Nurses play as much of a role in OB patient safety as physicians, notes Jennifer Flynn, CPHRM, manager at Aon Affinity Healthcare Risk Management. Nurses are perceived as highly skilled and educated professionals who are charged with making clinical observations, exercising discretion, and taking appropriate treatment actions based on a patient’s changing clinical picture, she notes.
During labor and delivery, nurses working in this specialty area and involved in the birth are responsible for using professional judgment during treatment to ensure that the process goes as smoothly as possible, she says. One of the ways nurses can do this is by properly monitoring patients, timely reporting changes in the patient’s condition, and taking appropriate actions when signs of distress are present.
Flynn notes the following case illustrating the important role of nurses:
A 38-year-old patient was admitted for a cesarean delivery of twins. The babies were delivered without incident, but the patient experienced excessive postoperative vaginal bleeding attributed to placenta accreta. An emergency total abdominal hysterectomy was performed to control the bleeding. After surgery, the patient, who appeared stable, was transferred to the ICU with blood pressure of 110/60 mmHg. The receiving ICU nurse had orders to transfuse the patient with two units of fresh frozen plasma and monitor vital signs every 30 minutes.
After the first unit of plasma was given, the patient’s blood pressure was 108/59 mmHg. She was assessed by the attending ICU practitioner, who ordered a complete blood count to be conducted after the second unit of fresh frozen plasma. The ICU practitioner noted that the patient’s post-surgical hemoglobin and hematocrit levels were 7.4 gm/dL and 22%, respectively. However, one hour after the second unit of plasma was given, the patient’s hemoglobin was 5.9 gm/dL, and hematocrit was 17.7%.
The nurse documented the results in the health record but did not notify the ICU practitioner because he assumed the practitioner was returning to the unit to reassess the patient. Two hours after the second unit of plasma, the patient’s blood pressure was reported as 63/21 mmHg. The nurse notified the on-call resident of the blood pressure and received an order for stat transfusion of two units of packed red blood cells. The blood bank records indicated that the blood was available 20 minutes after stat order was received.
One hour later, upon arrival of the oncoming shift, the ICU nurse reported to the oncoming nurse that the blood had still not been delivered. Even though both nurses were concerned about the situation, neither nurse called to ascertain the blood’s location. Fifteen minutes into the oncoming nurse’s shift, the administration of one unit of packed red blood cells was started. While the blood was transfusing, the patient went into respiratory distress, and the admitting ICU practitioner was notified.
Later that evening, the patient underwent a second abdominal surgery. Due to her extensive hypovolemia, she slipped into a coma postoperatively and currently remains in a vegetative state.
“During deposition, the admitting ICU practitioner testified that he was not informed of the second laboratory results or the patient’s vital signs until the patient went into respiratory distress,” Flynn says. “The claim asserted against our insured nurse settled for greater than $600,000.”
Several other healthcare practitioners also were included in the lawsuit, but their settlement amounts were not available.
Nurses are perceived as highly skilled and educated professionals who are charged with making clinical observations, exercising discretion, and taking appropriate treatment actions based on a patient’s changing clinical picture.
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