Let’s look at the following situation involving a nursing malpractice case:
Facts of a Nursing Malpractice Case
A 42-year-old is admitted to an orthopaedic unit after being found in a collapsed abandoned building. He was trapped and pinned under rubble for approximately 27 hours. He sustained a right femur fracture and was also diagnosed with rhabdomyolysis. His femur fracture was surgically fixed on the day of admission.
He was placed on telemetry at 11 AM to observe his cardiac activity. Additionally, he was to receive increased volume of intravenous fluids at 150 cc/hour to assist with the rhabdomyolysis. Neurovascular assessments were necessary as well.
During the night shift (7P-7A), the patient had to travel for a chest x-ray and VQ scan (at 10 PM) to check for a pulmonary embolism. The night nurse 7P-7A nurse documented the following symptoms: shortness of breath, tachypnea, tachycardia, anxiety, chest pain and decreased oxygen saturations intermittently.
He returned to the unit at 11:45 PM. The cardiac monitor was not reattached until 1:10 AM and the alarms were off. The nurse found the patient at 1:30 AM in asystole. A code was called and the patient was pronounced at 2:05 AM.
What can technology tell us about the chain of events? Let’s take a closer look.
When we look at the technology trail for the 7P-7A nurse, we are able to ascertain the following:
6:45 PM nurse arrives to the floor for her shift (scanned her badge)
7:25 PM she scans IV fluids and hangs it for the patient
7:55 PM she prints a strip from the telemetry monitor and records vital signs “heart rate 84 normal sinus rhythm, blood pressure 122/66, respiratory rate 14; oxygen saturation 97% room air…pain level 4 right leg.”
8:30 PM she documents an 8:00 PM assessment: “lungs WNL (within normal limits); cardiac (WNL); neurovascular WNL….”
8:55 PM vital signs “heart rate 142 sinus tachycardia, blood pressure 86/42; respiratory rate 32; oxygen saturation 86% on room air and after 6 minutes oxygen saturation increased to 91% – oxygen 2 liters nasal prongs applied and increased oxygen saturation to 95%.”
8:57 PM the on call physician was paged stat
9:10 PM stat orders for chest x-ray and VQ scan obtained
9:11 PM nurse enters the medication room (scanned her badge)
9:12 PM morphine 2 mg vial removed from the Pyxis machine for patient pain complaint of 8 – right leg
9:24 PM morphine scanned into the EMR and administered
9:26 PM she documents a 9:00 PM assessment: “lungs WNL; cardiac WNL, neurovascular WNL….”
9:27 PM vital signs “heart rate 156 sinus tachycardia, blood pressure 84/48; respiratory rate 30; oxygen saturation 89% on oxygen 2 liters nasal prong”
9:30 PM call from radiology placing patient on call for tests
9:52 PM patient travels via stretcher with nurse and transport to radiology
10:10 PM chest x-ray done
10:17 PM VQ scan done
11:45 PM patient and nurse return and re-enter unit (nurse scanned her badge)
01:10 AM cardiac monitor reattached by a nursing assistant
01:30 AM patient found in asystole; code called; CPR initiated
01:34 AM code team arrived
01:40 AM patient intubated
02:05 AM patient pronounced dead
This timeline raises several questions. What did the nruses assessment at 9:26 of WNL actually indicate? Computer systems have templates which define WNL. There are opportunities for nurses and others to document a description of assessments. Many computer systems have drop down boxes for staff to document details of assessments.
Was this patient’s death an unexpected event? Did the nurse follow the standard of care? Were there any deviations from the standard of care? Do you believe the outcome would have changed if the nurse met the standard of nursing care in this nursing malpractice case?
Barbara J. Levin BSN RN ONC CMSRN LNCC teaches nurses about technology and electronic medical records.