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.
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.