In this blog I’ll be reviewing the difference between rotational and non-rotational maneuvers in the management of a shoulder dystocia. I’ll also discuss the efficacy in relieving the shoulder dystocia, and the risk of brachial plexus injury, comparing both types of maneuvers.
Non-rotational maneuvers: pose the least risk on the degree of stretch on the brachial plexus nerve. Examples include: McRoberts maneuver, suprapubic pressure, and delivery of the poster arm.
According to ACOG, in cases where the McRoberts maneuver and suprapubic pressure are unsuccessful, delivery of the posterior arm can be considered as the next maneuver to manage shoulder dystocia. Recent evidence has shown that delivery of the posterior arm has a high degree of success in accomplishing delivery. In a computer-generated model, delivery of the posterior arm required the least amount of force to effect delivery and resulted in the lowest amount of brachial plexus stretch. The use of the above maneuvers will relieve 95% of cases of shoulder dystocia within 4 minutes.
Below Image (delivery of the posterior arm) requires the delivering provider to insert a hand into the vagina and deliver the posterior arm by sweeping it across the fetal chest
Non-Rotational Maneuver
Rotational maneuvers: Examples include: The Rubin maneuver, the Woods Screw maneuver
The Rubin maneuver requires the delivering provider to insert a hand into the vagina and on the back surface of the posterior fetal shoulder. The provider then rotates the fetal shoulder anteriorly towards the fetal face with his/her hand.
The Woods Screw maneuver requires the delivering provider to rotate the fetus by exerting pressure on the anterior, collar bone region of the posterior shoulder to turn the fetus until the anterior shoulder emerges from behind the maternal symphysis (pubic bone).
Below Image (Rubin Maneuver)
Rotational Maneuver
References:
The American College of Obstetricians and Gynecologists. (2014). Neonatal brachial plexus palsy. ACOG Task Force on Brachial Plexus Palsy
The American College of Obstetricians and Gynecologists. (2017). Shoulder dystocia [Clinical Practice Bulletin #178]
P.S. Comment and Share: What has been your experience in a brachial plexus case involving a shoulder dystocia? How did the standards of care, specific to type of maneuvers, and type of traction employed, impact the outcome of the case?
In this blog, I’ll be reviewing the U.S. maternal morbidity statistics associated with hypertensive disorders of pregnancy. Additionally, I’ll be highlighting the elements of performance, specific to severe hypertension and preeclampsia, Joint Commission accredited hospitals are required to be in compliance with. Lastly, I will offer risk mitigation strategies specific to care delivery, risk assessment, prevention, documentation, consultation, and referral.
Statistics: Hypertensive disorders of pregnancy (chronic hypertension, gestational hypertension, severe hypertensive crisis, preeclampsia, eclampsia, HELLP Syndrome) continue to be the leading cause of maternal and infant death. Preeclampsia specifically, complicates 8% of pregnancies globally. It is estimated that 60% of maternal deaths from preeclampsia may be preventable. In the U.S., hypertensive disorders of pregnancy account for 6.8% of pregnancy related deaths. For women who had a hypertensive disorder of pregnancy cause of death, 12.2% had a stillbirth (fetal demise). Almost all (96.8%) pregnancy related deaths occurred by 42 days postpartum (CDC, 2018).
The Joint Commissions Perinatal Safety Standards: In response to the worsening maternal morbidity and mortality in the U.S. associated with severe hypertension and preeclampsia, The Joint Commission has identified clinical areas of greatest potential impact based on review of maternal mortality reports, and evidence-based practice recommendations.
The literature review performed revealed that prevention, early recognition of signs and symptoms, and timely treatment for severe hypertension, and preeclampsia had the highest impact on maternal, fetal, and neonatal outcomes.
Joint Commission accredited hospitals are now required to conform to the six new elements of performance (EPs) as identified below:
GOAL: PC.06.03.01 – Reduce the likelihood of harm related to maternal severe hypertension/preeclampsia
Requirement EP 1: Develop written evidence-based procedures for measuring and remeasuring blood pressure. These procedures include criteria that identify patients with severely elevated blood pressure.
Rationale: Procedures should address appropriate blood pressure measurement, including cuff size, proper patient positioning, and frequency of measurement. Inaccurate measurement can lead to a mother not receiving proper treatment and being discharged with elevated blood pressure. Untreated hypertension can lead to morbidities or even death. Criteria for what constitutes a severely elevated blood pressure should be established by the organization utilizing current recommendations from national organizations.
Requirement EP 2: Develop written evidence-based procedures for managing pregnant and postpartum patients with severe hypertension/preeclampsia that includes the following:
• The use of an evidence-based set of emergency response medications that are stocked and immediately available on the obstetric unit
• The use of seizure prophylaxis
• Guidance on when to consult additional experts and consider transfer to a higher level of care • Guidance on when to use continuous fetal monitoring
• Guidance on when to consider emergent delivery
• Criteria for when a team debrief is required
Note: The written procedures should be developed by a multidisciplinary team that includes representation from obstetrics, emergency department, anesthesiology, nursing, laboratory, and pharmacy.
Rationale: Studies have shown that delays in the diagnosis and treatment of severe hypertension/preeclampsia and receipt of suboptimal treatment of severe hypertension/preeclampsia are linked with adverse maternal outcomes. Having clear procedures in place and educating staff around these procedures should decrease failures to recognize and treat severe hypertension/preeclampsia
Requirement EP 3: Provide role-specific education to all staff and providers who treat pregnant/ postpartum patients about the hospital’s evidence-based severe hypertension/preeclampsia procedure. At a minimum, education occurs at orientation, whenever changes to the procedure occur, or every two years.
Note: The emergency department is often where patients with symptoms or signs of severe hypertension present for care after delivery. For this reason, education should be provided to staff and providers in emergency departments regardless of the hospital’s ability to provide labor and delivery services.
Rationale: Decreasing the blood pressure through rapid recognition and treatment has been shown to decrease maternal morbidity and mortality. It is imperative to provide education for staff and providers on how to measure accurate blood pressures, recognize severe hypertension/ preeclampsia, and provide evidence-based treatments to lower blood pressure in a safe and timely manner. Although not required, in situ simulations that allow staff to practice organizational procedures in actual clinical settings are encouraged.
Requirement EP 4: Conduct drills at least annually to determine system issues as part of ongoing quality improvement efforts. Severe hypertension/preeclampsia drills include a team debrief.
Rationale: Multidisciplinary drills give an organization the opportunity to practice skills and identify system issues in a controlled environment. It is crucial to have members from as many disciplines as possible available during drills to truly be able to test each level of the emergency and identify areas of improvement. Organizations should assess their level of proficiency to determine the frequency drills should be performed; organizations that have reached a high level of mastery may need less frequent drills.
Requirement EP 5: Review severe hypertension/preeclampsia cases that meet criteria established by the hospital to evaluate the effectiveness of the care, treatment, and services provided to the patient during the event.
Rationale: Continuous feedback loops are imperative for organizations to find errors and improve skills to ensure that patients are receiving the highest level of care. Root cause analysis, apparent-cause analysis, or similar tools to review the care in a rigorous, psychologically safe environment is critical to identify successes and opportunities for improvement in a way that creates a culture of safety and empowers staff to design safe and effective procedures and processes.
Requirement EP 6: Provide printed education to patients (and their families including the designated support person whenever possible). At a minimum, education includes:
• Signs and symptoms of severe hypertension/preeclampsia during hospitalization that alert the patient to seek immediate care
• Signs and symptoms of severe hypertension/preeclampsia after discharge that alert the patient to seek immediate care
• When to schedule a post-discharge follow-up appointment
Rationale: Maternal mortality reviews have shown that some patients with severe hypertension/ preeclampsia due after discharge because they were unaware of which symptoms to watch for and when to seek care urgently. Women should understand their severe hypertension/ preeclampsia diagnosis and inform healthcare providers of their pregnancy history when the seek care after discharge to ensure correct diagnosis and treatment.
How to Mitigate Medicolegal Risk & Increase Defensibility:
Confirm that your organization is conforming to the six elements of performance (EPs) that is now required for Joint Commission accredited hospitals. Become an active provider leader in implementing and educating staff/providers on the above (EPs). Render care according to the above (EPs). Consider implementing re-credentialing requirements to support required simulation drills and debriefings.
Identify women at risk: first pregnancy, new genetic makeup, pregnancy of artificial reproductive technology, multiple pregnancy, gestational diabetes, preexisting medical history: diabetes, chronic hypertension, renal disease, lupus, older maternal age, African American race, obesity, personal or family history of preeclampsia (list is not inclusive)
Document risks, and plan of care for surveillance and prevention strategies in pregnancy within the medical record.
Implement prevention strategies in plan of care, and document in medical record: exercise, low dose aspirin therapy, dietary supplementation
Diagnose and initiate timely management according to evidence-based practice criteria, and organizational policy: document diagnosis and management plan in the medical record.
Consider referral to Maternal Fetal Medicine, or higher level of care delivery based on organizational level of care, and maternal consultation and transfer agreement with Regional Perinatal Center.
Consultation/collaboration: ensure patient assessment is complete within the time frame designated within organizational by-laws, rules and regulations. Ensure timely entry of consultation / progress note as the consulting, or collaborating provider.
References:
Association of Women’s Health, Obstetric, and Neonatal Nurses. 2021.
CDC. 2018. Pregnancy mortality surveillance system
The Joint Commission. 2019. Provision of care, treatment, and services standards for maternal safety. Issue 24
P.S. Comment and Share: Do you have experience with a maternal hypertensive case that resulted in a maternal death. Did this case impact policy, procedure, process, or system changes as a result?
In this blog, I’ll be reviewing Independent Medical Examinations (IME’s): What they are, the role of the IME examiner, and IME nurse observer.
What is an IME: Independent Medical Examinations (IME’s) are medical examinations performed by a qualified physician or other examiner who has not previously treated the injured client. The IME examiner’s goal is to evaluate the injured client’s prior treatment, and the current condition of the injuries reported by the plaintiff. The IME serves as ammunition, a means to challenge claims, lawsuits, and evaluations of injured workers’ treating physicians. IMEs are also referred to as Defense Medical Examinations (DME’s) as the provider examining the client was hired by the defendant’s attorney, or insurance company to defend their side of the case.
IME Examiner: The role of the IME examiner is restricted to examining only what pertains to the event in question, questioning about the nature of the accident, or how the injury occurred. The IME examiner is not permitted to ask questions that would raise liability issues/concerns. E.g., inquiring about cell phone use while driving.
IME Nurse Observer: Legal Nurse Consultants are well qualified to serve as IME observers. LNC’s have the dual nursing, and legal nurse consulting educational background (LNC educational background should be verified by the hiring attorney client), hands-on clinical experiences to support application of knowledge, and skill sets, strong leadership acumen, and effective communication skills. These qualities leverage IME nurse observers favorably to professionally, and diplomatically hold the IME examiner accountable.
Roles of the IME nurse observer:
Educate the client on the IME process, procedures, limitations per the state’s regulations, and case specific court paperwork, as well as office procedures (E.g., evolving Covid-19 safety protocols)
Observe the examination, and take detailed notes during the examination specific to tests performed, client’s response to tests, type of focused assessment performed, completion of comprehensive head to toe assessment, omissions in examination, or tests.
Compile time stamped authoritative reports of all that was said and done during the examination to be compared with the IME examiner’s reports
Be aware of what screening and diagnostic tests are permitted within the IME examiner’s scope of practice, and based on the alleged injury
Object to inappropriate history taking, screening processes, and tests not relevant to the alleged injury
Serve as a client advocate
Testify regarding the examination (E.g., in the event the IME examiner’s report differs from the IME nurse observers report)
Paralegals are at time sent to attend IMEs to act as legal representatives as they are knowledgeable about what is and is not permitted during an IME. However, paralegals cannot testify in the event a discrepancy is identified.
Paralegals do not have the medical training to support a critical IME observation.
The profession of nursing is viewed as the most honest and ethical profession. When nurses serve as testifying experts, they are often viewed honorably by jury members.
Know Your State Codes and Regulations: Review your states Code of Civil Procedure, and regulations. In New York State, for example, the plaintiff is “entitled to be examined in the presence of his or her attorney or other legal, or non-legal representative, as well as interpreter.” Additionally, in NYS, women have the right to have a female IME examiner, or a woman of their choosing present when the IME is performed by a male IME examiner. This section of the NYS Labor Law (Section 206A) is often violated.
Importance of Knowing Basic IME Rules: Failure to comply with the rules and regulations of IMEs can influence the outcome for the client, and the lawsuit.
Know your state’s Code of Civil Procedure as each state has different regulations.
Identify yourself upon entry into the examination room
Observe examination without interference
Refrain from bringing surveillance materials (applicable to NYS) (Know your state’s Code of Civil Procedure as each state has different regulations)
If the IME examiner refuses to allow the IME nurse observer into the examination room, encourage the client to leave the examination location. The IME nurse observer should then follow up with the client’s attorney
Prevent the client from completing unnecessary intake forms that could be misinterpreted. Support the opportunity for relevant intake questions to be asked in the presence of the IME nurse observer to allow for recording
Ensure that the client does not sign documents unless the legal team permits
No member from the defense team should be permitted to attend the IME examination
P.S. Comment and Share: What has been your experience with IMEs? Historically, who have you retained as IME observers? What worked well? What didn’t work well?
When is missed or delayed colorectal cancer (CRC) considered negligence?
In this blog, I’ll be reviewing the elements that are reviewed to identify if a missed, or delayed CRC diagnosis constitutes negligence. I will also provide some examples of breaches in the standards of care specific to missed CRC cases. As a means to promote greater awareness of colorectal health, and CRC awareness, I will also share current statistics, screening recommendations from authoritative sources, risk factors for CRC, and CRC symptoms.
Evaluating your CRC Case for Negligence / Mitigating Risk for Medical Negligence:
Having an awareness of the current standards of care, and rendering care in accordance to current standards of care specific to risk-based screening, and treatment reduces the risk of medical negligence. A missed or delayed diagnosis of CRC is associated with greater morbidity and mortality. Literature suggestions that delays in diagnosis are related to avoidable factors, such as improving the quality of bowel preparation, ensuring further investigations in patients with incomplete endoscopies, and colonoscopies, having endoscopies performed in accredited endoscopy centers, and timely follow up when non-cancer pathology is identified.
Secondary to the fact that 2%-6% of CRC cases are missed following colonoscopy, most professional societies recommend counseling patients about this “miss rate.”
When evaluating a missed CRC diagnosis case for negligence, the four legal elements of negligence must be proven:
Duty: Did the defendant have a duty to the plaintiff?
Breach of Duty: Did the defendant fail to deliver care that an ordinarily careful, reasonable, and prudent person would do under the same or similar circumstance? Were there acts of omission related to the standards of care being met?
A. Failure to identify that the patient was at high risk for CRC.
B. Failure to recognize the patient’s symptoms as a risk factor for CRC.
C. Failure to order CRC screening.
D. Failure to include CRC in the differential diagnoses.
E. Failure to order appropriate tests, and/or referrals following a diagnosis of CRC
3. Damages & Injuries: Were there damages or injuries, such as economic and non-economic damages, that the plaintiff is alleging?
4. Causation: Did the acts of the defendant cause the damages, or injuries that the plaintiff is claiming?
Statistics:
CRC is the third most commonly diagnosed cancer in men and women combined in the U.S.
CRC is the second leading cause of cancer death in men and women combined in the U.S.
Estimates for 2022:
151,030 people will be diagnosed with CRC in the U.S.
52,580 people will die from CRC in the U.S.
Young-onset CRC is on the rise
Rates for people under 50 increased 2.2% each year
Median Age of Diagnosis: Age 66 (both men and women)
Screening:
All men and women without a family history, or risk factors for colorectal cancer (CRC) should begin CRC screenings at age 45, according to the American Cancer Society.
With screening, CRC is one of the most preventable cancers, and highly treatable if caught early.
If you have certain risk factors, you may need to be screened earlier than 45.
Risk Factors:
Family history of CRC or polyps
African American
Have a genetic link to CRC such as Lynch Syndrome
Have a personal history of cancer
Have ulcerative colitis, inflammatory bowel disease, or Crohn’s disease
Types of screening chart
Symptoms: CRC often does not cause symptoms early on. When symptoms do occur, they may include:
Change in bowel habits such as diarrhea and/or constipation, a change in the consistency of your stool, or stools that are more narrow than usual.
Persistent abdominal discomfort such as cramps, gas, or pain. Feeling full, bloated, with or without nausea & vomiting.
Rectal bleeding. You may notice blood in or on your stool that is bright red, or the stool may be black, tarry, or brick red.
Weakness and/or fatigue associated with anemia (a low red blood cell count).
Hayes B., et al. (2019). Why are we missing colorectal cancer? A study investigating the cause of delays in diagnosis. BMJ Journal. 68:A190
P.S. Comment and share your experience with reviewing the standards of care to develop your delayed or missed CRC diagnosis case, while considering the “miss rate.”
In this blog, I’ll be reviewing U.S. annual statistics specific to injuries requiring medical care, as well as the types of insurance claims Barber Medical Legal Nurse Consulting, LLC has the expertise to support specific to case development. I’ll provide some common examples of insurance liability defense cases, as well as some common defenses. I’ll close with examples of the scope of work our Senior CLNC performs specific to insurance liability cases.
2020 Statistics:
24.8 million injuries in the U.S. require medical care
200,955 unintentional injury deaths in the U.S. annually
6 million motor vehicle accidents in the U.S. annually
40,698 motor vehicle accident deaths in the U.S. annually
87,404 unintentional poisoning deaths in the U.S. annually
Annual number of injuries on construction job sites:
266,530 cases involving sprains, strains, tears
128,220 cases involving injuries to the back
211,640 cases involving falls, slips, trips
Types of Insurance Claims Barber Medical Legal Nurse Consulting, LLC Supports(Case Development)
Commercial liability (business insurance)
Personal liability (automobile, homeowners, property)
Workers’ compensation
Medical Personal Injury Protection (no-fault insurance)
Insurance Liability Defense Case Examples (Commercial and Personal Injury Allegations):
slips, trips, and falls resulting in orthopedic injury such as rotator cuff injury
automobile accidents resulting in spine injury such as “whiplash”
injury from dental procedures such as broken teeth
food poisoning
nail salon injury
injury from urogynecological interventions such as surgical mesh implants resulting in mesh exposure and erosion causing vaginal scarring, fistula formation, painful intercourse, pelvic, back and leg pains
Common Defenses for Insurance Liability Cases:
plaintiff’s injuries were present before the incident
mechanism of injury does not correlate with alleged injury
condition is degenerative, not acute or traumatic
plaintiff delayed seeking treatment after incident
Barber Medical Legal Nurse Consulting, LLC Supports Insurance Liability Case Development (Scope of Services):
Interacts with members of each case (E.g., claims representative, defense attorney, insurance company, education division, special investigations unit for fraud or criminal investigation)
Investigates claim
Reviews medical documents, medical records, school, and employment records, medical bills
Reviews police and accident reports
Reviews photographs
Organizes records
Performs medical research
Performs case analysis and report writing including development of a chronology
Educates staff to support a successful outcome
Submits requests for production, interrogatories, preparation of deposition questions for claims department, and defense attorney
Attends independent medical examination (IME)
Interviews witnesses
Obtains a life care plan
Identifies and locates testifying experts, and medical reviewers
Reviews and analyzes testifying expert reports and depositions
In this blog, I’ll be reviewing some causes of perinatal litigation, the importance of providing care according to current standards of care, ways to mitigate perinatal liability exposure, common allegations specific to alleged injuries resulting from shoulder dystocia, and current standards of care intended to decrease professional liability exposure, and reduce the risk of iatrogenic (relating to injury or illness caused by medical examination or treatment) maternal and neonatal injury.
Causes of Perinatal Litigation: Findings suggest that allegations against nurses, certified nurse midwives, physicians, and/or institutions often result from a lack of knowledge or commitment to practice in accordance to current standards, guidelines, and evidence. In other instances, care is rendered according to personal experiences, preferences, and history of practice over a long period of time during which the provider has not experienced an adverse outcome. Moving toward a science based clinical practice environment, rather than “that’s the way we’ve always done it” is a challenge to promoting safe care (AWHONN, 2014; AWHONN, 2021).
Ways to Mitigate Perinatal Liability Exposure: Certainly, all adverse events are not preventable, however, practices inconsistent with current standards of care offer opportunity for the plaintiff to demonstrate a breach of the standard of care (AWHONN, 2021). One key way to reduce liability exposure is to provide care consistent with current standards of care.
Shoulder dystocia is a common area of perinatal litigation with common allegations including:
Failure to accurately predict the risk of shoulder dystocia
Failure to diagnose labor abnormalities
Failure to appropriately initiate shoulder dystocia corrective maneuvers
Failure to prioritize delivery of posterior arm
Failure to perform cesarean birth
Application of forceps or vacuum at high station, or continued application without evidence of fetal descent, resulting in shoulder dystocia
Application of fundal pressure during shoulder dystocia, further affecting the shoulder and delaying birth, thereby resulting in maternal-fetal injuries
Standards, Guidelines, Recommendations:
Although there are a number of known risk factors, shoulder dystocia cannot be accurately predicted or prevented (ACOG, 2017)
When shoulder dystocia is suspected, the McRoberts maneuver should be attempted first because it is a simple, logical, and effective technique (ACOG, 2017)
In cases where the McRoberts maneuver and suprapubic pressure are unsuccessful, delivery of the posterior arm can be considered as the next maneuver to manage shoulder dystocia (ACOG, 2017, AWHONN, 2021)
Simulation exercises and shoulder dystocia protocols are recommended to improve team communication and maneuver use because this may reduce the incidence of brachial plexus palsy associated with shoulder dystocia (ACOG, 2017)
The Joint Commission’s Sentinel Event Alert, Preventing Infant Death and Injury during Delivery, recommends conducting periodic drills for obstetric emergencies such as shoulder dystocia (AWHONN, 2021)
P.S. Comment and share your experience with a shoulder dystocia litigation. What were the strengths and weaknesses of the case?
In this blog, I’ll be reviewing the statistics specific to mortality associated with heart disease, the monetary cost of heart disease in the United States, risk factors for heart disease, as well as available “tool kits” for the management of heart disease.
Prevalence in the U.S.: Approximately 659,000 people in the U.S. die from heart disease annually, accounting for 1 in every 4 deaths. Heart disease is the leading cause of death in the U.S. (Department of Health and Human Services (2022).
Monetary Cost: Heart disease cost the U.S. approximately $363 billion annually from 2016 – 2017. This included the cost of health care services, medications, and lost productivity due to death (Department of Health and Human Services (2022).
Risk Factors:High blood pressure, high blood cholesterol, and smoking are key risk factors for heart disease.There are other medical conditions and lifestyle choices that can also put people at a higher risk for heart disease, including, but not limited to:
Management by Standardization of Evidence Based Practice and Use of “Tool Kits”: It is recommended that providers make a commitment to following the most current clinical guidelines for the management of high blood pressure control to ensure that care is cost-effective, evidence based, and accessible and controlled amongst all populations. The use of the following “tool kits”, in conjunction with The Surgeon General’s Call to Action to Control Hypertension is a recommended approach to implementing protocols, and using data to improve health outcomes.
The Surgeon General’s Call to Action to Control Hypertension focuses on Standardization of patient care, minimization of variation in care delivery, prompt medication initiation for the management of high blood pressure and high cholesterol, standardization of timely patient follow-up, and reinforcement of lifestyle counseling and referrals. All members of the clinical care team are empowered to engage in the management of the patient to ensure a positive outcome
In this blog I’ll be reviewing the most common nursing malpractice claims, common causes of nursing litigation, common plaintiff allegations, common defenses for nursing liability claims, and ways to mitigate risk.
The Role of the Healthcare Consumer: Our society is evolving into savvy healthcare consumers who are increasingly more aware, frequently relying on their electronic devices to capture events, and for some, have adopted the notion that hospitals are “deep pockets” when it comes to litigation.
Most Common Nursing Malpractice Claims: The Nurses Service Organization (NSO), the largest provider of nurses’ liability insurance in the United States, and CNA, the liability insurance underwriter, published a report of nursing malpractice claims from 2006 to 2010. While the claim history range is not current, the findings are applicable in regards to what lessons we can learn from the report. I’ll be comparing some of the findings from the 2011 report to the most current NSO nurses’ claim report.
The 2011 report reviewed 3,222 closed claims against nurses insured by CNA through NSO. The total payment on behalf of the RNs was approximately $80 million.
The average cost of a registered nurses’ malpractice claim (payment per case) was approximately $170,000.
Insurers paid approximately $8.6 million in indemnities related to medication administration. 26% of the claims were related to wrong medication dose, 20% to improper technique, 18% to wrong medication, and 13% to failure to properly monitor and maintain the infusion site.
In comparison to the most current nurses’ claim report (5-year study) (NSO, 2021),
Over $90.3 million was paid for malpractice claims over a 5-year period by CNA. This is 10.3 million dollars more that what was reported in 2011.
The average cost of a registered nurses’ malpractice claim is $201,916. This is $31,916 more than what was reported in 2011.
Death is the most common patient injury that results in a lawsuit. It accounts for 44.3% of all malpractice claims against nurses.
Comas resulted in the highest severity among patient injury claims, averaging $620,833. They were often due to medication errors. The high cost reflects the need for lifelong medical care.
Allegations related to treatment and care continue to represent the highest percentage (45.9%) of all malpractice claims asserted against nurses.
Lawsuits against nurses due to medication errors were reduced by nearly half, while the claim cost almost doubled since the last 5-year study.
The number of license defense paid claims increased by 15.4% since the last study in 2011.
Unprofessional conduct resulted in the majority of license complaints (24.2%) made against RNs. The majority of complaints against LPN/LVNs involved medication errors.
Experience as a nurse does not equate to less risk of malpractice claims. The majority of nurses (85%) who experienced a malpractice claim had been in practice at least 16 years.
Common Causes of Litigation:
Professional malpractice
Unprofessional conduct
Professional negligence
Involuntary manslaughter
Common Plaintiff Allegations:
Failure to assess and monitor the patient
Failure to administer a medication
Failure to provide treatment and care
Failure to maintain patient advocacy
Failure to respond to a change in condition
Patient abuse or neglect
Common Defenses for Nursing Liability Cases:
Physician was informed
Care was provided consistent with the standards of care
Care was provided within the scope of nursing practice
Death was related to the patients pre-existing condition and co-morbidities
Ways to Reduce Nursing Liability Risk:
Practice within the regulations of your State Nurse Practice Act, remain in compliance with your professional organizations and facilities policies and procedures, practice within national standards of care
Maintain clinical competencies
Clarify your direct care assignments and responsibilities
Document in real time to the best of your ability, objectively, accurately, completely, and legibly. Document all patient assessments, re-assessments, observations, communications, and actions. Comply with your employer’s documentation standards.
Do not alter the medical record for any reason after the fact, unless necessary for patient care. If you must add to the medical record after the fact, be sure to label the entry as a late entry.
Maintain signed and dated copies of employer contracts
Maintain effective communication with your work team
Utilize the chain of command (communication) when necessary to advocate for interventions with significant change in patient status
Having an awareness of common causes of nursing litigation, as well as plaintiff allegations may help reduce risk. Being armed with knowledge reduces risk of potential litigation, and improves patient outcomes.
P.S. Comment and share your role in mitigating nursing, or APRN (APP) liability risk
All adverse outcomes cannot be prevented; however, defensibility is strengthened when care rendered is consistent with standards of care.
Olympic Cool-Cap System, Natus Medical Inc.
In this blog I’ll provide a brief overview of Hypoxic Ischemic Encephalopathy (HIE) neonatal brain injury. I will review the definition, the incidence (U.S. and worldwide), associated complications, possible causes, and recommended treatment. I will also share possible defenses to consider when developing a HIE neonatal brain injury case.
What Is It? HIE neonatal brain injury is injury to the brain as a result of hypoxia. Hypoxia is a deficiency of well oxygenated tissue. This can result from a combination of insufficient blood flow and/or decreased oxygen levels.
How Common Is HIE? HIE is the leading cause of brain injury in the perinatal period.
Occurs in 1 to 8 of every 1,000 live births in the United States
HIE causes 30% of cerebral palsy cases in the United States
HIE causes 23% of neonatal deaths world-wide. The fifth leading cause of deaths worldwide in children under 5 years of age (World Health Organization, 2020).
Complications of HIE (including, but not limited to…): cerebral palsy, epilepsy, mental retardation, visual impairment, hearing impairment, learning disabilities, cardiac arrest, death.
Causes (including, but not limited to…) of HIE neonatal brain Injury: (literature suggests 70-80% of HIE neonatal brain injury cases are not preventable)
Antepartum and Intrapartum Events – placental abruption, umbilical cord prolapse, uterine rupture, acute blood loss (maternal hemorrhage), infection
Treatment: Therapeutic hypothermia, or induced cooling, has been shown to reduce death and disability in many HIE cases. Reduction in the core body temperature reduces the brain temperature resulting in neuroprotection. Therapeutic hypothermia is the standard of care for infants who are diagnosed with moderate to severe HIE following birth (no later than 6 hours of life) and who meet specific criteria per standard of care adopted by organizational policy, procedure, and order set.
*Sarnat Staging System is the standard of care to grade severity of HIE
Cooling can be done on the whole body, or through a cooling cap placed on the head. The infant may need other medical interventions to support their organs or to treat seizures.
Infants who experience HIE may require early intervention therapy services after discharge. These include services from a neurodevelopmental pediatrician, physical therapist, occupational therapist, speech therapist, feeding and swallowing therapist, and/or a pediatric neurodevelopmental ophthalmologist.
Possible Plaintiff Allegations for HIE Neonatal Brain Injury:
Failure to transfer mother to tertiary care center (higher level of care)
Failure to or delay in transferring infant to Level III NICU for hypothermia therapy
Failure to attend or delay in arrival of a NICU team to a high-risk delivery
Failure of medical staff to recognize and treat neonatal seizures
Failure of Midwife to have appropriate resuscitative equipment and personnel for home delivery
Failure to follow hypothermia treatment protocol
Possible Defenses for HIE Neonatal Brain Injury:
The infant did not meet criteria for hypothermia protocol
The manifestations of the brain injury were metabolic or genetic in nature and not a result of HIE
The infant was not stable for transport to a higher level of care
The mother was non-compliant with regimen for high-risk pregnancy conditions
The mother had no prenatal care
Synthesis of Data and Case Development: Knowing which relevant maternal and infant medical records to request and what questions to ask are essential. Having an awareness of standard physician orders, and standing nursing orders will support the development of a case. A strong understanding of the electronic medical record and documentation requirements, as well as standard laboratory and diagnostics ordered will support case development.
Below are some clinical areas of focus for case development:
pathophysiology of fetal monitoring and fetal strip interpretation: identification of fetal hypoxia
acid-base balance: identification of fetal and/or neonatal metabolic acidosis
newborn Apgar scoring: identification of the presence of birth asphyxia
gestational age assessment: evaluation of the appropriateness of implementing hypothermia treatment
staging and classification criteria for HIE: identification of the level of neurological compromise, identification of eligibility criteria of newborn for hypothermia treatment
hypothermia treatment: identification of treatment as the standard of care, criteria for treatment, treatment modalities, procedure, staff competencies and continuing education
Perinatal Safety and Professional Liability: All adverse outcomes cannot be prevented; however, defensibility is strengthened when care is consistent with relevant, current evidence-based practice recommendations and standards of care.
P.S. Comment and Share: What were your successes and challenges working through a HIE birth injury case?
References:
Douglas-Escobar & Weiss. (2015). Hypoxic-Ischemic Encephalopathy: A review for the clinician. JAMA pediatrics. 169(4):397–403. doi:10.1001/jamapediatrics.2014.3269
(Share the American College of Obstetricians and Gynecologists patient FAQs)
In this blog I’ll be addressing cervical cancer incidence and mortality, risk factors, the role that the Human Papilloma Virus (HPV) plays in the development of cervical cancer, as well as screening recommendations.
Incidence and Mortality:
It is estimated that in the U.S., in 2021, there were 14,480 new cervical cancer diagnoses, and 4,290 cervical cancer deaths (American Cancer Society, 2021).
Approximately 1,250,000 women are diagnosed with precancers annually by cytology using the Papanicolaou (Pap) smear. Lesions can regress, persist, or progress to malignancy (American Cancer Society, 2021).
Who’s At Risk / The Role of HPV:
Carcinogenic types of HPV are the primary agents that cause virtually all cases of cervical cancer (U.S. Department of Health and Human Services). Once HPV infection occurs, additional risk factors are associated with a higher risk of the development of cervical cancer. For example: high parity (5 or more pregnancies with gestational ages greater than or equal to 20 weeks), long-term use of oral contraceptives, as well as active and passive cigarette smoking. Diethylstilbestrol (DES) exposure in utero is also associated with an increased risk of developing cervical dysplasia.
HPV vaccination:
Based on reliable evidence, vaccination against HPV types 16 and 18 is effective in preventing HPV infection in HPV negative individuals and is associated with a reduced incidence of cervical intraepithelial neoplasia 2 and 3. By extrapolation, these vaccines should also be associated with a reduced incidence of cervical cancer.
Magnitude of Effect: Vaccination against HPV types 16 and 18 reduces incident and persistent infections with efficacy of 91.6% (95% confidence interval [CI], 64.5%–98.0%) and 100% (95% CI, 45%–100%), respectively (U.S. Department of Health and Human Services).
All forms of the HPV vaccine are currently recommended by the Centers for Disease Control and Prevention (CDC) in the United States as a two-dose schedule at least 6 months apart for adolescents younger than 15 years. The current CDC recommendation for older individuals is to receive the original three-dose series.
Cervical Cancer Screening:
Screening With the Papanicolaou (Pap) Test:
Based on reliable evidence, regular screening with the Pap test in an appropriate population of women reduces mortality from cervical cancer. The benefits of screening women younger than 21 years are small because of the low prevalence of lesions that will progress to invasive cancer. Screening is not beneficial in women older than 65 years if they have had a recent history of negative test results.
Magnitude of Effect: Regular Pap screening decreases cervix cancer incidence and mortality by at least 80%.
Screening With the Human Papillomavirus (HPV) DNA Test:
Based on reliable evidence, screening with an HPV DNA or HPV RNA test detects high-grade cervical dysplasia, a precursor lesion for cervical cancer. Additional studies show that HPV DNA testing is superior to other cervical cancer screening strategies.
Magnitude of Effect: In one prospective, clustered, randomized trial, HPV DNA testing was superior to other strategies for preventing cervical cancer mortality
Screening With the Pap Test and the HPV DNA Test (Co-testing):
Based on reliable evidence, screening every 5 years with the Pap test and the HPV DNA test (co-testing) in women aged 30 years and older is more sensitive in detecting cervical abnormalities, compared with the Pap test alone. Screening with the Pap test and HPV DNA test reduces the incidence of cervical cancer.
Magnitude of Effect: HPV based co-testing provides 60% to 70% greater protection against invasive cervical carcinoma, compared with cytology (pap smear) alone
Screening Women Without a Cervix
Based on reliable evidence, screening is not helpful in women who do not have a cervix as a result of a hysterectomy for a benign condition.
Magnitude of Effect: Among women without cervices, fewer than 1 per 1,000 had abnormal Pap test results.
U.S. Preventive Services Task Force (USPSTF) cervical cancer screening recommendations adopted by the American College of Obstetricians and Gynecologists (ACOG):
Barriers: In 2020, the American Cancer Society (ACS) updated its cervical cancer screening guidelines to recommend primary hrHPV testing (High Risk HPV DNA testing) as the preferred screening method for average-risk women aged 25–65 years. Despite the efficacy and efficiency of primary hrHPV testing, adoption of this screening method has been slow secondary to the limited availability of FDA-approved tests and the laboratory infrastructure changes required to switch to this screening platform (The American College of Obstetricians and Gynecologists, 2021).
Future Implications:
The ACS strongly advocates phasing out cytology-based screening options (pap smears) in the near future
Although HPV self-sampling has the potential to improve access to cervical cancer screening, and has been identified as effective, it is still investigational in the United States
The Journal of the American Medical Association (JAMA) published a study demonstrating that self-collected menstrual blood capture and testing for hrHPV is a feasible and accurate approach for cervical cancer screening. This study found that this method is associated with superior performance in identification of HPV genotypes and true-negative events compared with cervical HPV testing (Zhang, 2021).
Risk Mitigation:
As a means to reduce the risk of delayed or missed cervical cancer diagnosis, and to ensure cervical cancer treatment is rendered in accordance to current standards of care, it is essential to be aware of cervical cancer signs and symptoms, risk factors, screening guidelines, as well as treatment recommendations.
P.S. Comment and share if you have learned of other alternatives to self-collected hrHPV DNA testing options that are currently being studied.
References:
American Cancer Society: Cancer Facts and Figures 2021. American Cancer Society, 2021. Available onlineExit Disclaimer. Last accessed October 8, 2021.
Moyer VA; U.S. Preventive Services Task Force: Screening for cervical cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 156 (12): 880-91, W312, 2012. [PUBMED Abstract]
The American College of Obstetricians and Gynecologists. (2021). Practice advisory, Updated cervical cancer screening guidelines.
