Nurse and Medical Malpractice Case Study with Risk Management Strategies
Presented by NSO and CNA
Medical malpractice claims may be asserted against any healthcare provider, including nurses. The two insureds in this case were registered nurses employed by a community hospital. The primary RN had been a nurse for 10 years and had been working on the telemetry unit of this hospital for two years. The charge nurse had been an RN for 20 years and had been a charge nurse at the hospital for 10 years. Both nurses were working on the evening shift on the second day of the patient’s admission.
Summary
The patient was a 66-year-old married female who presented to the emergency department (ED) with complaints of left-sided back pain radiating to the chest and shortness of breath. The patient had a past medical history of aortic valve replacement, diabetes, coronary artery disease, hypertension, peripheral vascular disease, obesity and chronic obstructive pulmonary disease. Diagnostic testing ruled out acute cardiac findings and she was diagnosed with atypical pneumonia, treated with antibiotics and discharged home.
About two weeks later, the patient returned to the ED complaining of shortness of breath and abdominal pain. The patient was tachycardic and had an oxygen saturation of 94 percent on four liters of oxygen. Coagulation studies revealed that her INR level was elevated at 5.1, so the anticoagulant medication was held. A chest x-ray was performed which revealed a large pleural effusion. The patient was admitted to the hospitalist service with an admitting diagnosis of “rule out C. Difficile”, based upon the patient’s gastrointestinal complaints (C. Difficile cultures were subsequently negative).
The admitting hospitalist was working on a locum tenens basis and was covering the weekend 7 a.m. to 7 p.m. shifts. He was employed full-time at another area hospital. The patient was admitted to the telemetry unit at 6 p.m. with orders for intravenous (IV) fluids and pain medication. Diagnostic imaging orders included a cardiac echocardiogram and a chest CT to be performed on a routine basis. There was also an order for nursing to report a heartrate above 130 beats per minute (bpm) or if the patient’s oxygen saturation level fell below 90 percent. The patient was stable overnight. However, the following day, the patient complained of increasing abdominal pain. She was evaluated by the hospitalist at 9:00 a.m. The physical exam revealed tachycardia and diminished lower left lobe breath sounds. The hospitalist documented that the tachycardia was likely related to volume depletion and dehydration as the patient had reported vomiting at home. The clinical plan included pain medication, volume replacement, lung CT scan with a “possible” thoracentesis to drain the pleural effusion. A follow-up assessment was performed by the day shift RN (not the defendant) at 10:00 a.m. The RN documented that the patient had abdominal distension, diminished breath sounds and normal vital signs. The patient’s oxygen saturation was within normal limits at that time. Morphine IV was administered as ordered for pain. At 11:20 a.m., an echocardiogram was performed which revealed a large left pleural effusion as well as moderate to severe left ventricular hypertrophy. The hospitalist was aware of this result.
The insured RN (primary RN) began her shift at 3:00 p.m. and conducted an initial patient assessment at 3:30 p.m. The patient’s condition was unchanged from the previous shift. The primary RN reviewed the results of the chest CT performed at 2:30 p.m. that day, which stated, “Large left pleural effusion which is inverting the left hemidiaphragm and causing inferior and medial displacement of the structures in the left upper quadrant of the abdomen, as well as near complete collapse of the entire left lung and mediastinal shift to the left. Findings suggest that the pleural fluid is under significant pressure and is likely either infectious or malignant in etiology rather than simple effusion.” She immediately reported the abnormal CT findings to the hospitalist and asked him if the patient should be transferred to the ICU. The hospitalist stated that he was comfortable with the patient remaining on the telemetry unit and that he would order a pulmonary consult. The primary RN inquired as to whether the pulmonary consult order should be placed as a STAT order versus a routine order. The hospitalist stated that a routine order would be “fine.” The hospitalist mistakenly believed that consults would be performed the same day as they were ordered, but this assumption was based on the protocols in place at the other hospital where he was on staff. The primary RN informed him, “we may not get those results today”, but the order was kept as “routine”.
The primary RN remained concerned about the patient’s CT results and was not satisfied with the plan for a “routine” pulmonary consult. She reported her concerns to the charge nurse who agreed that this matter warranted further escalation of the chain of command. The charge nurse contacted the chief medical officer (CMO), who was a cardiologist, and informed her about the patient’s CT results. The CMO advised the charge nurse to contact a pulmonologist directly to request a STAT consult. The charge nurse immediately called the pulmonary service and left a message at 5:15 p.m. requesting a STAT consult. The pulmonologist called back at 5:30 p.m. and the charge nurse reported the CT results verbatim to him. The pulmonologist ordered a Vitamin K injection to treat the patient’s elevated INR, in anticipation of performing a thoracentesis the following day, if the patient’s condition warranted. The phone consultation was not documented by the pulmonologist; however, it was documented in detail by the charge nurse.
The charge nurse then notified the hospitalist that she had spoken with the pulmonologist and that she had administered Vitamin K in response to the pulmonologist’s verbal order. The hospitalist agreed with the pulmonologist’s plan to consider performing a thoracentesis the following day. The charge nurse continued to keep the nursing supervisor apprised of the situation. The supervisor advised her to keep in close contact with the treating physicians to ensure that they were aware of any changes in the patient’s condition and to document all conversations, which was done.
At 6:30 p.m., the primary RN documented that the patient was complaining of increased abdominal pain and nausea. She administered Zofran 4 mg and Morphine 2mg intravenously, as ordered. She again contacted the hospitalist to inform him of the patient’s continued complaints of pain, despite receiving pain medication, as well as to alert him to the patient’s decrease in oxygen saturation to 78 percent. The hospitalist did not see the patient at this time. However, he ordered the RN to increase the patient’s oxygen from 2 liters per minute to 4 liters per minute and to request that respiratory therapy provide a nebulizer treatment. At 7:00 p.m., a nebulizer treatment was performed by respiratory therapy, and the patient’s oxygen saturation level increased to 96 percent. However, her heartrate remained elevated at 134 bpm. The hospitalist was preparing to end his shift at 7:15 p.m. and was on the unit speaking with the patient and her husband about the plan of care. The RN interrupted him to inform him that the patient was having a sustained heart rate in the 130s. The hospitalist advised the primary RN that he believed that the tachycardia was related to pain gave a verbal order for a STAT one-time dose of Dilaudid 2mg, which was administered at 7:30 p.m.
At 8:00 p.m., a new hospitalist was on duty and received report from the previous hospitalist. The primary RN updated him about her concerns regarding the CT results. The incoming hospitalist stated that he did not need to see the patient at this time, as the previous hospitalist examined the patient shortly before the shift change and reported that her condition was stable. At 8:45 p.m. the primary RN again contacted the hospitalist stating that she believed that the patient needed a higher level of care. The hospitalist advised that the patient could remain on the telemetry unit as her oxygen saturations were within normal limits.
Approximately 30 minutes later, the patient became unresponsive, and a code was called. Resuscitative measures were initiated including emergent drainage of the pleural effusion, yielding several hundred milliliters of serosanguineous fluid. The code was unsuccessful, and the patient expired. The cause of death was cardiac arrest due to a left pleural effusion.
Risk Management Comments
One year following the patient’s death, the patient’s husband (plaintiff) filed a lawsuit naming the hospital, the treating physicians, the charge nurse and the primary RN. The plaintiff asserted that the treating physicians failed to perform an emergent thoracentesis of the large pleural effusion which was the direct cause of the patient’s death. Plaintiff further asserted that the primary RN and the charge nurse failed to use critical thinking skills to recognize that the patient’s symptoms required emergent treatment.
The plaintiff’s expert in pulmonary medicine opined that the hospitalist should have ordered a STAT pulmonary consult and Vitamin K to proactively prepare the patient for a thoracentesis upon learning of the large pleural effusion. This expert criticized all the physicians for disregarding the nurses’ concern that the patient needed a higher level of care based upon the persisting tachycardia and abnormal CT results. The plaintiff’s nursing expert opined that the primary RN deviated from the standard of care by failing to conduct ongoing nursing assessments and failing to communicate with the physicians regarding the patient’s respiratory status.
Both defense experts-- an RN and a board certified pulmonary critical care physician-- were supportive of the nursing care provided. They testified that the primary RN documented frequent assessments and ongoing communications with the treating physicians. The experts opined that both nurses appropriately invoked the chain of command to advocate for the wellbeing of the patient. The nursing documentation demonstrated that the primary RN kept the hospitalist apprised of all changes in the patient’s condition including questions about the patient needing a higher level of care. The defense experts also refuted the plaintiff’s assertion that the primary RN failed to utilize critical thinking skills. They testified that her knowledge was demonstrated by her attention to detail and concerns regarding the CT results. The defense RN expert concluded that the ultimate care was governed by decisions that could only be made by the treating physicians and that nurses cannot render clinical decisions regarding whether a thoracentesis was indicated.
The most significant challenge for the defense was the finger-pointing amongst the co-defendants. The pulmonologist testified that he was not informed about CT scan details and the extent of the pleural effusion. He stated that he relied on the primary RN’s report and did not review the CT results in the electronic healthcare information record. The night shift hospitalist admitted that the primary RN asked him to see the patient at the start of his shift, but denied being informed about the patient’s tachycardia, shortness of breath or CT results. He testified that they only discussed whether the patient met the criteria to be transferred to the ICU. The primary RN’s testimony that she notified the night shift hospitalist about the CT results was supported by her documented note which read, “explained patient’s condition--CT results and ongoing pain, to night hospitalist and requested that he come up to the floor to see the patient, and physician said he would…”
In further support of the RN’s credibility, the defense attorney obtained an audit trail of the electronic medical record which revealed that the night shift hospitalist viewed the patient’s CT scan results at 8:45 p.m. The day shift hospitalist was not critical of the nursing care. He testified that he was distracted with an emergency in the ICU and that he did not acknowledge the severity of the patient’s condition. He stated the primary RN informed him that the pulmonologist had been called so he believed that the patient’s care was being managed. He also agreed that he received multiple calls from the primary RN regarding the patient’s condition and confirmed that the primary nurse’s notes about the call were accurate.
Resolution
The nurses’ defense team concluded that, based upon the supportive expert opinions, both nurses acted within the standard of care. The defense team was able to successfully obtain a dismissal for both RNs in exchange for a nominal settlement to avert the nurses having to experience a lengthy trial. The successful outcome of this case was based upon tireless efforts of the nurses to advocate for the patient, as well as their complete, detailed documentation in the healthcare information record.
Total Incurred: More than $30,000 on behalf of each nurse.
(Note: Figures represent the payments made on behalf of the insured RNs and do not include any payments that may have been made from co-defendants.)
Risk Management Recommendations for Nurses
- Ensure that the patient receives appropriate and timely care, as nurses are the patient’s advocate.
- Maintain clinical competencies aligned with the relevant healthcare specialty of nursing practice.
- Report all significant information regarding the patient’s condition, including test results, medications, and outstanding orders, to the treating providers, and document this action in the healthcare information record.
- Conduct comprehensive nursing assessments to identify patients requiring close monitoring to recognize early signs and symptoms of changes in the patient’s condition, and advocate for patients requiring additional treatment.
- Utilize effective communication techniques to avoid misunderstandings amongst the healthcare team. Consider using an evidence-based tool to ensure consistent communication of critical patient information. The Agency for Healthcare Research and Quality (AHRQ) offers several tools for effective hand-off 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).
- Invoke the organization’s chain of command when leadership support is needed to advocate for patients at risk.
- Know and comply with your state scope of practice requirements, nurse practice act and organizational policies.
- Follow documentation standards established by professional nursing organizations and your employer’s policies. Document any changes in the patient’s condition and/or response to treatment in the healthcare information record, as well as all patient-related discussions and actions taken.
Risk Management Recommendations for Charge Nurses
- Monitor patient acuity and staffing to proactively manage patient safety issues.
- Engage in continuing education to maintain clinical competencies as well as leadership skills.
- Adhere to organizational policies regarding the roles and responsibilities of a charge nurse, including but not limited to the following:
- Ensuring that all nursing functions within the department run efficiently.
- Supervising and assisting staff nurses with patient-related questions.
- Providing patient care as needed to support staff nurses.
- Monitoring patient care and invoking the chain of command, when indicated.
- Acting as a liaison and resolving conflicts between nurses and other members of the healthcare team.
- Delegating staff assignments based upon staff members’ competencies.
Disclaimers
These are illustrations of actual claims that were managed by the CNA insurance companies. However, every claim arises out of its own unique set of facts which must be considered within the context of applicable state and federal laws and regulations, as well as the specific terms, conditions and exclusions of each insurance policy, their forms, and optional coverages. The information contained herein is not intended to establish any standard of care, serve as professional advice or address the circumstances of any specific entity. These statements do not constitute a risk management directive from CNA. This material is for illustrative purposes and is not intended to constitute a contract. No organization or individual should act upon this information without appropriate professional advice, including advice of legal counsel, given after a thorough examination of the individual situation, encompassing a review of relevant facts, laws and regulations. CNA assumes no responsibility for the consequences of the use or nonuse of this information.
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