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Shift. Change

"Shift. Change.  Empowering Nurses with Medical Legal Knowledge"

"This book is a must read for all nurses. You need to get it into the schools of nursing as part of the curriculum.
Nurses need to know and you do it brilliantly!"

Clinical Educator, Ontario

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As the originator of Legal Nurse Consulting in Canada, the owner of one of the largest healthcare expert witness companies and a sought after expert witness and speaker, Chris Rokosh RN, PNC(C) offers unique insight to the world of nursing.

She has personally analysed hundreds of medical malpractice lawsuits and appeared as an expert witness in court. Her career is now focused on sharing the lessons learned with nurses everywhere.

Her new book "Shift. Change. Empowering Nurses with Medical Legal Knowledge" is the most accessible opportunity to learn invaluable lessons about the legal risks in healthcare.

"Shift. Change." was developed on the belief that legal knowledge can improve healthcare outcomes and promotes an understanding of nursing responsibility as a way to improve patient safety and avoid litigation.

This is your opportunity to:

  • Learn about the medical legal landscape and an understanding of the legal process
  • Work through a nursing negligence case study
  • Identify the most frequently sued nursing specialty areas
  • Identify the top five issues in nursing negligence
  • Learn valuable tips to minimize your legal risk

This book is for all nurses from all specialty areas including RNs, RPNs, LPNs, NPs, NAs, Midwives, student nurses, risk managers, policy makers, nursing managers and nursing and clinical educators.

The price is $40 including taxes and shipping.

For bulk rates, further information or bookstore sales contact .

For Canadian Buyers

 

For U.S Buyers

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Invite Chris Rokosh to speak at your event

Chris is an engaging, humorous and motivating speaker. Her captivating stories move the audience with touching, surprising and real life medical malpractice cases that offer practical lessons for all nurses everywhere.

The knowledge gained will inform, help to improve patient safety and improve nursing documentation.

Thousands of nurses and healthcare professionals who attended Chris's seminars said that they left more confident, motivated to improve their practice and documentation and assured of the value of patient centred care.

Chris is available for keynote speeches, ½ or full day presentations, workshop leader, and panel participant at nursing, leadership, healthcare and business conferences.

Partial list of engagements:

  • Alberta Nursing College/Association Centenial Conference, Edmonton
  • American Association of Legal Nurse Consultants Annual Conference, Denver, Pittsburgh
  • Nova Scotia RN/LPN Annual General Meeting, Halifax
  • Canadian Obstetrical Malpractice Conference, Vancouver
  • Birth Trauma Conference (in partnership with Thomson Rogers), Toronto, Calgary, Vancouver
  • Canadian Association of Neonatal Nurses Conference, Montreal
  • Legal Issues in Nursing, Ottawa, Guelph, London, Peterborough, Toronto, Hamilton, Calgary, Edmonton, Winnipeg, Saskatoon, Prince George, Fort McMurray, Lethbridge, Vancouver
  • Canadian Bar Association, Calgary, Edmonton
  • AWHONN International Conference, Los Angeles
  • International Home Health Conference, Chicago

For availability and pricing, email us or call toll-free at 855-278-9273.

Case Outcome

The lawyer representing Dave in this malpractice lawsuit asked a Legal Nurse Consultant to review the medical record to provide expert opinion on whether Nurse Donna and Nurse Lucinda had met the standards of care. Their opinion was that Donna and Lucinda had not meet the standards in two important areas; first by not assessing Dave’s leg as thoroughly and frequently as required by hospital policy. Secondly, by not communicating his pain, weakness, colour change and sensory loss to the doctor in a timely manner.

Their opinion was that Nurse Donna should have called the doctor no later than 2 a.m., when she documented that that Dave had severe weakness and tingling in his right leg. Since this did not happen, their opinion was that Nurse Lucinda should have performed a full assessment of the leg at the start of her shift at 8 a.m. and asked the doctor to see Dave immediately.

The Legal Nurse Consultant said that nursing documentation in the medical record indicated a lack of nursing knowledge and critical thinking, as well as a failure to meet the standard of care surrounding both assessment and communication. The opinion was that the lack of communication contributed to a delay in accessing medical attention, which the medical experts stated ultimately contributed to the loss of Dave’s leg. Based on this, the case settled out of court for an undisclosed amount of money.

The doctor who performed Dave’s surgery was also sued, but later released from the lawsuit when it was discovered that the nurses had not communicated significant clinical information to him. By the time the Orthopedic resident examined Dave, and contacted the surgeon on the morning after surgery, Compartment Syndrome had already caused irreversible damage. The opportunity to prevent or minimize the injury was lost.

 

compartment syndrome

What is Compartment Syndrome?

Compartment Syndrome is a potentially life-threatening condition caused by high pressure in a closed fascial space. The most common site of compartment syndrome is the lower leg (Abramowitz and Schepsis 1994) and young men with traumatic soft tissue injury are known to be at particular risk (McQueen et al 2000). It is a potentially devastating complication of tibial fractures which requires prompt recognition and intervention; as early intervention is critical to avoid permanent damage to the muscles and nerves.

Symptoms of compartment syndrome can include pain that is disproportionate to the injury, pallor of the affected limb, altered sensation (numbness, tingling), tension of the affected muscles, pulselessness below the level of the swelling and, as a late sign, paralysis. Post-operative narcotic administration may mask or dull pain, which is often the first symptom of compartment syndrome. Therefore, careful monitoring for the other symptoms is important.

The nursing plan of care for a patient with a traumatic fracture must include, among other things, knowledge and awareness of the possible development of compartment syndrome. Monitoring of color, warmth sensation, movement and pulse strength may be required as frequently as every 15 to 60 minutes, but certainly every four hours in the early post-operative period.

Depending on the lines of communication in your department, signs and symptoms of compartment syndrome must be reported immediately to the charge nurse and/or responsible physician. Based on the expected knowledge that early intervention is key, the nursing standard of care would be to notify the physician immediately, provide an accurate clinical picture of patient status, request a ‘hands-on’ assessment of the patient. If the physician does not respond promptly to the request for assessment, the nurse may be required to raise the level of concern, act in the best interest of the patient and persist in finding appropriate medical attention. This may require repeated pages/phone calls to the physician, refusing to take doctors’ orders over the phone, notifying the nursing supervisor or accessing the appropriate chain of command.

 

Chris Rokosh is a popular speaker on medical legal issues in nursing across Canada and the U.S. She is an RN and founder of Connect Medical Legal Experts, a Calgary-based leader in Expert Witness Services, with a database of hundreds of medical, nursing and cost of future care experts across the country. Explore this website for more information on courses and books on Legal Issues in Nursing and the role of the Legal Nurse Consultant.

Case Outcome 3

Do you think the nurses met the standard of care?

Anaphylaxis is a serious, potentially life-threatening allergic response that is marked by swelling, hives, decreased blood pressure and dilated blood vessels. In severe cases, the patient can go into shock which can be fatal. Anaphylaxis occurs when the immune system develops a specific allergen fighting antibody (called immunoglobulin E or IGE) that initiates an exaggerated response in the body. When exposed to the substance later, the body can produce a large amount of histamine which leads to the development of the symptoms above. It may begin with itching of the eyes and face then progress, within minutes, to difficulty breathing and swallowing, abdominal pain, vomiting, diarrhea and hives. Medications are known causes of anaphylaxis.

Ancef or Cefazolin is a cephalosporin antibiotic used to treat many types of bacterial infections. Although it is in a different class of drugs from Penicillin, cross-sensitivity reactions can occur in up to 10% of patients. Caution and careful observation are advised when administering Ancef to a patient with a Penicillin allergy. If any signs of an allergic reaction occur, the nursing plan of care includes immediate discontinuation of the Ancef and notification of the physician. The physician may then order epinephrine and other emergency measures such as Oxygen, IV fluids, IV antihistamines, Steroids, Blood pressure medications and airway management.

The lawyer hired a nursing expert to review the medical records and provide opinion on whether or not Nurse Belinda and Nurse Winnie breached the standard of care. The nursing expert emphasized that medication administration is so much more than a task to be completed. It requires critical thinking, skill and nursing knowledge. She further stated that nurses must be knowledgeable of the actions, side effects and contraindications of all medications they administer. She stated that Penicillin and Ancef are two commonly administered medications in the hospital setting, so it was expected that Nurse Belinda and Nurse Winnie would be knowledgeable of their potential for cross reaction.

Based on this, the nursing expert determined that the nurses failed to meet the standard in three areas; failing to question the physician for ordering Ancef, administering Ancef to a patient with a serious Penicillin allergy without providing careful monitoring and failing to intervene to signs of an allergic reaction shortly after 1:00 a.m. when Elizabeth was rubbing her eyes and scratching her arms. All of the experts who reviewed the case stated that nursing and medical intervention at 1:00 a.m. would have most likely prevented Elizabeth’s death.

When the nurses were asked if they know of the potential for cross reaction, they responded that they did not. They said that because the doctor knew of Elizabeth’s Penicillin allergy, and ordered Ancef anyway, they assumed that it was safe to give. They were simply following doctors’ orders. Their lack of knowledge coupled with the failure to recognize and respond to early signs of an allergic reaction provided little defense in the lawsuit. This case settled out of court. Both Nurse Belinda and Nurse Winnie were disciplined by their professional body, required to take a course in safe medication administration and undergo a period of supervised practice.

Use this case study to spark a conversation about medication administration with your colleagues. Do you think the doctor was also responsible for this medication error? What are your thoughts on one nurse administering a medication that another nurse has prepared? How would you rate the safety of medication administration in your workplace? Have you ever witnessed or made a medication error? Did the patient suffer as a result? What is the process for reporting a medication error in your workplace? Does the process allow for open discussion, learning and improvement? If not, what can you do to promote safer medication practices? What will you do differently now that you know what you know? Want to learn more? Watch for one more article coming up!

This article was written by Chris Rokosh RN, PNC(C), Legal Nurse Consultant and president of Connect Medical Legal Expert. Chris is a popular speaker on legal issues in nursing across Canada and the US. If you want to learn more about this topic, go to the website www.ConnectMLX.com for a list of available courses.

Case Outcome 2

Do you think that Nurse Amy met the standard of care?

Pancreatitis is an inflammation of the pancreas, the large gland behind the stomach that is responsible for the release of digestive enzymes into the small intestine and the release of insulin or glucagon into the bloodstream. Pancreatic inflammation happens when the digestive enzymes are activated before they are released into the intestine and begin attacking the pancreas itself. The most common causes are gall stones and chronic alcohol use. There are two forms of pancreatitis: acute and chronic. Acute pancreatitis affects approximately one per cent of the population (Lam and Lombard, 1999) and about 70 per cent of attacks are mild. However, of those individuals who develop severe forms of the disease, one in four will die (Forrest et al, 1995).

The main symptom of pancreatitis is a sudden onset of abdominal pain in the epigastric region that may radiate to the back and be associated with nausea and vomiting (Alexander et al, 2000). A serum amylase more than four times the upper limit is diagnostic of pancreatitis. Physically, the patient may appear acutely unwell with signs of shock, abdominal tenderness and guarding or rigidity (Henry and Thompson, 2001). The nursing plan of care includes the administration of analgesia, antibiotics and anti-nausea medications, IV fluids, accurate measurement of intake and output and regular observation of vital signs. In the acute stage it may be necessary to take the patient’s blood pressure, pulse, temperature and respirations every hour and respond to the results accordingly. Signs and symptoms of septic or hypovolemic shock, such as falling BP, rising pulse, lack of urinary output and decreased temperature, must be reported immediately due to the risk of injury to the patient.

The lawyer representing Margaret in this lawsuit retained a nursing expert to review the medical records and determine whether or not Nurse Amy had met the standard of care. The reviewing nurse discovered that, at 10:20 p.m., Nurse Amy had drawn a small downward arrow next to the blood pressure and a small upward arrow beside the pulse on the graphic record. This indicated that Nurse Amy recognized that the blood pressure had fallen and that the pulse had risen, yet she had failed to reassess the vital signs until nearly 8 hours later. When Nurse Amy was asked why she didn’t reassess Margaret’s vital signs, she referred to the doctors’ orders which said to monitor vital signs as per protocol and the unit policy which said to assess vital signs QID. She said that Margaret had looked tired and unwell at 10:20 p.m. and said that it was important for her to get some rest. She also said that she had never looked after a patient with pancreatitis.

The nurse expert responded that hospital polices provide minimum guidelines for assessment and that doctors’ orders can only be altered if the doctor is made aware of a change in the patient’s condition. She also said that regardless of Nurse Amy’s inexperience with pancreatitis, it is the expected knowledge of all nurses that unstable vital signs in an acutely ill patient can indicate impending decompensation. The nurse expert stated that patients can present as stable, but very quickly become unstable; that there are no hospital policies or doctors’ order that can adequately cover all of the emergency situations that develop on medical units. For that reason, nurses are required to use critical thinking in situations involving the risk of injury and to assess patients more frequently based on their clinical condition. She confirmed that a nurse does not need a doctors’ order or change in hospital policy to assess vital signs more frequently than ordered. Her opinion was that Nurse Amy failed to meet the standard of care by not revising the plan of care to include reassessment of Margaret’s vital signs within 15 to 30 minutes and urgent communication with the charge nurse or the doctor no later than 10:30 p.m. This case settled out of court for an undisclosed amount of money.

Use this case study to spark a conversation on nursing assessment with your colleagues. Note any similarities between this case and the Kolesar vs. Jeffries judgement which sparked the ‘nothing written, nothing done’ saying we’re all so familiar with. Were you able to identify issues with both communication and assessment? How would you rate the level of nursing assessments in your workplace? Have you ever witnessed, or been part of a situation, where a lack of assessment caused a problem? Did the patient suffer as a result? What currently guides your patient assessments? Is it doctors’ orders, hospital policy, what the charge nurse says, the ‘culture’ on your unit or the patient’s clinical condition? What will you do differently now that you know the outcome of this case? Want to learn more? Watch for more articles coming up!

 

Chris Rokosh is a popular speaker on medical legal issues in nursing across Canada and the U.S. She is an RN and founder of Connect Medical Legal Experts, a Calgary-based leader in Expert Witness Services, with a database of hundreds of medical, nursing and cost of future care experts across the country. Explore this website for more information on courses and books on Legal Issues in Nursing and the role of the Legal Nurse Consultant.

Case Outcome 4

Do you think the nurses met the standard of care?

As nurses, we have a significant role to play in infection control. Washing hands, cleaning the environment and sterilizing equipment are proven to prevent infections and prevent patients from harm. The lawyer hired a nursing expert to review the medical records and provide opinion on whether or not the nurses breached the standard of care. The expert opined that infection control is one of the most basic of nursing skills and that nurses are required to recognize and respond to signs of infection. The expert further stated that it was part of the expected knowledge for all surgical nurses that post op patients are at risk for infection, and that early recognition and intervention to infection is a key to avoiding injury. The expert concluded that the nurses failed to monitor Steve’s condition appropriately, failed to recognize well-known signs of infection and failed to communicate important information to the physician. You may notice that this case involves elements of two other litigation issues discussed in previous articles; assessment and communication.

Now let’s talk about equipment errors. Medical equipment includes IV pumps, BP monitors, PCA pumps, cautery equipment and even beds, wheelchairs and lifts. Injuries can happen when the equipment is either not used properly (such as when an IV pump is programmed to deliver too much or too little fluid or medication) or when information obtained from the equipment is not interpreted properly (such as when the temperature gauge in a bathtub is ignored). Both nurses and their employers have a key role to play in the safe use of equipment. Nurses must apply skill and knowledge and employers have a responsibility to train and support nurses on the equipment they provide to nurses.

For a case study on equipment errors please watch the powerful and thought provoking video titled ‘Transparency, Compassion and Truth in Medical Errors which you can find here: https://www.youtube.com/watch?v=qmaY9DEzBzI. This video, about a child who died when the nurse turned off the alarms on a cardio/respiratory monitor, addresses this issue better than I ever could in this article. Use it to refocus your commitment to protecting patients from harm.

Use this article and video to spark a conversation with your colleagues about infection control. What are your thoughts on Steve’s case? Have you ever overlooked or downplayed potential signs of infection? Did the patient suffer as a result? Do you perform hand hygiene as often as you should? Have you ever wrongly used medical equipment or felt unsure about how to interpret the information you received? Are you well trained on the medical equipment that you use every day? If not, what can you do to advocate for more education? What will you do differently now that you know what you know?

This article was written by Chris Rokosh RN, PNC(C), Legal Nurse Consultant and president of Connect Medical Legal Expert. Chris is a popular speaker on legal issues in nursing across Canada and the US. If you want to learn more about this topic, go to the website www.ConnectMLX.com for a list of available courses.

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