A female in her late 70s was a long-term patient of our insured nurse practitioner (NP) and of the family practice where the NP worked.
A female in her late 70s was a long-term patient of our insured nurse practitioner (NP) and of the family practice where the NP worked. The patient’s history included arthritis, atrial fibrillation, and TIAs. She was taking Vicodin® for knee and hip pain and had been for over two years. She was also on warfarin for atrial fibrillation and her international normalized ratio (INR) was being monitored by our insured.
The patient presented to the emergency department (ED) on August 24th at approximately 09:25 a.m.: “Patient made a complaint of painless vaginal bleeding with blood in the groin area. There was no trauma.” The concern on the part of the ED physician was that the bleeding was somehow related to the fact the patient was on warfarin.
The ED physician specifically noted that there were no focal complaints of chest pain, shortness of breath, abdominal pain or leg pain. The ED physician instructed the patient to follow-up with her primary care provider that same day. He prescribed a Premarin® cream, instructed her to hold one dose of warfarin and documented that the patient had a 2:00 p.m. appointment at her primary care provider office.
Our insured NP saw the patient later that day in the family practice office. She documented:
“Subjective: Patient here after visit this a.m. to ED and she was very alarmed after vaginal bleeding. After visit felt lots of pain in right hip after vaginal exam.
Objective: Gait with limp right leg knee within normal limits bilaterally. Further pelvic exam deferred due to patient complaints of cramps in the right thigh and right buttock. INR 1.4 per verbal report from ED.
Assessment: 729.5 (which is the code for pain in a limb).
Plan: ED provider used silver nitrate to small raw abraded area (in or near vagina) and ordered Premarin® cream. Patient had hysterectomy in about 1996, not on HRT (hormone replacement therapy) for a long time. Encouraged her to start cream and to use Vicodin® PRN (as needed for leg pain).”
On August 25th, the patient called the NP’s office and spoke with the NP’s “nurse” who documented that the patient stated her leg pain had increased and the Vicodin® only helped a little. The nurse noted a verbal order from the NP for the Vicodin® dose to be increased. On that same day, our NP left a note for the nurse to follow-up with the patient about a repeat INR. However, for unknown reasons, the nurse did not follow up with the patient on the 25th.
The patient again presented to the ED on August 26th at 06:30 a.m. with complaints that her right leg was numb. The decision was made to have the patient admitted at 09:25 a.m. While the patient was in the ED, a CT scan was ordered in order to rule out a brain bleed since the patient was on warfarin. The thought was that the numbness in the leg may have been due to a stroke, but a bleed was ruled out.
There was a change in the patient’s condition between the time she was seen and evaluated in the ED and the time that she reached the floor. The hospital staff called the admitting provider’s office and spoke to our insured NP at 9:57 a.m. Our insured requested an evaluation by the Rapid Response Team (RRT), and the RRT responded at approximately 10:15 a.m.
The EKG at 10:18 a.m. was abnormal; troponin levels were ordered at 10:40 a.m. and were reported at less than 0.04. By 11:20 a.m., the patient had a second EKG and by then a cardiologist had been called in to the case. The cardiologist documented that the patient’s initial telemetry strips suggested ST elevation and myocardial infarction (MI), but it was not evident on the 12-lead electrocardiogram. Therefore, a repeat electrocardiogram was performed and that showed ST elevation with reciprocal changes.
It was the cardiologist’s impression that the patient was having an ST elevation MI. Patient was hypotensive, so nitrates were not given, but the patient was started on Heparin. The patient’s condition continued to deteriorate over the next few hours and she suffered a CVA as well as an MI. Discussions were held with the family, including two adult children, about the patient’s critical condition.
The patient passed away on September 8th. An autopsy was performed and an important finding under “Final Autopsy Diagnosis” referenced an extensive acute myocardial infarct on the posterior wall that was 7 to 10 days old.
The patient’s two adult children (plaintiffs) filed a lawsuit one-year after the death of their mother.
Risk Management Comments
The plaintiff experts claimed our insured:
- Failed to properly monitor the therapeutic levels of the anticoagulation theory. That is, there was an alleged failure to properly monitor the INR levels to make certain that the INR values were within the therapeutic levels leading to an unacceptable risk of myocardial infarction which is what occurred.
- Failed to appropriately assess the decedent’s right lower extremity following complaints of pain and limping on August 24th.
- Failed to timely assess and treat the decedent’s complaints of increased pain in the right lower extremity on August 25th.
- Failed to consult with and communicate with a physician if unclear or unsure about the appropriate regulation and management of anticoagulation therapy and lower extremity pain.
We obtained several experts, and each stated that the insured was clearly in a difficult situation because the patient had a history of heavy vaginal bleeding when she presented to the ED on August 24th, and the ED physician seemed to be concerned the bleeding was related to warfarin. The INR at that appointment was 1.4, per verbal report from the ED.
All experts were confident the patient was not having an MI on the 24th. However, they were concerned about what was done with respect to continuing the warfarin. All recognized the difficulty with restarting the warfarin because it could very well lead to a hemorrhage if the patient was bleeding. However, not restarting the warfarin would have increased her risk of developing a clot in the heart, secondary to atrial fibrillation, which could lead to an MI or stroke and that seems to be what happened here.
We had a very strong panel of experts who supported the care and treatment our insured provided to the patient. According to the autopsy the MI was 7-10 days old. Working our way backwards from the date of death September 8th, that would time the MI to September 1st, if it was 7 days old, and August 28th or August 29th, if was 10 days old, and all of those dates are well after our insured saw and evaluated this patient in the office on August 24th.
The defense filed a motion to dismiss based on our experts’ opinions. The plaintiffs voluntarily dismissed the case against our insured nurse practitioner.
Defense of the claim lasted nearly eight years, and legal fees paid to defend the insured NP totaled more than $120,000.
Risk Control Recommendations
- Develop, maintain and practice professional written and spoken communication skills. Follow documentation standards established by professional organizations and comply with your employer’s standards, as appropriate.
- Document the clinical decision-making process and rationale for any deviations in practice from established clinical protocols, guidelines and standards.
- Educate the patient and/or responsible party regarding the diagnosis, treatment plan, and the need for compliance with treatment recommendations, medication regimens and screening procedures.
- Ascertain the patient’s level of compliance with currently ordered treatment and care instructions, medication regimens and lifestyle suggestions.
- Document in the health record contemporaneously, factually and thoroughly. A complete health record is the best legal defense. Discussions with the patient and/or responsible party regarding diagnostic test results (both normal and abnormal), as well as recommendations for continued treatment and patient response to results.
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