Tag medicalmalpractice

In this blog, I’ll be reviewing the common allegations specific to obstetrical triage.  I’ll also review the incidence of obstetrical triage, the sources of recommendation specific to the use of standardized obstetrical triage acuity tools, and offer an introduction to the Maternal Fetal Triage Index (MFTI):

Common Allegations Specific to Obstetrical Triage:

• Failure to perform a medical screening exam
• Failure to perform a timely assessment of the fetus
• Delay in completing a medical screening exam
• Failure to have a policy delineating conditions that require a bedside evaluation by an obstetrical care provider prior to discharge following a medical screening exam by an obstetrical nurse
• Failure of the provider to perform a bedside evaluation for an obstetrical patient with a high risk medical or obstetrical condition
• Discharge of a patient without confirming fetal well-being
• Discharge of a pregnant woman who is unstable for discharge
• Failure to meet all aspects of the Emergency Medical Treatment and Labor Act (EMTALA) regulations in assessing, treating, and discharging a pregnant woman who presents for care

Incidence of Obstetrical Triage:

According to the American College of Obstetricians and Gynecologists, ACOG (2020), obstetrical triage exceeds the overall number of hospital births by 20–50%.  Up to one third of evaluated obstetrical patients will not deliver. These obstetrical patients will be discharged home, or transferred to another unit following initial obstetrical evaluation.   In addition to labor evaluations, obstetrical patients commonly present for (but not limited to) evaluation of preterm labor, preeclampsia, decreased fetal movement, preterm premature rupture of membranes, vaginal bleeding, and acute abdominal pain.  Critical conditions such as motor vehicle collision injury, large placental abruption, or seizure, are less common, but require immediate triage, assessment, and management (ACOG, 2020).

Recommendations for Standardized Obstetrical Triage Acuity Tools:

ACOG recommends that women should be cared for according to triage acuity rather than by time of arrival.  Historically, women have been evaluated on a first come, first serve basis when presenting to the labor and delivery unit (or, obstetrical triage unit).  This method didn’t support timely identification of urgent or emergent obstetrical events (AWHONN).

Several obstetrical triage acuity tools have been developed to classify patients based on the urgency of the patient’s condition, often using a five-level system. These tools have increased the proportion of high-acuity patients being seen urgently.  Several of these tools have been tested for content validity and interrater reliability and may be used to improve quality and efficiency of care and guide allocation of resources (JOGNN, 2015).

Many professional organizations recommend that hospital obstetrical units develop triage protocols based on local conditions, resources, but also informed by evidence-based decision making. ACOG recommends the validated algorithm, the Association of Women’s Health, Obstetric and Neonatal Nurses’ Maternal–Fetal Triage Index (MFTI).

The Maternal Fetal Triage Index (MFTI):    

The Association of Women’s Health, Obstetric and Neonatal Nurses’ (AWHONN) implemented a Maternal Fetal Triage Index (MFTI) which serves as the first obstetrical acuity tool developed by a professional society for use across the United States.

The MFTI serves as an acuity tool (scale) that standardizes obstetrical triage and assists providers and nursing staff to prioritize urgency for provider evaluation and promotes effective multidisciplinary communication. 

The MFTI evaluates maternal vital signs, fetal heart rate, presenting condition, status of labor, fetal movement, current obstetrical, medical and surgical history. 

The ultimate goal of utilizing this tool is to improve patient safety and care.  These improvements will assist in mitigating the common allegations associated with obstetrical triage medical malpractice cases.  The elements of the MFTI prompts timely medical screening exams, with the inclusion of fetal assessment and evaluation of current history that supports risk stratification of the patient and fetus.  Based on the risk assessment, the tool offers clinical guidance specific to follow up care.     

Resources:

American College of Obstetricians and Gynecologists (ACOG) 2020. Hospital Based Triage of Obstetrical Patients, Committee Opinion, #667.

Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN)

Ruhl C, Scheich B, Onokpise B, & Bingham D. 2015. Content Validity Testing of the Maternal Fetal Triage Index. J Obstet Gynecol Neonatal Nurs. 44(6):701-9. doi: 10.1111/1552-6909.12763.

P.S. Comment and Share:  What is your experience in representing an obstetrical triage case?  During case development, did you identify the use of an obstetrical triage acuity tool?

In this blog, I’ll be reviewing common allegations specific to the use of oxytocin for labor management, as well as current standards of care.  I’ll also identify some risk reduction strategies. 

Oxytocin management is a common area of professional perinatal liability claims.  Knowledge of this, and being armed with current evidence and standards of care from professional organizations can reduce a clinician’s liability risk.  

Common Allegations:

• Initiation of oxytocin in the absence of evidence of fetal well-being.  Failure to complete a non-stress test prior to initiation of oxytocin
• Failure to accurately assess maternal-fetal status during labor induction.  Continuous fetal monitoring not performed; failure to assess and document fetal heart rate and uterine activity per organizational policy and standard of care
• Excessive doses of oxytocin resulting in uterine tachysystole, with or without an indeterminate or abnormal fetal heart rate (FHR) pattern.
• Failure to discontinue or decrease oxytocin in the presence of a Category II and/or Category III fetal heart rate (FHR) tracing unresolved with intrauterine resuscitation

Standards of Care:

• Assess and document fetal well-being prior to the initiation of oxytocin
• Administer the lowest dose to achieve cervical change and labor progress (ACOG, 2017)
• Initiate oxytocin at 1-2mU/min and increase by 1-2mU/min no more frequently than every 30-40 minutes.  Approximately 90% of women at term will have labor successfully induced with 6mU/min or less (AWHONN, 2014).
• Titrate the dose of oxytocin to fetal response and uterine activity / labor progress (ACOG, 2017)
• Avoid uterine tachysystole (more than 5 contractions in 10 minutes averaged over 30 minutes) and treat (decrease or discontinue) in a timely manner if it occurs (ACOG, 2017; JOGNN, 2020)
• Avoid prolonged uterine contractions lasting greater than 2 minutes, avoid inadequate uterine resting tone (contractions occurring less than 1 minute of each other) (ACOG, 2017)
• If labor is progressing, there is no need to increase the dosage rate
• If utilizing a labor management and/or oxytocin policy, follow all policy elements
• Ensure adequate personnel are available to monitor maternal-fetal status (ACOG, 2017).  E.g. one nurse to one woman receiving oxytocin for labor induction or augmentation (AWHONN, 2014)

Risk Reduction Strategies:

• Ongoing education and periodic competence validation for health care professionals who engage in fetal heart monitoring (FHM) (JOGNN, 2015)
• Consider the requirement for electronic fetal monitoring (EFM) education for obstetrical provider re-credentialing   
• Implementation of a pre-oxytocin and in-use oxytocin checklist.  Such checklists offer a guideline for care and reinforces to the providers that if the checklists cannot be completed, Oxytocin should not be initiated and/or continued (HCA, 2009) 
• Utilize the organizational chain of command and conflict resolution policy in the event of disagreement in fetal monitor strip interpretation.  Document employment of the chain of command.
• Per JOGNN, 2020: Organizational implementation of a quality improvement initiative – Identify quality measures related to induction of labor and augmentation of labor that emphasizes
  • perinatal structure measures:
    • completed 39 weeks gestation prior to elective induction
    • criteria for prioritizing inductions based on medical necessity
    • standard policy for oxytocin administration
    • standard order set for oxytocin
    • agreed upon definitions of tachysystole base on NICHD/ACOG/AWHONN terminology
    • agreed upon and standardized treatment for tachysystole
  • perinatal process measures:
    • greater than or equal to 39 weeks gestation if elective induction
    • if <39 weeks, indication is consistent with ACOG and The Joint Commission (TJC) clinical indications
    • cervical readiness or ripening before induction
    • oxytocin protocol starting at 1-2mU/min; increase by 1-2mU/min; at least 30min. between oxytocin dosage increase
    • fetal status is normal
    • appropriate and timely interventions for tachysystole if it occurs (use of a tachysystole audit tool)
    • compliance with all aspects of care (clearly identified aspect of care)

References:

ACOG. (2017). Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles

AWHONN. (2014). Perinatal Nursing 4^th ed.

HCA. (2009). Perinatal Safety Initiative Recommended Pre-Oxytocin Checklist For Women with Term-Singleton Babies

JOGNN. (2015). Fetal Heart Monitoring

JOGNN. (2020). AWHONN Practice Monograph

P.S. Comment and Share: What has been your experience with a case involving oxytocin for labor induction or augmentation?

In this blog, I’ll be reviewing maternal sepsis. I’ll be defining what maternal sepsis is, national statistics, the causes of maternal sepsis, the recommended screening and diagnostic criteria, assessment and monitoring recommendations, management recommendations, and the role of the Safe Motherhood Initiative Sepsis Bundle.

What is Maternal Sepsis: 

Maternal sepsis is a life-threatening condition defined as organ dysfunction resulting from infection during pregnancy, childbirth, post-abortion, or postpartum period.

• Presentation: pregnant patients appear clinically well prior to rapid deterioration  with the development of septic shock, multiple organ dysfunction syndrome, or death.  This is due to pregnancy-specific physiologic, mechanical, and immunological adaptations (JAMA, 2021).

National Statistics:

Maternal sepsis is the second leading cause of maternal mortality in the United States.  Among all maternal deaths in the U.S., 13% are attributed to infection or sepsis, with case fatality rates as high as 10% to 30% in the obstetric population (JAMA, 2021). It is estimated that 4 to 10 per 10,000 live births are complicated by maternal sepsis (ACNM, 2018).

Causes of Maternal Sepsis:

Screening & Diagnostic Criteria:

The use of a maternal early warning system (MEWS) is recommended.  This is a set of specific vital sign and physical exam findings that prompt a bedside evaluation and/or work-up (see ACOG’s MEWS example below)

Management Recommendations:

Survivability requires early detection, prompt recognition of the source of infection, and targeted therapy

Delayed antibiotics > 1 hour = increased mortality

How the ACOG Safe Motherhood Initiative (SMI) Sepsis Bundle Reduces Maternal Morbidity:

The SMI is a collaborative initiative between ACOG and the New York State Department of Health (NYSDOH) to improve patient safety and raise awareness about risk factors that contribute towards maternal morbidity & mortality.  The SMI supports provider readiness and recognition through the availability of education, standardized sepsis work-up criteria and diagnostic tools. The SMI supports timely provider response and reporting by the availability of a standardized sepsis management algorithm, recommended criteria for consultation and transfer to a higher level of care, and case debriefing tools.

If you are in need of a medical legal expert specific to a maternal sepsis case, contact Barber Medical Legal Nurse Consulting, LLC

Resources:

ACNM, 2018. Recognition and Treatment of Sepsis in Pregnancy

ACOG, 2020. Maternal Safety Bundle for Sepsis in Pregnancy

JAMA Network Open. 2021;4(9): Perinatal Outcomes Among Patients with Sepsis During Pregnancy

P.S. Comment and Share your experience with a maternal sepsis case.  Was the case a wrongful death case or missed diagnosis, other?

When reviewing content from the electronic health record (EHR), there are many elements to assess.  One of the elements is the use of the copy/paste functionality (CPF).  In this blog, I’ll be reviewing the use of CPF within the EHR.  I’ll also will be reviewing The American Health Information Management Association’s (AHIMA) position on the use of CPF, statistics, and risks associated with CPF.  I will conclude with reviewing the role of the medical legal consultant, as well as best practice recommendations to mitigate documentation risk. 

Use of the Copy/Paste Functionality (CPF) in EHR’s: The American Health Information Management Association (AHIMA) maintains the position that “the use of copy/paste functionality in EHRs should be permitted only in the presence of strong technical, and administrative controls, which include organizational policies, and procedures, requirements for participation in user training and education, and ongoing monitoring.  Users of the copy/paste functionality should weigh the efficiency and time savings benefits it provides against the potential for creating inaccurate, fraudulent or unwieldy documentation.”

CPF – A Common Occurrence in the EHR: The use of CPF continues to be a common occurrence which can lead to adverse outcomes. 

The Joint Commission published the results of the Partnership for Health IT Patient Safety work group.  Their literature review identified 51 publications:

• One study of diagnostic errors found that CPF led to 2.6% of errors in which a missed diagnosis required patients to seek additional unplanned care.

• Several case reports identified clinical harm related to CPF, including a patient who died from a heart attack after his primary care physician (PCP) failed to diagnose cardiac disease.

A. Two years prior, the patient was discharged from the ED after a new diagnosis of atrial fibrillation, and potential heart disease; he was instructed to follow up with his PCP for a stress test.

B.  The PCP copied and pasted the assessment and plan (A/P) section of the patient’s record
for 12 office visits during the next two years, updating the A/P or reviewing medical entries
from the ED or other department.

C.  The PCP was found liable in the death.

• A study published in 2017 reviewed inpatient progress notes written in 2016 by direct care hospitals, residents, and medical students totaling 23,630 notes by 460 clinicians.  In a typical note, 18% of the text was manually entered, 46% copied, and 36% imported.

Risks of CPF:

• Inaccurate or outdated information can lead to medical errors.
• Redundant information, which makes it difficult to identify the current information.
• Inability to identify the author or intent of documentation.
• Inability to identify when the documentation was first created.
• Propagation of false information: inflates, duplicates or creates fraudulent healthcare claims.
• Internally inconsistent progress notes.
• Unnecessarily lengthy progress notes.

Role of the Medical Legal Consultant:

Attorney-Client Education

• EHR documentation standards
• Discoverable items not included in the designated record set
• Regulatory requirements: user specific

Development of interrogatories & requests for production

Development of discovery responses

Recommend expert witnesses – specific to the EHR at issue

Witness Preparation

Educate staff/end users of the EHR

• Assess knowledge of the workflow
• Evaluate if end users have observed the native EHR in printed format
  A. Determine if they know how to read the printed version
• Types of assessments
  A. Standardized by EHR platform
  B. Customized by provider
  C. Use of free text

Evaluate the type of, and how much training the end user received prior to
using the EHR.  Evaluate what the training consisted of

Evaluate if the organization has consistency across EHR user roles,
access and permissions

Evaluate the organizations processes specific to record set-up, changes, revisions, additions,
and retirement of modules to the EHR

Ways to Mitigate Risk / Joint Commission Best Practice Recommendations:

• Chart timely: during the same scheduled shift
• Limit use of copy/paste functionality
• Be cognizant of scope of practice
• Disable drafts
• Utilization of the EHR report feature to track, trend, and audit. Ensure that copy/paste practices are regularly monitored, measured, and assessed
• Provide a mechanism to make copy/paste material easily identifiable
• Ensure adequate staff training, and education regarding the appropriate, and safe use of CPF
• Develop policies, and procedures addressing the proper use of the CPF to assure compliance with governmental, regulatory, and industry standards
• Address the use of features such as copy/paste in the organization’s information governance processes
• Monitor compliance, and enforce policies, and procedures regarding use of copy/paste, and institute corrective action as needed.

Resources:

The Joint Commission. Sentinel Event Alert 54. “Safe Use of Health
Information Technology.” March 31, 2015. Retrieved from: https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert-54-safe-use-of-health-information/#.YpkLlFTMIos

The Joint Commission. “The Joint Commission Standards.” https://www.jointcommission.org/standards

The Joint Commission. Quick Safety 10. “Preventing Copy-and-
Paste Errors in EHRs.” Updated July 2021. Retrieved from: https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety–issue-10-preventing-copy-and-paste-errors-in-ehrs/preventing-copyandpaste-errors-in-ehrs/#.YpkLcFTMIos

P.S. Comment and share – How will this information change your documentation practices, or how you analyze the EHR?

In this blog, I’ll be reviewing the national, and New York State statistics related to maternal mortality associated with obstetrical hemorrhage.  I’ll also highlight one of the risk factors associated with obstetrical hemorrhage, and discuss the standards of care that should be employed to mitigate the risk of maternal morbidity and mortality. 

Statistics: Obstetrical hemorrhage is a preventable cause of maternal morbidity and mortality and continues to be one of the leading causes of maternal death in the U.S.

How the U.S. compares to 10 other developed countries:

In New York State, postpartum hemorrhage is the 2^nd most frequently reported postpartum complication, and accounted for 29% (18) of maternal deaths between 2012-2013 according to the NYS Maternal Morbidity and Mortality Review Report (2017).

Prolonged oxytocin exposure as a risk factor: In a recent (published May, 2022) retrospective cohort study performed by Boston University School of Medicine, prolonged (greater than or equal to 12 hours) oxytocin exposure for induction of labor increased the risk of obstetrical hemorrhage by 52% compared to those women exposed for less than 12 hours.  Use of obstetrical risk assessment tools alert the perinatal team to the risk of obstetrical hemorrhage and prompts evidence-based interventions.

The importance of standardized safety bundles: The American College of Obstetricians and Gynecologists (ACOG) recommends the use of the Obstetrical Safety Bundle as a means to guide standardized management of obstetrical emergencies associated with maternal morbidity and mortality in accordance to evidence-based practice.  ACOG’s Safe Motherhood Initiative (SMI) focuses on the four leading causes of maternal death: maternal sepsis, obstetric hemorrhage (severe bleeding), venous thromboembolism (blood clots), and severe hypertension in pregnancy (high blood pressure).

The Obstetrical Hemorrhage Safety Bundle includes:

• Risk assessments: prenatal, antepartum, labor & delivery, and postpartum.
• Use of a staged obstetrical hemorrhage checklist to guide interventions in real-time.
• Team debriefing recommendations and a standardized debriefing form.
• Suggested standardized obstetrical hemorrhage tool kit.
• Recommendation to perform quantitative blood loss assessment (QBL) with every delivery.

The Joint Commission Perinatal Safety Standards: Effective January 1, 2021, the Joint Commission implemented new perinatal safety standards required of all Joint Commission accredited hospitals.   One of the new standards aims to improve care for women experiencing maternal hemorrhage.  The Joint Commission requirements focus on evidence-based written procedures, education, training, and drills for staff and providers, education for patients and families, and quality review.  The requirement also focuses on evidence-based risk assessments and hemorrhage supply kits. 

References:

ACOG’s Obstetrical Hemorrhage Safety Bundle. https://www.acog.org/community/districts-and-sections/district-ii/programs-and-resources/safe-motherhood-initiative/obstetric-hemorrhage

MedPage Today. 2022. https://www.medpagetoday.com/meetingcoverage/acog/98676

NYS Department of Health. 2017. NYS Morbidity and Mortality Review Report

OECD Health Data. 2020

P.S. Comment and share your experience with a maternal death case associated with obstetrical hemorrhage. What were the deviations in the standards of care? 

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:

1. Duty: Did the defendant have a duty to the plaintiff?
2. 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).
• Unexplained weight loss

References:

Colorectal Cancer Alliance. (2022). American Cancer Society’s Cancer Statistics Center and Colorectal Cancer Facts & Figures 2020-2022.

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 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?

References

Simpson K.R. et al. (2021). AWHONN Perinatal Nursing, 5^th ed. Wolters Kluwer

Simpson K.R. & Creehan P.A. (2014). AWHONN Perinatal Nursing, 4^th ed. Wolters Kluwer, Lippincott

The American College of Obstetricians and Gynecologists. (2017). Shoulder dystocia [Clinical Practice Bulletin #178]

Joint Commission. (2004). Preventing infant death and injury during delivery. Sentinel Event Alert Issue 30

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:

• Diabetes
• Overweight and obesity
• Unhealthy diet
• Physical inactivity
• Excessive alcohol use

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.   

1. Lifestyle changes   

Eat Smart, Move More!

Recipes for a Heart-Healthy Lifestyleexternal icon

2. Health equity

Alliance for the Million Hearts^® Campaign Partner Toolkit

Reducing Out-of-Pocket Costs for Medications

Grady Implementation Guide

3. Self-measured Blood Pressure Monitoring

Self-Measured Blood Pressure Monitoring

Self-Management Support and Education

4. Medication Adherence

Pharmacy: Collaborative Practice Agreements to Enable Collaborative Drug Therapy Management

Improving Medication Adherence Among Patients with Hypertension

Community Pharmacists and Medication Therapy Management

5. Standardizing and Improving Patient Care

Million Hearts^® Hypertension Control Change Package, Second Edition

Implementing Clinical Decision Support Systems

Team-Based Care: Promoting Team-Based Care to Improve High Blood Pressure Control

6. Identifying Patients with Hypertension

Undiagnosed Hypertensionexternal icon

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

References

Department of Health and Human Services (2022), Heart Disease, Tools and Training. https://www.cdc.gov/heartdisease/tools_training.htm

Department of Health and Human Services (2022), National Center for Chronic Disease Prevention and Health Promotion , Division for Heart Disease and Stroke Prevention

Department of Health and Human Services (2020), The Surgeon General’s Call to Action to Control Hypertension.

https://www.cdc.gov/bloodpressure/docs/Surgeon_General_HTN_Control_Health_Professionals.pdf

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

References:

CNA Healthpro and Nurses Service Organization. Understanding Nurse Liability, 2006–2010: A Three-Part Approach. http://www.nso.com/nurseclaimreport2011

Nurses Service Organization. 2021. 10 Surprising Facts from the Nurses Claim Report. https://www.nso.com/Learning/Artifacts/Articles/10-most-surprising-things-from-the-nurse-s-claim-report

All adverse outcomes cannot be prevented; however, defensibility is strengthened when care rendered is consistent with standards of care.

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)

1. Antepartum and Intrapartum Events – placental abruption, umbilical cord prolapse, uterine rupture, acute blood loss (maternal hemorrhage), infection
2. Maternal Underlying Risk Factors – hypotension, hypertension, placental vasculopathies, insulin dependent diabetes
3. Neonatal Risk Factors – congenital heart disease, pulmonary disease, severe apnea, patent ductus arteriosus, hypoglycemia, hyperglycemia, meconium aspiration syndrome, 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 

Simpson K.R., & Creehan P.A. (2020). AWHONN’s Perinatal Nursing. 5^th edition. Lippincott Williams & Wilkins

World Health Organization. (2020). Newborns: improving survival and wellbeing. https://www.who.int/news-room/fact-sheets/detail/newborns-reducing-mortality

World Health Organization. (2022). The top 10 causes of death. https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death