Nurse Case Study: Failure to follow Physician orders

A 23-year old woman with no significant prior medical history presented to the emergency room with complaints of generalized body ache of two weeks duration and a fever of 102.6.  

Following laboratory testing and an abnormal CT scan of the chest she was diagnosed with pneumonia, elevated white blood count, abnormal liver function tests and an abnormal coagulation profile. She was admitted to the intensive care unit (ICU) under the care of an assigned attending physician. The patient was treated with oxygen and antibiotic therapy.  Infectious disease and hematology consultations were requested. Blood cultures were drawn and showed Streptococcus Pneumoniae. Antibiotics were appropriately adjusted in accordance with the recommendation of the infectious disease specialist.
The attending physician cared for the patient in the ICU. The patient was not in significant respiratory distress and was responding well to the oxygen and antibiotic therapy.  The physician noted an abnormal potassium level of 2.9 and ordered 30mEq of potassium to be added to each bag of the patient’s intravenous fluid, infused at 80 milliliters per hour. Two days later, and notwithstanding the potassium added to her intravenous fluids, the potassium level was 3.0. The attending physician ordered 80 mEq of potassium to be administered by mouth, but the patient vomited the medication.  The physician then ordered two doses of 40 mEq of intravenous potassium to infuse over a four hour time period. Despite the order for two doses of potassium 40 mEq to be infused over four hours, the nurse administered two intravenous potassium doses of 20 mEq over approximately one hour. 
The nurse documented the patient’s increasing heart rate in the patient care record.  At 7:30 a.m., it was 72 beats per minute, at 1:30 p.m., it was 96 beats per minute, and at 4:30 p.m., it was 116 beats per minute. The patient’s blood pressure remained stable at 120/80.  The nurse did not notify the physician of the pattern of rising heart rate.  At the time the physician saw the patient that day, he noted that the patient’s white blood cell and platelet counts remained higher than normal but were dropping, her vital signs were within normal range, and she was not in respiratory distress.  He ordered a pulmonary consultation for possible bronchoscopy and ordered the patient to be transferred to the telemetry unit.
The nurse’s documentation fails to provide the exact time of transfer to the telemetry unit (estimated at between 7:00 p.m. and 7:30 p.m.) and also fails to validate the nurse’s statement that the patient was transferred to the telemetry unit with a cardiac monitor and oxygen therapy.  The telemetry unit nurse stated the patient did not arrive with a monitor.  Other telemetry unit staff indicated that the telemetry unit was in an overflow situation when the patient was transferred, and the central monitoring station was not functioning.  Irrespective of the actual reason, there are no telemetry unit electrocardiogram strips available for this patient.
At approximately 10:00 p.m. the patient experienced cardiac arrest. The on-call emergency physician attempted to resuscitate but was unable to obtain a heart beat and she was pronounced dead.
The family of the deceased sued the attending physician, the hospital and three of the hospital’s registered nurses, and sought $3,000,000 in damages. The allegations against the ICU nurse/defendant included alleged failure to properly administer the medications as ordered by the physician and failure to notify the attending physician of significant changes in the patient’s vital signs and laboratory results.
During the investigation of the claim, it was noted that English is not the nurse’s primary language, and she had some difficulty expressing herself. The nurse stated that she did not believe that she had sufficient experience and should not have been working in the intensive care unit.  Despite her language difficulties and limited clinical skills, she believed she followed the physician’s orders appropriately and documented her actions thoroughly. She recalled administering the potassium and believed she had followed the orders correctly and that she had advised the physician of the patient’s condition when necessary.
Do you think this nurse was negligent?
Do you think indemnity and/or expense payments were made on behalf of the nurse? If yes, how much?

The Outcome

  • Indemnity payment - Low six figures
  • Expense payment -  Low five figures
(Often the payments made on behalf of co-defendants are not available. In this particular case, it is known that payments made on behalf of the multiple co-defendants totaled seven figures.)

Risk Management Recommendations
  • When assigned to a clinical area, the nurse’s training and experience should provide the skills necessary to demonstrate competencies required for performing the nursing role specific to the clinical specialty or area. If not, it is the responsibility of the nurse to:
    • Notify the charge nurse and/or supervisor that the assigned clinical area transcends the nurse’s training and experience. The nurse should note expressly his/her lack of training and experience in that area/specialty and request an alternate assignment.
    • Request close supervision and/or the assistance of an experienced nurse if the assignment is not changed to an area/specialty where the nurse is trained and experienced and also request that all treatments and medications be checked prior to administration.
    • Obtain assistance for lack of complete understanding of any aspect of the patient’s condition, plan of care, progress notes, physician orders and/or medication orders.
    • Utilize the chain of command, including the director of nursing and/or hospital administrator, until provided with an assignment appropriate to his/her level of training and experience or until appropriate support and supervision with an experienced nurse is provided.
  • Monitor and document the patient’s vital signs, symptoms, response to treatment and changes in condition in the patient care record.
  • Timely report all significant findings to the patient’s physician.
  • Adhere to physician medication orders, including the correct drug, dosage, route and administration times.
  • Contact the physician and/or pharmacist with questions, concerns or to obtain clarification regarding the medication(s) ordered for the patient. If the physician does not respond in a timely manner, follow the chain of command to the point of resolution.
  • Manage any deviation from the physician’s order regarding administration of a medication as a medication error, including reporting, investigating and developing a plan of correction to prevent subsequent recurrences.
  • Perform and document formal handoff procedures when transferring a patient and report all significant patient information regarding the patient’s treatment, including a review of treatments, tests, medications and outstanding orders, to the accepting nurse.



#Best Practices #LegalCases #Malpractice #Patient Safety

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