Nurse Case Study: Alleged failure to perform hand-off communication resulting in inappropriate patient monitoring

Nurse 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 insured in this case was a registered nurse (RN) who held a Bachelor of Science degree in Nursing. At the time of this incident, the RN was working in the emergency department (ED) of a community hospital and had been a practicing RN for 25 years. 
 

Summary

This case involves a 47-year-old male patient who underwent a total thyroidectomy and neck dissection for thyroid cancer. The patient was discharged from the hospital where the surgery was performed. The hospital was located fifty miles from his home. He was instructed at the time of discharge to go to the nearest emergency department if he experienced signs of bleeding or shortness of breath. Two days later, at 5:00 a.m., the patient, accompanied by his 21-year-old son, presented to the nearby community hospital for complaints of acute onset neck swelling and shortness of breath. The patient informed the triage nurse that he heard “a pop” in his neck which was followed by neck swelling and shortness of breath. At 5:05 a.m., the patient was taken to a treatment room and seen by the ED physician. The physician ordered bloodwork and a neck CT for the presumptive diagnosis of a hematoma related to the recent thyroid surgery.
 
The insured RN was the assigned primary nurse for this patient. At 5:30 a.m., he completed an initial assessment, started an intravenous line, and sent the ordered bloodwork to the lab. The patient’s vital signs were within normal limits. However, the RN noted that the patient had a hoarse voice, significant neck swelling, and appeared anxious stating that he felt the swelling was getting worse. At this time, the neck CT ordered by the physician was still pending and the RN was waiting to receive a call from the radiology department to confirm the exam time.
 
At 6:05 a.m., the RN was called to assist with transferring a critically ill patient to the intensive care unit. He testified in his subsequent deposition that he asked the nurse manager, who was helping with patient care that day, to monitor this patient while he was off the unit. Although the RN did not recall specific details about the hand-off communication with the nurse manager, he testified that he would always conduct a hand-off before leaving the unit and that his normal practice would be to inform the covering nurse about the patient’s diagnosis, pending tests and any abnormal vital signs. During the litigation process, the nurse manager, a co-defendant in the case, was also deposed and contradicted the RN’s testimony – she denied being asked to cover this patient or having received any hand-off communication from the primary RN. There was no documentation of a hand-off occurring. Both the RN and nurse manager testified that it was extremely busy during this shift with high acuity patients which may have impacted their memories of the hand-off.
 
Shortly after the RN left the unit, the patient’s son presented to the nursing station to report that the patient was becoming increasingly short of breath. A second RN (co-defendant) immediately went into the patient’s room and paged the physician. The physician evaluated the patient and placed an order for Ativan.  The physician informed the patient that he believed that the increased shortness of breath was related to anxiety. Ativan was administered by the second RN at 6:15 a.m. as the primary nurse had not yet returned from the ICU. Based upon the central nervous system effects of Ativan, the patient should have been monitored closely for respiratory depression, but this was not done. Neither the charge nurse nor the second RN came into the patient’s room at this time.
 
Ten minutes later, the patient’s son again presented to the nursing station, frantically stating that his father could not breathe. The ED physician immediately went into the patient’s room and observed that the patient was cyanotic with labored respirations. The primary RN had just returned to the unit and assisted with resuscitation including bag/mask ventilation. The ED physician attempted to intubate the patient but was unsuccessful. Anesthesia was called STAT to assist with intubation.  The anesthesiologist presented to the bedside within minutes to intubate the patient. However, intubation was unsuccessful due to the extensive neck swelling which had increased significantly since the patient’s arrival.
 
At approximately 6:45 a.m., the ED physician placed a STAT page for a surgery consultation.  Within minutes, a surgeon was at the bedside performing an incision and drainage of the neck, and then evacuated a large hematoma which had been compromising the patient’s airway. The patient had an immediate return of normal respirations. However, due to the extended period of suboptimal oxygenation, the patient suffered a hypoxic event with permanent neurological sequelae.
 
Following a complicated hospital course, the patient was transferred to a rehabilitation facility where he was eventually weaned from the ventilator. The patient’s cognitive status returned to baseline, though he suffered permanent left-sided paralysis, proprioception impairment, and cortical blindness. As a result of these injuries, the patient was no longer able to work in his previous career as an architect and required lifelong nursing care for activities of daily living.
 

Risk Management Comments

The patient (plaintiff) filed a lawsuit six months after the incident naming the ED physician, the primary RN, the nurse manager, and the secondary RN. The plaintiff asserted that the ED physician failed to diagnose and treat an expanding hematoma expeditiously, resulting in respiratory compromise and permanent neurological injuries. It was further asserted that the primary RN, nurse manager and secondary RN all failed to communicate effectively to ensure that an unstable patient was monitored appropriately.
 
Plaintiff’s experts were critical of the ED physician for failing to consult with a surgeon earlier, given that the differential diagnosis included a neck hematoma with the potential for an airway obstruction. The plaintiff’s emergency nursing experts opined that the primary RN failed to appreciate the criticality of the patient’s condition and failed to conduct an appropriate hand-off to ensure that the patient would be monitored closely while he was off the unit. In addition, plaintiff’s experts were critical that the nurse manager did not identify that this patient was not being monitored, regardless of whether or not she received formal hand-off communication from the primary RN.
 
The defense team was unable to retain a supportive nursing expert. The lack of documentation during the timeframe that the primary RN was off the unit and the contradictory deposition testimonies of the nurse manager and the primary nurse were viewed as weaknesses in the defense of this case. Both nurses were adamant that their recollection of the events was factual, creating a “he said, she said” situation and potential credibility issues. Emergency nursing experts for the defense opined that this patient required closer nursing monitoring in light of the presenting symptoms (i.e. recent neck surgery, shortness of breath, raspy voice and a visible neck hematoma and the triage level of ESI 2). Nursing experts noted that the documentation of anxiety in the initial nursing note should have raised a concern for a potential airway obstruction, as anxiety is often an early sign of impending respiratory compromise. The nursing documentation was considered a weakness in the case by the defense attorneys. The primary RN’s initial nursing note lacked pertinent details regarding the assessment and nursing care plan, and there were gaps in documentation during the period that the RN was off the unit.
 

Resolution

The defense attorneys concluded that this case had the potential for a high jury award based upon the above-noted challenges and the plaintiff’s visible injuries. The optics of the case (i.e. that this patient was allegedly “abandoned”) would be a significant challenge to overcome before a jury. Defense attorneys concluded that there was a low likelihood for a successful defense verdict, and, therefore, a decision was made to settle this case in mediation on behalf of the insured RN.
 
Total Incurred: More than $445,000
(Note: Figures represent the payments made on behalf of the insured RN and do not include any payments that may have been made from co-defendants.)

 
Risk Management Recommendations

• Ensure that the patient receives appropriate and timely care, as nurses are the patient’s advocate.
• Follow organizational policies regarding hand-off communication with nurses, providers and other staff members during transition points in emergency department care (e.g. EMS to triage, triage to treatment areas,  ED to ICU/floor and for instances when a nurse/provider or staff member is off the unit). Communication and teamwork are critical elements of patient safety, especially in high acuity areas such as the emergency department. 
• Report all significant information regarding the patient’s treatment, including a review of treatments, tests, medications, and outstanding orders to the accepting nurse.
• Document formal handoff procedures contemporaneously, factually, and thoroughly, and include objective, descriptive words and details pertaining to the timing of events including hand-off communication to avoid potential allegations of patient abandonment. 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.
• Utilize an evidence-based tool to ensure consistent hand-off communication of critical patient information.
  • The Joint Commission defines handoff as a “transfer and acceptance of patient care responsibility, achieved through effective communication” and offers recommendations for improving the hand-off process.
  • The Agency for Healthcare Research and Quality (AHRQ) offers several tools for effective hand-off communication, including but not limited to:
    • Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS)
    • Illness Severity, Patient summary, Action List, Situation Awareness and Synthesis by Receiver (I-PASS)
    • Situation, Background, Assessment and Recommendations (SBAR).
• Include patients and families in the hand-off process and utilize the “teach-back” technique to confirm their understanding of the information being communicated by having them repeat back your instructions in their own words.
• Engage in continuing education related to best practices for hand-off communication in order to maintain competency.
• Conduct comprehensive nursing assessments to identify patients requiring close monitoring in order to recognize early signs and symptoms of changes in the patient’s condition and advocate for patients requiring additional treatment.
• Invoke the organization’s chain of command when leadership or administrative support is needed to advocate for patients at risk.

 
 
Resources:

• Journal of Emergency Nursing, Volume 45, Issue 2, March 2019, Pages 149-154, Denise Campbell DNP, RN, ACNS-BC, CEN, Katherine Dontje PhD, RN, FNP-BC, FAANP.
• National Association of EMS Physicians, The EMS-ED Handoff: A Critical Moment in Patient Care; July 27, 2017; The EMS-ED Handoff: A Critical Moment in Patient Care - NAEMSP
• ANA on the Frontline-Safe Patient Handoffs by Susan Trossman, RN; American Nurse Today, January 2019
• The Joint Commission, 2017-8 Tips for High-quality Hand-offs; 2017.
• Tool: Handoff; Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/teamstepps-program/curriculum/communication/tools/handoff.html
• https://www.jems.com/operations/the-key-to-a-successful-patient-care-hand-off/
• BJ Strickland MSN JD – Nurse Guidance-April 25, 2017; Abandonment: What It Is and Is Not.

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These case scenarios 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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