler and Prednisone PO.”

Our insured registered nurse (RN) took over care of the patient once he arrived in a room at 6:38 p.m. The RN provided the patient with the inhaler and Prednisone and documented:

Patient appears in no apparent distress or uncomfortable. He has a history of asthma and is currently wheezing and difficulty breathing. Airway is patent, respiratory effort is even and unlabored. Respiratory pattern is regular, symmetrical. Breath sounds with wheezes bilaterally in both upper and lower lobes. Patient given Albuterol Atrovent and Prednisone per order. No adverse reaction.”

At 6:59 p.m., the ED practitioner noted:

Patient having mild respiratory distress, respirations include accessory muscles, breath sounds are wheezing, moderate and heard diffusely. Cardiovascular indicates that he is tachycardic.”

The ED practitioner and our insured RN were scheduled to finish their shifts at 7:00 p.m., but because the patient was to be admitted, they kept the patient and never actually turned over care to the on-coming providers. The ED practitioner ordered an IV saline lock and venous blood gases. She diagnosed him with acute asthma and contacted the PICU to send someone to evaluate him, noting:

Symptoms have continued to worsen despite treatment. We will give epi, mag, Solumedrol [Solu-MEDROL®] and continue nebs.”

At 7:05 p.m., the ED practitioner ordered a bolus of normal saline, a dose of magnesium sulfate, a second dose of Solu-Medrol® and a dose of Epinephrine. These were all administered by our insured RN within 5-10 minutes of the order.

By 7:20 p.m. the patient was noted by the ED practitioner to be “in moderate distress”, so the ED practitioner ordered Terbutaline. By that time the PICU resident had arrived to evaluate the patient, but the ED practitioner was still attending to him.

At 7:23 p.m. the patient suddenly went into respiratory arrest and resuscitation efforts were started. Over the next 30 minutes the records document a frantic effort to save this patient, who was pronounced at 8:28 p.m. The final diagnosis was acute asthma, respiratory arrest.

The results of the blood gases ordered at approximately 7:00 p.m. were later reviewed at 8:53 p.m., and they were markedly abnormal. The PH was 7.191 and the PO2 was 29.7 (slightly low). The PCO2 was 85.2 (critically high). The oxygen saturation level was 36.7 (very low) and the bicarb was 31.3 (slightly high).

The patient’s mother filed a lawsuit against the pediatrician, the hospital, ED practitioner and all nurses who were listed on the patient's chart. 

Risk Management Comments
The plaintiff’s attorney was very experienced in medical malpractice claims. The attorney had a reputation of being difficult to work with and did not mind taking cases to trial as he had a record of some very large jury verdicts in his clients’ favor. The plaintiff’s experts claimed our insured RN:

  • Failed to start an IV on the patient as soon as the RN received the patient.
  • Failure to perform a peak flow to assess the patient’s pulmonary status.
  • Failure to order and obtain critical laboratory as soon as the RN received the patient.
  • Failure to monitor the patient’s vital signs more frequently and more closely.
  • Failure to keep ED practitioner informed of the patient’s critical condition.
  • Failure to act as a patient advocate and initiate the chain of command.

During the patient’s mother’s deposition, she testified that a hospital staff member involved in the code told her that her son would be alive if our insured RN had started an IV earlier.

However, defense experts were supportive of our nurse’s actions. Defense experts felt that the plaintiff’s allegation that failing to place an IV line sooner was the cause of the patient’s poor outcome was not supported by the facts. None of the medications ordered prior to the decompensation required an IV and when an IV line was required it was in place within minutes.

Nevertheless, there was concern among the defense that the fact that a 15-year-old walked into an ED and died shortly afterwards could lead a jury to side with the plaintiff. The potential verdict should the case go to a jury trial was estimated to be at least $800,000.

The defense filed a motion to dismiss our insured nurse from the lawsuit based on our positive experts’ testimony and the positive testimony of the other defendants (the hospital and the ED practitioner). The courts granted our motion to dismiss with prejudice. Defense of the claim ultimately lasted nearly eight years and legal fees paid on behalf of our insured nurse totaled more than $142,000.

Meanwhile, the hospital and the ED physician settled the claim with the plaintiff prior to trial for an undisclosed amount. The plaintiff was not pleased with the pediatrician’s settlement offer so the plaintiff took the pediatrician to trial. The outcome of that trial is unknown at this time.

Risk Control Recommendations

  • 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.
  • Invoke the chain of command policy to ensure timely attention to the needs of every patient and persist to the point of satisfactory resolution.
  • Proactively address communication issues between nursing and medical staffs, and identify instances of intimidation, bullying, retaliation or other deterrents.
  • 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.


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