By Stacey Kusterbeck
Nurses usually are not the central focus when experts are analyzing ED malpractice claims. “Our experience is generally that physicians and hospitals get sued more than nurses,” says Maryann Small, MBA, senior director of risk management and analytics for Coverys.
In light of the COVID-19 pandemic and the nursing shortage, Small and colleagues started wondering how those crises would affect malpractice claims. “It’s too soon to fully evaluate the impact, since malpractice claims can take several years to be adjudicated. But the data on what’s currently happening with nursing claims shed light on where future claims might occur,” Small suggests.
Coverys, a medical professional liability insurer, analyzed 4,634 claims that closed from 2018-2021.1 In those claims, nurses were directly involved in 850 of the alleged medical errors. Nursing events accounted for 26% of payouts.
“ED teams can take the Coverys report and have internal conversations about the insights that risk managers can take from the data,” says Small, one of the report’s authors.
By the time a plaintiff files a malpractice claim, months or even years have passed since the visit in question. However, says Small, “these hypotheses can show vulnerabilities that might still exist today.”
Eighteen percent of the nursing-related malpractice claims involved ED nurses. “The ED is fast-paced, and all the patients are new,” notes report author Susan Montminy, EdD, MPA, BSN, RN, CPHRM, CPPS, Coverys’ director of risk management.
There is no time to build relationships with patients. Acute conditions are undiagnosed, there is plenty of distraction, and patients often cannot communicate due to severe pain or cognitive issues. “A higher risk exists because of this type of environment,” Montminy says.
Treatment delays, and delayed transport from the ED to surgery, also came up in nursing-related claims. In one claim, the patient was discharged home before lab results returned. Another case involved inappropriate triage resulting in a patient fall in the waiting room. “Building strong teams and communicating throughout the entire care team is a way to avoid some of the delays,” Small says.
Overall, the ED nursing-related claims showed the importance of teamwork and structured communication. “The ED is one piece of the puzzle. It’s the entry point where the patient is passed through in a timely manner,” Small says.
The authors encouraged leaders to examine how communication happens during handoffs between shifts, among providers, to and from diagnostic testing, admission to inpatient units, and external transfers to rehab and long-term care facilities. “One of the things that jumped out at me were the multiple handoffs that can occur while they’re forming a diagnosis,” Montminy observes. The following are some other common nursing-related issues Coverys discovered:
• Patient monitoring. Forty-nine percent of these events resulted in the patient’s death. “ED monitoring issues were related to falls and medication status,” Montminy reports.
Monitor placement also is important, to ensure vital signs can be seen from multiple locations so nurses can respond quickly. “EDs should consider their layout, and whether there is visibility into individual patient rooms,” Montminy says.
• Patient falls. Adverse events included hemorrhages, fractures, and dislocations. Some fall injury claims involved patients who were receiving care in ED hallways. “EDs should consider what visual indicators alert people that the patient is a fall risk,” Montminy says.
• Medication administration errors. Thirty-nine percent of events resulted in patient deaths. Overall, 11% of medication events happened in the ED. For most claims involving opioids, the patient overdosed, resulting in anoxic brain injuries or death. In some cases, the opioids were administered in the ED; in other cases, the patients presented with opioid overdoses. “We had several medication issues that we attributed to nursing involvement,” Small reports.
One such case involved a woman who arrived with a rib fracture and COPD exacerbation. Although cephalexin allergy was documented electronically, the patient was discharged with a handwritten prescription for the medication. The patient collapsed at home after the first dose and was resuscitated, but suffered an anoxic brain injury and died.
The claim underscored the importance of medication reconciliation happening as soon as possible. “EDs should also leverage technology and use all of the safety features in the EHR that can assist with, for example, allergies for antibiotics,” Montminy says.
If ED nurses use those safety features, conduct prompt medication reconciliation, and somehow a provider orders a drug to which the patient is allergic, the safety alert would prevent anyone from carrying out the order. For the decision support to execute its job throughout the hospital stay, medications must be accurately entered in the system. That must happen in the ED. “In some claims, we do see that because the patients came through the ED, the patient might not have an accurate list of medications in the EHR,” Small says.
• Pressure injuries. None of the claims involved the ED specifically. However, pressure injuries often begin during long ED stays. Emergency nurses should be provided with training for pressure injury prevention. Medical equipment such as nasal cannulas and Foley catheters sometimes contribute to pressure injuries.
To prevent harm, ED nurses can reposition the patient at regular intervals, assess the skin under medical equipment, and ensure the skin stays clean and dry. “It’s important that the nurses make sure they are not causing skin breakdowns,” Montminy says.
All nurses receive training on pressure ulcer intervention, but may not focus on it in their actual clinical practice because ED visits typically last hours, not days. “Refresher training for ED nurses is a good idea in light of lengthier patient stays in the ED,” Montminy says.
REFERENCE
1. Hakin MJ, Hanscom R, Icenhower M, et al. A nurse’s critical role in patient safety: Through the lens of malpractice claims. Coverys. Sept. 9, 2022.
In an analysis of more than 4,600 claims, researchers found 18% of nursing-related malpractice claims involved ED nurses. Treatment and transport delays were top complaints, underscoring the importance of teamwork and structured communication.
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