A 38 ½ weeks pregnant patient arrived at the emergency department (ED) at 8:29p.m. with complaints of abdominal pain and decreased fetal movement.
Case Study: Failure to monitor and report changes in the patient’s medical condition to practitioner; failure to act as the patient’s advocate; failure to invoke the nursing chain of command
Total Incurred: Greater than $59,000
(Monetary amounts represent only the payment made on behalf of the insured registered nurse.)
Summary
A 38 ½ weeks pregnant patient arrived at the emergency department (ED) at 8:29p.m. with complaints of abdominal pain and decreased fetal movement. The patient’s mother described the patient’s symptoms as “continuous episodes of vomiting for the past three hours, left side abdominal pain, the pain is cramping that does not radiate, is aggravated by movement, and nothing seems to alleviate the symptoms.” She stated that the patient had some takeout earlier that afternoon and later she began having abdominal pain and vomiting. She presented to the ED because her mother (a registered nurse at the same hospital) instructed her to come to the ED because she would be seen faster. Initially, there was some confusion regarding if the patient should be sent directly to the Labor and Delivery (L&D) unit or evaluated first in the ED.
The patient was seen in the ED by a nurse at 8:31p.m. She reported her pain as an 8 on a 10-point scale. The health information record states that the patient was first seen by an ED nurse practitioner (NP) at 8:33p.m. and then by an ED physician at 8:37p.m. The NP documented a complete physical examination. Her differential diagnosis was: “gastritis, cholecystitis, labor.”
At 8:42p.m., the insured L&D registered nurse came to the ED to monitor the mother and baby. The nurse applied a fetal heart monitor in the ED and noticed the fetal heart rate was in the 130’s with minimal variability, and no decelerations noted. The nurse started IV fluids and only infused 50 ml as she wanted to see if the fluids would improve the fetal heart rate. After 20 minutes of monitoring the patient, the nurse determined that the contractions and fetal heart rate were unlikely to be reversed by hydration.
The patient was in the ED for less than 35 minutes when the decision was made to transfer and admit the patient to the L&D unit. The insured disconnected the fetal heart monitor and transported the patient to the L&D unit. When the nurse and patient arrived at L&D, the monitor was reattached. The nurse documented that at 9:18p.m. she had “Reviewed the fetal heart monitor strip and the patient was being examined by OB1.”
At 9:20p.m. the OB practitioner documented a progress note, “Patient is G1 @ 37+ weeks2, presented to ED with nausea and vomiting, mild abdominal pain. Didn’t feel well today. Decreased fetal movement, FHTs3 130s NR4, decreased LTV5. Assessment/Plan: probable GI6 virus, hydrate with IV fluids – monitor FHTs”.
At 9:25p.m. the insured nurse documented that she turned the patient on her right side “due to minimal variability”.At 9:30p.m. an entry was made by a second L&D nurse, “The contractions are moderate. The FHR7 baseline was 125 and the variability was minimal with no accelerations or decelerations”.
At 9:55p.m. the insured documented that “Contractions are mild to moderate and the FHR baseline are 120 with minimal variability and no accelerations or decelerations.”
At 10:16p.m. the insured documented, “The FHR baseline is 115 with minimal variability and no accelerations. OB performed an ultrasound and a biophysical profile.”
At 10:35p.m. the OB called for an operating room team in order to perform a C-section8. The last note by the OB prior to the C-section stated:
“C-section was performed due to non-reassuring fetal testing. The patient had felt movement earlier that morning, but it had decreased throughout the day and the biophysical profile after IV hydration showed an AFI9 of 5, no movement, no breathing. Since patient is only 1 cm and remote from delivery she will proceed with C-section.”
The delivery was accomplished at 11:21p.m. Apgar scores were 1 at one minute, 4 at five minutes and 6 at ten minutes.
The baby’s global condition is that of hypoxic-ischemic encephalopathy, cerebral palsy with spastic quadriparesis, and profound brain damage. The child cannot sit up or crawl; and is totally dependent for all activities of daily living. The child is nonverbal, but by using gestures can respond to simple questions.
Risk Management Comments
There were several defendants in the case. They included our insured registered L&D nurse, a second L&D nurse, the OB practitioner and the hospital. The allegations against our nurse were:
- Failure to immediately transfer plaintiff to L&D;
- Failure to identify the risk of placental abruption in light of the history and presentation;
- Failure to properly interpret non-reassuring fetal heart monitor tracings;
- Failure to attach a scalp electrode when the toco (cardiotocograph) was not picking up the fetal heart tones; and
- Failure to advocate for a timelier C-section and implement the chain of command.
Resolution
There were supplemental key issues to consider:
- Given the allegation that the insured RN failed to implement the chain of command, presenting an expert who was critical of the OB practitioner might serve to directly or indirectly support the claim that the RN should have recognized the MD was mishandling the delivery, and escalated.
- The defense expert opined the fetal heart monitor strips in this case were non-reassuring despite hydration; thus, an emergent C-section was appropriate and should have been performed shortly after the patient arrived on the L&D floor.
Given the deviations from the standard of care, the decision was made to settle the case on behalf of the defendant. Several other healthcare practitioners were also included in the lawsuit, but their settlement amounts were not available.
Risk Management Recommendations
- Recognize and report any change in a patient’s condition to the appropriate practitioner.
- 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.