This medical malpractice case study and risk management strategies, presented by NSO and CNA, involves an insured registered nurse (RN) who was employed in the post-anesthesia care unit (PACU) for an outpatient surgery center.
Summary
The patient was a 2-year-old female who had a well-documented history of sleep apnea, obesity, hypertrophy of the tonsils and adenoids and other respiratory issues. After undergoing a sleep study at a large regional children’s hospital, a tonsillectomy and adenoidectomy (T&A) was recommended. Rather than perform the procedure at the hospital, and despite the risks, the patient’s family was referred to the outpatient surgery center where the insured RN was employed.
Soon afterwards, the patient was scheduled for a T&A procedure. The patient’s well-documented healthcare information record indicated that the pre-operative phase of her surgery was difficult with the patient crying, screaming, clinging to her mother, spitting out meds and being otherwise noncompliant.
Although the surgery seemed to proceed without complication, the patient’s post-operative course was difficult. The insured RN was monitoring the patient in the PACU, and the patient failed to emerge well from anesthesia. The patient alternated between waking/sleeping and she had to be bagged for respiratory support. While in the PACU, she also required four doses of two different reversal agents (Narcan and Romazicon).
The anesthesiologist was known to leave early after surgeries and did so after this surgery – notwithstanding the nature of this difficult, high risk, pediatric patient. The duty of discharging – especially the decision of when to discharge – was left solely to the insured RN and another PACU RN on duty that day.
Prior to discharging the patient, neither RN contacted the anesthesiologist to confirm readiness or appropriateness for discharge. The facility had a written policy that required patients receiving Romazicon to remain at least two hours after receiving the medication prior to discharge. Approximately one hour after receiving Romazicon, however, the patient was discharged. The reason for this deviation from facility policy was not documented in the patient’s healthcare information record.
Based on the insured RN’s testimony, and that of the other PACU nurse, there were discrepancies in how the insured RN calculated the patient’s Aldrete score to determine suitability for discharge. The second PACU nurse testified that she did not agree with the score that the insured RN gave the patient. The second PACU nurse said that she believed that the insured RN “rushed” the patient out of the surgery center, especially given her difficulty coming out of anesthesia.
Once discharged, the patient’s family left the facility and headed home. Unfortunately, the patient stopped breathing on the way home and was rushed to a local hospital emergency department. Later that day, the patient was transferred to the larger, regional children’s hospital where she died a few days later.
Risk Management Comments
Shortly after the patient’s death, the family filed a lawsuit against the insured RN and the other providers working at the surgery center. The allegations against the insured RN included:
- Failure to monitor the patient;
- Failure to follow facility policy and procedure regarding medication administration;
- Failure to follow facility policy and procedure regarding discharging a patient;
- Failure to meet the standard of care when providing treatment to a patient;
- Failure to use accepted nursing standards when calculating a patient’s discharge score;
- Failure to communicate with other providers on a change in the patient’s condition;
- Failure to advocate for the patient;
- Failure to assess the need for medical interventions.
As the investigation advanced, additional facts about the case were revealed, including the following:
- The patient’s surgical case was the last one of the day, and the patient was, therefore, the last patient to be discharged from the surgery center.
- The day of the patient’s T&A surgery was the day before a forecasted snowstorm. It was speculated that this may have contributed to the desire of the insured RN to rush discharge.
Three expert witnesses reviewed the case and were harshly critical of the insured RN’s actions. They opined that the death of a 2-year-old child from complications of a T&A was avoidable and would be difficult to defend. Further, a jury would be inherently sympathetic to the family’s loss of their 2-year-old. The decision was made to pursue resolving the claim through a settlement rather than risk taking the case to trial.
Resolution
Approximately 20 percent of the liability in this case was attributed to the nursing staff, including the insured RN. The majority of liability was assigned to the surgery center, the surgeon, and the anesthesiologist. Amounts paid on behalf of these co-defendants are not available.
Total Incurred: More than $250,000
(Note: Figures represent only the payments made on behalf of the insured RN and do not include any payments that may have been made by any co-defendants. Amounts paid on behalf of the multiple co-defendants named in the case are not available.)
Risk Control Recommendations
- Know, understand and follow your facility policies and procedures, especially related to medication administration and patient discharge.
- Follow accepted nursing standards when calculating a patient’s discharge score. A focus on productivity numbers may lead to deviations from the standard of care, which can impair patient safety and outcomes.
- Communicate with other providers on a change in the patient’s condition. Document all patient-related discussions and communication with providers, as well as all attempts made to reach the provider.
- Assess or reassess the need for medical intervention, especially with high risk, difficult patients and in the event of changes in a patient’s condition. Vigilance, relaying important information to the receiving clinician, and performing your own patient physical assessment should be documented comprehensively in the patient’s healthcare information record.
- All providers and patient care team members should have a clear understanding of their role and responsibility in patient care management.
- Contact the provider or the on-call provider with questions, concerns or to obtain clarification regarding the medication(s) ordered for the patient. If the provider does not respond in a timely manner, follow the chain of command to the point of resolution.
- Invoke the chain of command, when necessary, to focus attention on the patient’s status. Nurses are the patient’s advocate, ensuring that the patient receives appropriate care when needed.
- Serve as your patient’s advocate in ensuring patient safety and the quality of care delivered.
- Maintain thorough, accurate and timely patient assessment and monitoring, which are core nursing functions.
- Contact the risk management department, or the legal department of your organization regarding patient or practice issues.
Disclaimers
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.