News: A patient was admitted to the hospital with abdominal pain. She was diagnosed with appendicitis and underwent surgery. While recovering in the hospital, the patient died.
The patient’s survivors sued the hospital for wrongful death predicated on medical malpractice based on hospital nurses’ failure to adequately assess the patient’s risk for deep vein thrombosis (DVT), failure to appropriately use the sequential compression devices ordered by the physician, failure to administer a preoperative dose of heparin, and the surgeon’s alleged failure to provide adequate DVT prophylaxis care. The lower court granted hospital’s motion for summary judgment, and the patient’s survivors appealed.
Background: A 60-year-old woman complaining of abdominal pain was admitted to a hospital, where she was diagnosed with perforated appendicitis with abscess formation. She was scheduled to undergo surgery the following morning. The diagnosing physician performed a preoperative venous thromboembolism (VTE) or DVT risk assessment using the Caprini score, on which the patient recorded a 4. The next day, the patient underwent a diagnostic laparoscopy, an open appendectomy, and an open drainage of intra-abdominal abscess, all performed by the same diagnosing physician. The physician ordered preoperative heparin to reduce the risk of DVT and blood clots that can form at induction and/or maintenance of anesthesia. The physician learned much later that no one followed his order to give heparin.
The physician ordered the nurses to assist the patient with ambulation and to increase her activity to prevent DVT or VTE. The physician also ordered sequential compression devices (SCDs) to be placed and functioning by the time of surgery and to stay on through patient’s hospitalization. The nurses were ordered to assure the SCDs were on and operating at all times the patient was in bed or in a chair. However, the nursing notes confirm the SCDs were not used as ordered by the physician, particularly in the last several days of the patient’s life.
On Sept. 25, 2014, four days after surgery, the patient developed an intra-abdominal abscess, which was drained in a second procedure. The physician testified a patient’s risk assessment can change daily and he re-evaluated patient daily, except for Sept. 26-28, when another surgeon covered for him. According to the patient’s daughter, while she was staying with her mother in the hospital Sept. 27- 29, the patient complained her legs, calves, and feet were hurting. The daughter relayed this information to nursing staff but there is no evidence it was passed on to a physician. On the morning of Oct. 2, 2014, the patient developed acute respiratory distress and medical staff struggled to intubate. She was transferred to the ICU, where she coded and could not be resuscitated. The physician’s notes from the discharge summary indicated no confirmed, definitive cause of death was determined, and family refused autopsy. The death certificate indicated the immediate cause of death as cardiac arrest due to respiratory failure. It listed other significant conditions contributing to death, such as pneumonia, obesity, and perforated appendicitis history. The physician could not confirm a pulmonary embolism caused the patient’s death.
The plaintiffs filed a medical malpractice/wrongful death lawsuit, alleging the hospital’s nursing staff deviated from the standard of care by failing to appropriately evaluate the patient’s thrombosis risk following her surgery to ensure she received necessary anticoagulants, proximately causing the patient’s death. The hospital moved for summary judgment, alleging the plaintiffs could not establish the nurses’ conduct was the proximate cause of patient’s death since the plaintiffs’ expert admitted even if the nurses had properly or more consistently used the SCDs, this may not have prevented a pulmonary embolism or death. The trial court granted the motion, concluding the plaintiffs failed to present sufficient evidence of causation as to the nurses. The Georgia Court of Appeals reversed the trial court’s decision, noting the plaintiffs’ evidence created a jury issue as to whether the nurses breached the standard of care by failing to report patient’s leg pain to a physician.
What this means to you: This case highlights the importance of communication. In this case, a lack of communication was the material issue that prevented the defendant from adjudicating its liability. Clearly, the case shows the importance of communication between physicians and supporting medical staff. Despite the nursing staff failing to follow the doctor’s orders to preoperatively administer heparin, provide SCDs, and encourage ambulation, the appellate court noted the staff’s failure to disclose the patient’s pain. None of the other factors, either alone or collectively, sufficed to overturn the summary judgment. The failure to relay patient’s complaints of pain to the physician proved fatal and was sufficient to overturn the lower court’s decision.
Additionally, the case highlights the importance of communication between the patient and medical professionals. It is imperative that hospitals instruct their employees to not take lightly any comments or complaints that can be interpreted as symptoms of a medical condition. In addition, medical professionals should be trained and encouraged to follow up on any such comments or complaints. All this information should be clearly documented. Litigation inherently relies on evidence, and failure to document not only the concerns but also the follow-up actions taken will prevent any defendant from summarily adjudicating any claims against them. In turn, this weakens negotiating power and undoubtedly will result in either higher settlement amounts or exorbitant litigation costs.
Note many risk management principles were overlooked by nurses and physicians involved in this case. Every nurse learns in his or her first year of study that if it is not documented, it did not happen. The second lesson involves the nurses’ requirement to follow every physician’s order completely and accurately. If the order is not followed, document to whom and when notification was made the order was not followed. Additionally, the nurse is required to document the patient’s response to treatments, medications, and other interventions ordered by the physician. Lastly — and just as importantly — the nurse is mandated to report patient and family concerns, complaints, and questions. The urgent, unexpected, unusual, or concerning issues should be reported to the physician and all calls and responses documented. Any nurse who has participated in a deposition learns these principles the hard way. However, adherence can lower litigation costs and, more importantly, prevent harm to patients.
Moreover, this case highlights the importance of the tension between independent medical providers and employed medical support staff. In this case, the physician clearly ordered the nursing staff not to administer heparin postoperatively. If the nursing staff had relayed the complaints of leg pain, the physician alleged he would have subsequently ordered heparin. While providers and support staff work shoulder to shoulder, they can be on opposite sides in litigation — especially when negligence is alleged. It is important for hospitals to encourage and incentivize employed medical staff to adhere to policies to protect the entity in the event of litigation, even when it is pragmatically inefficient.
One final interesting takeaway from this case is the autopsy report. Although an autopsy report might have prevented this litigation entirely (if, for instance, the cause of death was unrelated to the symptoms or conditions for which the patient was receiving care), the hospital had no say in whether one was conducted. The unilateral discretion of a decedent’s survivors on whether to conduct an autopsy only magnifies the importance of the communication and documentation considerations discussed.
REFERENCE
- Decided Sept. 2, 2022, in the Court of Appeals of Georgia, Case Number A22A0990.
This case highlights the importance of communication. In this case, a lack of communication was the material issue that prevented the defendant from adjudicating its liability.
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