Nurse case study: Float nurse’s failure to follow sepsis protocol guidelines and institute chain of command contributes to extensive patient injury

Medical malpractice claims may be asserted against any healthcare practitioner, including nurses. This medical malpractice case study with risk management strategies, presented by NSO and CNA, involves a registered nurse working in a hospital emergency department setting.



The insured was a registered nurse (RN), who was recently hired as a per diem “float” nurse at a local community hospital. On the date of the incident, the insured RN was working in the emergency department (ED) and was assigned to a female patient in her early 40s who presented with complaints of abdominal pain, fever (104°), chills and vomiting. The patient had a past surgical history of a splenectomy, which was not included in the initial ED nursing assessment. The initial assessment, performed at 0700, revealed that the patient was hypotensive and tachycardic, prompting the insured RN to initiate the sepsis protocol, place an order for the recommended laboratory tests and notify the ED physician about the patient’s condition. The ED physician acknowledged the nurse’s concerns but did not share her sense of urgency. At approximately 0800, the ED physician conducted an initial evaluation, ordered fluids, and documented that the patient was tachycardic and did not appear to be septic.

Over the course of the next 1-2 hours, the RN remained concerned about the patient’s hypotension and tachycardia and the fact that the laboratory results were not yet reported. Upon contacting the laboratory to investigate the status of the lactic acid results, among others, the nurse was informed that the test was not being processed because the proper ordering protocol was not followed. In an attempt to advocate for the patient, the RN became hostile with the laboratory staff for their refusal to assist, and a verbal altercation ensued. Notably, the hospital was on a planned downtime procedure for EPIC computer-based orders, requiring the use of alternative paper methods for ordering diagnostic studies. Although the insured RN completed the hospital online training for downtime procedures, the procedure for manually labeling specimens was not followed.

The RN repeatedly reported the patient’s deteriorating condition to the charge nurse and ED physician, and was instructed to “give more fluids,” although 1500 cc of fluids had already been infused over a two-hour period with no improvement in vital signs.  The ED was extremely busy and the recently hired RN was not familiar with support available through the hospital chain of command. Due to an escalating concern for the patient, and an overwhelming sense of frustration, the RN verbally attacked the ED physician and charge nurse regarding their apparent lack of concern/urgency about this patient The following day, the RN was reprimanded for this conduct.

At approximately 1200, the laboratory called to report a critical result—a white blood cell differential count of 26 percent bands. At the same time, the chest x-ray report confirmed the presence of pneumonia. Based upon these results, as well as the patient’s critically low systolic blood pressure in the 70’s, antibiotics were ordered, and the patient was transferred to the intensive care unit (ICU). The physician transfer note listed the patient’s diagnoses as sepsis and pneumonia. Seven hours after the patient’s presentation to the hospital, antibiotics were administered to the patient in the ICU.

The patient’s condition continued to deteriorate, as evidenced by ongoing tachypnea and tachycardia, critical serum lactic acid levels and a mean arterial pressure below 65.  The patient required intubation and mechanical ventilation. The ICU physician diagnosed the patient with “severe sepsis and shock liver.” The blood culture results were positive for gram-positive bacteremia. Over the next 24 hours, the patient exhibited severe acidosis, multisystem organ failure and gangrenous extremities related to disseminated intravascular coagulation (DIC). High doses of vasopressors were required to maintain an adequate blood pressure. The family decided to transfer the patient to an academic medical center where bilateral upper and lower extremity amputations were performed as a lifesaving measure.
Two years later, a lawsuit was filed against the insured RN, the involved physicians, and the hospital. The allegation against the RN was failure to follow the sepsis protocol. The expert nursing review for the defense believed that the nurse did not adhere to the standard of care and was unable to offer support during litigation. The following opinions were rendered in the nurse’s expert review:
  • Failure to adhere to hospital policies, procedures, and/or guidelines regarding the sepsis protocol which contributed to the delayed diagnosis and treatment of sepsis.
  • Lack of knowledge pertaining to the EPIC downtime procedures for ordering tests.
  • Failure to conduct a comprehensive physical assessment and to document the patient’s history of a splenectomy, a condition which may predispose a patient to infection/sepsis.
  • Incomplete hand-off communications with ICU nursing staff about critical lab results.
  • Failure to institute the chain of command, whereby an RN may elicit assistance from hospital leadership for unresolved urgent patient matters.

Risk Management Comments

Although the insured RN attempted to advocate for this patient, albeit in an unprofessional manner at times, critical aspects of the sepsis protocol were not performed in a timely manner. Delays were related to the nurse’s lack of knowledge regarding downtime procedures and ineffective communication techniques with clinical team members.

The plaintiff’s nursing expert opined that the national sepsis protocols in place at the time of this incident indicated that antibiotics should be administered within three hours of the patient’s presentation, when sepsis is suspected. In this case, antibiotics were administered seven hours after the patient’s arrival to the ED.

The defense attorney believed that the nurse would make a poor witness at trial due to harbored anger and resentment about the interactions with the charge nurse and ED physician, as well as the disciplinary action that ensued regarding her unprofessional communications with the ED physician. During the deposition, and notwithstanding defense team preparation, the RN displayed a lack of confidence and made contradictory statements regarding hospital policies.


Based upon the above-noted defense challenges and diminished chance for a successful defense verdict, coupled with the patient’s extensive injury and lifelong care requirements, a settlement was negotiated in mediation on behalf of the insured RN.

Total Incurred: Greater than $500,000       
(Note: Figures represent the payments made on behalf of the insured nurse and do not include any payments that may have been made from co-defendants. Amounts paid on behalf of the other co-defendants named in the case are not available.)

Risk Control Recommendations

Sepsis is recognized as a global healthcare issue and is defined as “a clinical syndrome of life-threatening organ dysfunction caused by a dysregulated response to infection.” According to The Joint Commission (TJC), “Sepsis typically affects 1.7 million U.S. patients yearly, with about 270,000 of those cases resulting in death.” The Lippincott Nursing Center notes that “early identification, resuscitation, initiation of antibiotics and prompt identification and management of the underlying source and cause of sepsis is imperative in improving patient outcomes.”
Patients who suffer sepsis-related disabilities requiring lifelong medical care may seek legal recourse, with malpractice claims often asserting delayed or missed diagnosis and treatment. Lapses in following national guidelines and/or “sepsis bundles” to achieve early diagnosis may result in defense challenges in the event that a malpractice claim or lawsuit is filed.
The following recommendations are offered to assist in reducing nursing care liability exposures associated with sepsis:
  • Follow organizational sepsis protocols and be familiar with electronic medical record downtime procedures. Unfamiliarity with established policies is not a defense in a malpractice claim.
  • Maintain competencies, consistent with current national guidelines and sepsis bundles. Obtain education regarding sepsis identification and treatment and remain current regarding new updates to protocols.
  • Document all patient-related discussions, consultations, clinical information, and actions taken, including treatment orders that are provided.
  • Consider utilizing templates for reporting critical clinical information to other members of the healthcare team, such as the Situation-Background-Assessment-Recommendation (SBAR) tool.
  • Become knowledgeable about, and invoke, the organization’s chain of command when leadership or administrative support is needed to advocate for patients at risk.
  • Compile a comprehensive patient clinical history, as well as a relevant family history.
These are illustrations of actual claims that were managed by the CNA insurance companies.  However, every claim arises out of its own unique set of facts which must be considered within the context of applicable state and federal laws and regulations, as well as the specific terms, conditions and exclusions of each insurance policy, their forms, and optional coverages. The information contained herein is not intended to establish any standard of care, serve as professional advice or address the circumstances of any specific entity. These statements do not constitute a risk management directive from CNA.   This material is for illustrative purposes and is not intended to constitute a contract.  No organization or individual should act upon this information without appropriate professional advice, including advice of legal counsel, given after a thorough examination of the individual situation, encompassing a review of relevant facts, laws and regulations. CNA assumes no responsibility for the consequences of the use or nonuse of this information.

This publication is intended to inform Affinity Insurance Services, Inc., customers of potential liability in their practice. This information is provided for general informational purposes only and is not intended to provide individualized guidance. All descriptions, summaries or highlights of coverage are for general informational purposes only and do not amend, alter or modify the actual terms or conditions of any insurance policy. Coverage is governed only by the terms and conditions of the relevant policy. Any references to non-Aon, AIS, NSO, NSO websites are provided solely for convenience, and Aon, AIS, NSO and NSO disclaims any responsibility with respect to such websites. This information is not intended to offer legal advice or to establish appropriate or acceptable standards of professional conduct. Readers should consult with a lawyer if they have specific concerns. Neither Affinity Insurance Services, Inc., NSO, nor CNA assumes any liability for how this information is applied in practice or for the accuracy of this information.

Nurses Service Organization is a registered trade name of Affinity Insurance Services, Inc., a licensed producer in all states (TX 13695); (AR 100106022); in CA, MN, AIS Affinity Insurance Agency, Inc. (CA 0795465); in OK, AIS Affinity Insurance Services, Inc.; in CA, Aon Affinity Insurance Services, Inc., (CA 0G94493), Aon Direct Insurance Administrators and Berkely Insurance Agency and in NY, AIS Affinity Insurance Agency.

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