This case study involves a nurse practitioner working in a medical clinical environment.
Case Study: Alleged Failure to Obtain Proper Medical History; Improper Medical Clearance; Improper Management of Anticoagulant Medication; Failure to Communicate with the Referring Surgeon; Failure to Properly Document Clinical Findings; Failure to Provide Proper Patient Instructions for Preoperative Management of Coumadin Therapy; and Failure to Order an Appropriate Coumadin Substitute
Settlement Payment: $77,500
Legal Expenses: $166,696
Note: There were multiple co-defendants in this claim who are not discussed in this scenario. Monetary amounts represent only the payments made on behalf of the nurse practitioner. Any amounts paid on behalf of the co-defendants are not available. While there may have been errors/negligent acts on the part of other defendants, the case, comments, and recommendations are limited to the actions of the defendant; the nurse practitioner.
The patient / plaintiff was a 45-year old woman with cardiac disease including mitral valve replacement, aortic valve replacements (three), prior cerebral vascular accident (CVA) and atrial fibrillation, who was receiving anticoagulant therapy with Coumadin and who was experiencing persistent and increasing pelvic pain.
The patient’s gynecologist diagnosed enlarging uterine myoma and referred the patient for an endometrial biopsy. The treatment plan anticipated that if the biopsy were benign the patient would then undergo bilateral uterine artery embolization (UAE). The gynecologist ordered medical cardiac clearance in preparation for the proposed UAE.
The defendant nurse practitioner examined the patient and apparently did not correctly understand the nature of the procedure for which clearance had been requested. The defendant nurse practitioner also provided medical and cardiac clearance that she believed was clearance only for the biopsy procedure. The defendant nurse practitioner provided the patient with only a handwritten note instructing her to cease the Coumadin medication four days prior to her “procedure” and also instructing her to speak to her surgeon regarding her Coumadin. The physician performing the biopsy subsequently instructed the patient to continue her Coumadin before and after the biopsy.
The biopsy was negative and the patient was scheduled for the UAE procedure. The patient claimed to have been confused about her Coumadin prior to the UAE. Based upon the handwritten note provided by the defendant nurse practitioner, the patient ceased her Coumadin four days prior to the UAE surgery. It was disputed whether the patient informed her physician that she had stopped her Coumadin, but her surgeon did not order any replacement for the Coumadin prior to the UAE procedure. The patient was instructed to resume her Coumadin upon discharge. Shortly after discharge, and before the patient could resume her Coumadin, she suffered an embolic stroke and cerebral infarct. Her symptoms were significant, including left sided weakness, gait disturbance, loss of range of motion of her left arm and hand, memory loss, confusion, mental anguish and emotional distress.
Multiple expert opinions were sought. All were critical of one or more of the following elements of the defendant nurse practitioner’s care:
- Failure to obtain the patient’s entire medical and cardiac history
- Failure to identify that the biopsy did not require medical clearance
- Failure to communicate with the referring physician to clarify the plan of care and the reason for the medical clearance
- Improper management of the patient’s anticoagulant therapy
- Improper, informal patient instructions
- Inadequate and inappropriate documentation
When defense experts agreed that the defendant nurse practitioner had deviated from the standard of care in several areas, the decision was made to settle the claim on behalf of the nurse practitioner.
Risk Management Comments
Optimally, the defendant nurse practitioner would have discussed the surgical plan and coordinated the management of the anticoagulant therapy (including appropriate substitutes when Coumadin therapy was suspended) with the surgeon, ensured that all parties understood the plan and documented the plan for the surgeon, the patient and in the patient’s clinical record.
Risk Management Recommendations
- Obtain a full history and ensure a thorough understanding of the surgical plan of care prior to providing medical clearance. If there is any question or if more than one procedure is planned, clarify the scope of the clearance with the requesting surgeon prior to proceeding.
- Provide clear, concise patient instructions. Patient instructions should be written and discussed with the patient such that the patient can successfully repeat them back.
- Communicate the management of high risk medications such as anticoagulants among all members of the patient’s care team and document the agreed upon plan to ensure coordinated and continuous care.
- Provide written findings, recommendations and patient instructions to the referring physician.
- Document all findings, recommendations and patient instructions in the patient’s clinical record, including a copy of any written patient instructions and a copy of the document provided to the referring physician.