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.