This case study involves a family nurse practitioner (FNP) who was employed by an internal medicine practice.
This case study involves a family nurse practitioner (FNP) who was employed by an internal medicine practice. On October 1st, a patient sought treatment at an internal medicine practice (“the practice”) with a primary complaint of a potential skin infection. The patient was known to the practice and customarily saw another FNP in the practice, so this was the first time our insured FNP had seen and treated this patient.
The FNP noted that the patient was a healthy 33-year-old female, 5’3”, 190 pounds with a history of cerebral palsy at birth that was the cause of her chronic back pain. The patient reported experiencing discomfort in the groin/labial region. She tried OTC yeast cream the night before, but it had not helped her condition. The pain had become progressively worse, and she was experiencing burning with voiding. The patient also reported that she had two similar areas on her left buttock and right upper thigh.
The FNP documented the following:
- Patient afebrile but tachycardic with a heart rate of 136 BPM
- Blood pressure was 116/72
- Temperature of 99.8 degrees Fahrenheit
She presents complaining of bilateral labial swelling with scattered lesions on the left side labia, which appears to be of herpes origin. There is white vaginal discharge noted as well. On the left buttock, there is a quarter sized erythema abrasion and scabbing, but with no discharge. On the upper right thigh, there is a dime sized erythema area, but no discharge.
In addition to the FNP’s assessment and diagnosis, she requested that her collaborating physician examine the patient. The diagnosis was bacterial vaginosis; possible herpes simplex virus and skin rash. Cultures were taken from all three lesions, and she was prescribed antiviral and antifungal medications for a possible vaginal yeast infection. Both of the medications were prescribed based upon a presumed diagnosis subject to the cultures confirmation. The patient was advised to follow up in 48-72 hours if she did not feel better.
On October 2nd, the patient began running a fever and stayed home from work. Her husband wanted to take her to the emergency department (ED), but she refused because they had two small children and she didn’t have anyone to take care of them.
On October 3rd, around 2:30 a.m., the patient was brought to ED by her husband. Her complaints included:
- Numbness all over;
- Difficulty talking with a slurred, slow speech;
- Chills, weakness, and fatigue; and
- Three bruise/rash areas; perineum, left buttock and right upper thigh.
The patient reported a history of cerebral palsy, chronic lower back pain and a possible diagnosis of genital herpes. The ED healthcare records reflected that around 9:00 p.m. the night before, her husband noticed that the wound on her right thigh was growing in size. He circled the area and at that time, the boarders measured approximately 5cm x 8cm. By the time she arrived at the ED, the site measured 18cm x 20cm. The site was noted to be red, warm and tender to the touch, swollen with irregular margins that were not raised.
The patient was admitted to the intensive care unit (ICU) with sepsis, severe hypotension and tachycardia. Upon admission, her blood sugar was low at 54mg/dL, and her white blood count was 15.4 cells/L with a band count of 25, suggestive of infection. Her serum hemoglobin was low at 6.8g/dL and she was positive for occult blood, so blood was ordered.
Later in the day on October 3rd, the insured received the culture results. When the insured called the patient to inform her that the cultures were negative, the patient let her know that she was in the hospital and very ill.
On October 4th, the patient underwent debridement of the right thigh and perineum areas. There was no evidence of necrosis, and the subcutaneous tissue appeared to be healthy. Post-procedure, the wound on the right thigh measured 30cm x 40cm, extending all the way down to the thigh musculature. However, the perineum post-procedure wound measurements were fairly minimal. Later that day, she was seen by an infectious disease practitioner and he noted:
- Septic shock, on multiple vasopressors and antibiotics;
- Leukocytosis and anemia;
- Right upper thigh cellulitis, doubting it is necrotizing fasciitis since there is no gas underlying, status post-surgery;
- Cerebral palsy; and
- Chronic back pain.
Unfortunately, the patient’s condition continued to deteriorate that day, and she was started on renal replacement therapy due to severe metabolic acidosis and multiple organ failure. Due to the use of high vasopressors and sepsis, she suffered ischemia to multiple distal digits.
Later in the day on October 4th, the patient went into pulseless electrical activity and cardiac arrest, could not be resuscitated and passed away. The patient’s death certificate indicates that her immediate cause of death was multi-organ failure, due to or as a consequence of septic shock, due to or as a consequence of right thigh cellulitis, due to or as a consequence of ingrown hair.
The family insisted on an autopsy. The autopsy attributed the cause of death to toxic shock syndrome with disseminated intravascular coagulopathy and sepsis from Group A Streptococcus, which appeared to have started due to several infectious lesions to her perineum area, left buttock and right upper thigh.
Risk Management Comments
Within two years of the patient’s death, the patient’s husband (co-plaintiff), mother (co-plaintiff) and estate (co-plaintiff) filed a lawsuit against our insured FNP, the practice and the collaborating physician who examined the patient.
The plaintiffs alleged that our insured failed to recognize and assess dangerous signs of infection. The elevated heart rate (136 BPM) and scattered lesions should have prompted the insured to order additional testing (i.e., laboratory or blood work) or send the patient to the ED for evaluation. Plaintiffs’ experts were expected to testify that had the insured sent the patient to the ED on October 1st, she would have survived because time is of the essence with septic infections.
When the lawsuit was filed, initially the defense experts were supportive of our insured’s actions and stated that they could offer explanations as to the elevated heart rate. They felt that the FNP’s documentation was comprehensive and thorough. However, as the lawsuit progressed, and additional infectious disease and internal medicine experts were retained, there was a great deal of questioning placed on the unexplained elevated heart rate during the visit with the insured, regardless of the presence of a lesion.
During the insured’s deposition, she testified that the patient’s heart beat did not trigger the need for further investigation. When the FNP auscultated the patient’s heart after sitting on the examination table for several minutes, it did not trigger her to think that her heart rate was very rapid or abnormal. The insured did recall noting the heart rate in the healthcare record and speaking with patient about her heartrate during the examination but failed to document that conversation. The insured assumed the 136 BPM rate was inaccurate as the nursing staff had made errors similar to this with other patients. The insured also stated that the heart rate is only one piece of information used to diagnose and that abnormality alone would not have prompted her to order further diagnostic testing.
Plaintiffs presented equally qualified counter FNP and medical experts. Between the two narratives the plaintiffs and the defense were presenting, the defense felt that there was a high risk that the jury would be swayed by the sympathetic narrative of the untimely death of a young woman.
The decedent’s mother and husband presented well at their depositions and would make strong and sympathetic witnesses. The patient’s mother was expected to testify to the emotional strain of helping raise her granddaughters after her daughter’s sudden and tragic death.
The defense experts placed a conservative value for the total, combined verdict for all defendants at approximately $5 million. However, given the patient’s otherwise good health, age, and young children beneficiaries, the defense experts advised that the potential for a defense verdict in favor of the FNP was remote.
The claim was settled on behalf of our insured FNP for the policy limits prior to a jury trial. The practice and the collaborating physician also settled with the plaintiffs, but the amount of the total settlement is unknown.
Indemnity and legal fees totaled more than $1.1 million
(Monetary amounts represent the payments made solely on behalf of the insured treating nurse practitioner.)
Risk Control Recommendations
- Work in areas that are consistent with licensure, specialty certification, training and experience.
- Gather, document and utilize an appropriate patient clinical history, as well as relevant social and family history.
- Perform a physical examination to determine the patient’s health status and evaluate the patient’s current symptoms/complaints.
- Utilize evidence-based clinical practice guidelines or protocols when establishing a diagnosis and providing treatment, and document the clinical justification for deviations in protocols.
- Document all patient-related discussions, consultations, clinical information and actions taken, including any treatment orders provided.
- Engage in timely and proactive discussions with physicians and other members of the care team to ensure that the team is educated about the patient’s treatment plan.