Why time-dependent treatments increase your risk of being sued
If a stroke patient arrives within four and one-half hours of symptom onset, this means two things. One, your patient could be saved from a devastating disability if he or she is a candidate for treatment with thrombolytics. On the other hand, however, you could end up getting sued for delaying care.
"In my 19 years as an emergency department expert witness, I have seen many cases involving a delay in care at the front end. Many involve undertriage of the patient's acuity," says Christine Macaulay, RN, MSN, CEN, nursing practice and safety specialist at The Children's Hospital of Philadelphia. "Nurses don't always appreciate the patient's presenting problem. That's the largest trend I see."
Macaulay adds that "any delay at the front end can cause a lost opportunity to treat within the standard window of time for drug administration." Other time-dependent treatments include antibiotics, and transfers to a higher-acuity facility or the catheterization laboratory for immediate intervention.
Elisabeth Ridgely, RN, LNCC, a Telford, PA-based emergency nurse and legal nurse consultant, says, "It is standard of care now for the triage nurse to evaluate, assess and perform some type of intervention in a matter of minutes."
Debra A. Gray, RN, MSN, LNC, principal of Gray's Analysis, a Beaverton, OR, legal nurse consulting company, says to remain up to date on time-sensitive treatments for diagnoses such as stroke, leaking abdominal aortic aneurysm, acute myocardial infarction, tension pneumothorax, compartment syndrome, vascular occlusion, meningitis, all shock states, eclampsia, hyperkalemia with EKG changes, and airway compromise.
Chris DeMeo, JD, a health care attorney with New Orleans-based McGlinchey Stafford says that in addition, "[p]rotocols for cardiac and other conditions put the burden on the nurse to initiate lab tests and other work-up." If these protocols are not followed and an adverse outcome results, the ED nurse could be named in a lawsuit. For example, when an ED nurse failed to accurately assess a patient's chest pain as cardiac, and the patient arrested and died, a lawsuit resulted in a September 2007 verdict of $1.9 million against the nurse, physician, and hospital.
The patient was seen three days prior and diagnosed with acid reflux, says Teri J. Cox, RN, MS, CLNC, president and owner of Point Pleasant, NJ-based TCK Consulting, a legal nurse consulting firm and former director of emergency services at Bellevue Hospital/New York University Medical Center in New York City. "When the patient called and spoke to the same nurse [with the same complaint], the ED nurse said to take Mylanta and didn't advise the patient to come into the ER for a repeat EKG and stress test," she recalls.
Gray says cases such as this one underscore that "one of the most common reasons for lawsuits against emergency nurses is delay in assessment and treatment. Things change fast in the ED. Your priorities are constantly changing as a result."
Immediate intervention is needed
If a physician fails to act in the face of compelling evidence, report this incident to your supervisor.
"If no action is taken, go higher," says Cox. "Follow the chain of command. It may cost you your job, but if you fail to do this, it could cost you your license."
Ridgely says, "I have testified in cases in which patients were not seen for hours after triage, despite complaints of chest pain, who succumbed to their illness in the waiting room because there was no immediate intervention."
She also has reviewed cases involving patients who presented with a severe headache or stroke symptoms and didn't receive thrombolytics, despite being within the window of opportunity to treat, and went on to have a stroke, and patients with chills and fever who weren't given antibiotics immediately who ended up with sepsis.
"A large number of these cases find fault with the nursing care, not for failure to treat, which is not necessarily the nurse's function, but rather for failure to recognize the urgency of the patient's complaint or presenting signs and symptoms and to seek immediate intervention," says Ridgely.
If a lawsuit alleges delayed care that resulted in a patient being outside the treatment window for thrombolytics, the ED nurse wouldn't be named because he or she didn't administer the drug, says Ridgley. Instead, the nurse would be named because she failed to recognize the urgency of the situation, get the patient a CT scan to rule out a bleed, or implement proper protocol for thrombolytic administration. "Nurses are named in a lawsuit because of specific deviations in the standard of care for nurses," she points out.
Do these 4 things to reduce your risks Elisabeth Ridgely, RN, LNCC, a Telford, PA-based emergency nurse and legal nurse consultant, recommends these four practices to reduce risk of being named in a lawsuit alleging delayed care:
"There is nothing wrong with asking your nursing supervisor, manager, or even the ED physician if you have a question about the patient's care," says Ridgely. Document and time not only patient interactions, but physician interactions as well. "It is important to document what you do for the patient, who you talked to, and what was said," says Ridgely. "This will help the nurse to protect herself should litigation arise. Problems arise when the information documented is not complete." There is no way that you will remember giving an antibiotic if called to testify about it months or years later, she underscores. "Your documentation preserves the record and the events of the shift," Ridgely says. "Read what you wrote, and see if it provides a clear picture of your care. If it does, you should be able to defend your actions without a problem." |
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