360 likes | 370 Vues
DO no harm: legal potpourri for neonatal nurses. Amy J. Jnah, DNP, APRN, NNP-BC. disclosures. Relevant financial relationships Director for the Center for Neonatal Nursing Education, LLC Paid medical malpractice expert witness. Learning objective. Medical liability.
E N D
DO no harm: legal potpourri for neonatal nurses Amy J. Jnah, DNP, APRN, NNP-BC
disclosures Relevant financial relationships • Director for the Center for Neonatal Nursing Education, LLC • Paid medical malpractice expert witness
Medical liability American Medical Association Liability Report • 95 liability claims filed (per 100 MDs) • 61% of all MDs have been named in a lawsuit • Defendant prevailed in 90% of all cases National Practitioner (APRN/RN) Data Bank Liability Report (2003-2013) • *1,458 APRNs named in a suit (FL highest) • *100,709 claims against RNs (NJ highest) • Defendant prevailed (indemnity payment made) in 3.7% of all cases *Increasing trends! Indemnity payment – Monies paid on behalf of an insured nurse in the settlement or judgment of a claim.
Why the increase in lawsuits against nurses? • Increased complexity of responsibility • Higher standards of care • Increased patient/family expectations (and pressure for higher satisfaction scores) • Increased patient load • Litigious society
“CARDIOPULMONARY RESUSCITATION ON TELEVISION: Miracles & Misinformation” TV influence Diem SJ, Lantos JD, Tulsky JA. Cardiopulmonary Resuscitation on Television — Miracles and Misinformation. The New England Journal of Medicine. 1996;334:1578-1582.
Malpractice & neonatology“we are special” Challenges: • Diagnostic errors (albeit unintentional) can cause life-long (and severe) injuries • Lifetime medical costs associated with injuries are HUGE • Juries sympathize with parents/families
Malpractice & neonatology“we are special” Challenges: • Cannot obtain patient history (from the baby) and sometimes from the mother • “Last Minute” calls to attend deliveries or emergencies and no verbal sign-out • No time to establish trusting relationship with family (often unexpected “code pink” call to delivery room) • Prolonged hospitalization = parental stress/fatigue, mistrust • Most meds we give babies are NOT approved by the FDA for use in NICUs • Most meds we give babies are intended for adult use (10-fold risk for error) – weight adjustment issues • Statute of Limitations is LONG (we often forget details and have to rely on charting come time for deposition, but the family definitely does not forget details)
Indemnity payments https://aonaffinity-blob-cdn.azureedge.net/affinitytemplate-dev/media/nso/images/documents/cna-nurse-claim-report-101615.pdf
Severity by allegation https://aonaffinity-blob-cdn.azureedge.net/affinitytemplate-dev/media/nso/images/documents/cna-nurse-claim-report-101615.pdf
Patient assessment • Failure to assess the NEED for medical intervention (60.5%) • Failure to properly or fully complete the patient assessment (19.8%) • Failure to consider/assess patient symptoms (11.6%) • Failure to reassess patient after a change of status (4.7%) • Delayed/untimely patient assessment (3.5%)
Patient monitoring • Failure to monitor/report changes in patient’s condition (in ICUs) (52.6%) • Failure to monitor/report changes in patient’s medical condition to the practitioner (21.1%) • Failure to monitor/report vital signs in timely manner (11.8%) • Failure to monitor/report blood levels for medications in timely manner (11.8%) • Failure to monitor results of ordered tests/consults/referrals or report to the practitioner (2.6%) https://aonaffinity-blob-cdn.azureedge.net/affinitytemplate-dev/media/nso/images/documents/cna-nurse-claim-report-101615.pdf
Treatment & care https://aonaffinity-blob-cdn.azureedge.net/affinitytemplate-dev/media/nso/images/documents/cna-nurse-claim-report-101615.pdf
Medication administration https://aonaffinity-blob-cdn.azureedge.net/affinitytemplate-dev/media/nso/images/documents/cna-nurse-claim-report-101615.pdf
Type of injury https://aonaffinity-blob-cdn.azureedge.net/affinitytemplate-dev/media/nso/images/documents/cna-nurse-claim-report-101615.pdf
Statute of limitations & Minor children • Definition: deadline for filing a personal injury claim • Unique to each State • North Carolina = 3 years after the child’s 18th Birthday
Litigation hot spots (neonatology) • NRP • Hyperbilirubinemia • Hypoglycemia • Sepsis • The Late Preterm (LPT) Infant • Neonatal Safety
NRP • Issues related to neonatal resuscitation may include the following: • Failure to provide appropriate neonatal resuscitation, including timely chest compressions. • Failure to use appropriate and necessary resuscitation equipment. • Failure to demonstrate adequate specialty knowledge and competency.
Hyperbilirubinemia Issues related to hyperbilirubinemia may include the following: • Failure to consult with the physician regarding an increased transcutaneous bilirubin or physical assessment. • Failure to recognize risk factors associated with hyperbilirubinemia. • Failure to document physical assessment, laboratory values, and teaching.
hypoglycemia Issues related to hypoglycemia may include the following: • Failure to recognize the at-risk infant • Failure to initiate glucose monitoring in a timely manner • Failure to properly hydrate infant who is at-risk or clinically hypoglycemic • Failure to monitor before and after treatments for hypoglycemia • Failure to reassess infant after interventions • Failure to administer the correct dose of glucose bolus
sepsis Issues related to sepsis may include the following: • Failure to recognize infant’s change in status • Failure to document change in infant status • Failure to consult with appropriate provider regarding change in infant status • Failure to reassess infant in a timely manner
Neonatal safety • Patient handling errors • Patient advocacy • Patient monitoring and communication errors • Medication and transfusion errors • Failure to monitor • Medication errors
Protect yourself • Document contemporaneously • Maintain record of continuing education (do not stagnate) • Communicate frequently with neonatal team and & document conversations in EMR • Do not “notify and tune out” – advocate, use chain of command, think for yourself! • Disclose mistakes (Just Culture) and apologize • Avoid paternalism – transparency with parents is VERY IMPORTANT …for not suing me
Did I mention documentation? • Observations, complaints, conversations or concerns AND instructions given to parents • Sensory method used when assessing an infant • Changes in infant’s condition AND intervention • Utilization/activation of the chain of command • Don’t write “MD/APRN notified” (need to state what happened, why, when, and what action you took as the RN)
Case study • Baby Ryan is a term (40 week EGA) infant delivered vaginally. At the time of birth, mother was a 27-year-old G1P4. • Mother’s blood type was A negative, and her other prenatal lab results included Hep B negative, RPR nonreactive, HIV negative, GBS negative, Rubella immune. • Labor was electively induced, with ROM approximately 85 minutes prior to delivery of a viable male infant. The vaginal delivery was uncomplicated. • Baby Ryan weighed 6lbs 12oz at birth (3016 grams—27%tile), head circumference 34.3cm (26%tile), length 50.2cm (59%tile). Per the WHO chart for growth, Ryan was of appropriate size for gestational age (AGA). • Ryan’s blood type was recorded as A negative, Coombs negative.
Case study • The first 24-hours of Ryan’s hospitalization proceeded normally. • Ryan was breast feeding and supplementing with formula, per mother’s wishes. • Ryan was voiding and stooling. • As is routine and customary, Ryan was weighed at 24-hours of life, and additional screening tests and lab work was obtained. Ryan weighed 2990 grams (2.3% below birth weight) and Ryan’s total serum bilirubin (TSB) at 24hrs of life was 8.7mg/dL and direct bilirubin = 0.3mg/dL.
Case study • A repeat TSB was ordered for 30 hours of life. • The TSB level at 30 hours of life was 9.5mg/dL. • Ryan was thereby discharged to home with his parents, at approximately 7:30pm on Friday 9/13/2019. • Discharge instructions: follow-up on Saturday 9/14/2019 in the hospital emergency room, for repeat TSB.
Case study • On Saturday 9/14/2019, the family returned to the emergency room, as directed. • Ryan’s TSB level at that time, (55 hours of life) was 14.4mg/dL. • The NNP on duty, and a neonatal RN, were called to the emergency room to see the patient and interpret lab results. The NNP subsequently discharged Ryan to home with an order for outpatient pediatric follow-up on Monday 9/16/2019 (48hrs later) for repeat TSB testing. • The neonatal RN executed the discharge, as ordered.
Case study • On Monday 9/16/2019, Ryan’s parents reported to the pediatrician as recommended. • Dr. DoNoHarm noted that Ryan was visibly jaundiced (skin and eyes) and ordered a TSB level to be obtained and analyzed by LabCorp, in a nearby office. • The repeat TsB was obtained at 103 hours of life, with an order for routine processing.
Case study • The TsB was analyzed on Tuesday 9/17/2019. Result = 31.8 mg/dL • Dr. DoNoHarm was thereby notified and called the parents. Ryan was subsequently directly admitted to the nearby hospital for intensive phototherapy and management of severe neonatal hyperbilirubinemia. • Ryan’s TSB at 126 hours of life, while receiving intensive phototherapy, rose to 38.9mg/dL. • Ryan demonstrated clinical manifestations consistent with acute bilirubin encephalopathy including progressive neurologic irritability, opisthotonos, posturing, and decerebrate movements of the right arm. • On 9/18/2019, Ryan’s TSB rose to 41.9mg/dL (direct bilirubin 3mg/dL); on that same date, a single copy of the allele-allele G6PD X-linked gene was identified. • Subsequent management included two (2) double volume exchange transfusions, the administration of IVIG, albumin, and phenobarbital for suspected seizures.
case study • Identify Risk Factors • Assign Neurotoxicity Risk Category • Assess phototherapy threshold • Assign hour-specific risk category for severe hyperbilirubinemia • Determine “when” the bilirubin level should be repeated • Compare your information to what was done • Determine if there were breaches in the standard of practice
Breaches in the standard of care • Ryan’s TsB at 24 hours of life was 8.7mg/dL, which was at the ≥95th percentile (high-risk zone). • Ryan’s TsB at 30 hours of life increased to 9.5mg/dL, again at the 95th percentile (high-risk zone). • Ryan’s TsB at 55 hours of life was 14.4mg/dL, which was at the 95th percentile (high-risk zone). His phototherapy treatment threshold at that time was a TsB ≥15.9mg/dL.
Thank you! Contact me: CFNNEducation@gmail.com or APNConsult@gmail.com