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Medical-legal lessons


From the CMPA files

Some cases based on the CMPA's files


Shelving units with medical files

The following cases demonstrate the importance of teamwork.

Case: An obstetrical team

Although the court judgment in this case focuses on the delegation and supervision by a head nurse, the lessons apply to all healthcare professionals including physicians.

Close up of pregnant stomach with fetal monitors attached

Background

A 36-year-old mother is admitted in active labour. The attending obstetrician ruptures her membranes, assesses the fetal heart tracing as normal, and asks to be notified when the patient is ready to deliver.

The case room is very busy and the head nurse assigns a young, recently graduated nurse to monitor the patient — despite the junior nurse's pleas that she is uncomfortable monitoring fetal heart tracings.

Background continued

Immediately on arriving at the patient's bedside, the junior nurse notes the fetal heart tracing shows marked decelerations. As she has been taught, the junior nurse turns the patient on her side and administers oxygen, however, the tracing continues to show marked decelerations.

Two hours later the head nurse remembers to check up on the junior nurse and her patient. The supervisor immediately requests a scalp electrode to better assess the fetal heart rate. The obstetrical resident applies the scalp electrode, diagnoses severe fetal distress and arranges for an immediate C-section.

The crash section occurs within 20 minutes, however the child is born with a severe anoxic brain injury.

Outcome

The child and family launch a lawsuit naming everyone on the obstetrical team, alleging that the failure to react to the abnormal tracing lead to the delay in delivering their child and ultimately caused the brain damage.

The hospital alleges the physicians should have verified that the nurses were monitoring the fetus.

Think about it

  • Should the physicians have been supervising the nurses?
  • Did the nursing supervisor appropriately delegate to the junior nurse?
  • Did the nursing supervisor adequately supervise the junior nurse?

Lessons learned

The judge concluded the following:
  • Each member of the obstetrical team had a defined role. It is essential that each person's role be carried out within a standard of care and training appropriate to that role.
  • Nurses are professionals who possess special skills and knowledge and have a duty to use their skills in making appropriate assessments of patients and to communicate those assessments accurately to physicians.
  • Limited resources preclude the ability of every provider to double-check the work of other providers.

Lessons learned continued

  • An obstetrician in a hospital setting is entitled to rely on staff nurses to monitor and assess a woman in labour and the fetus.
  • The head nurse on an obstetrical team has the obligation to supervise other nurses on the team and to ensure that they are competent to assess patients and to cope with the workload placed on them.
  • The head nurse was made aware of the junior nurse's lack of experience.
  • The head nurse failed to perform her assigning and supervisory duties in accordance with an appropriate standard of nursing care.
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Case: New equipment for a team
Female healthcare provider in surgery

Background

An interventional radiologist has considerable experience with the balloon angioplasty technique, but is using a new catheter for the first time to treat a patient's subclavian steal syndrome.

The new catheter is advanced in the patient's artery, however, the balloon does not readily inflate. Manipulation is unsuccessful and the physician specifically asks the nurse if she has removed the balloon sheath. She says she has, but the sheath has fallen on the floor, out of sight.

The patient returns to the hospital months later, with neck pain and headache. Investigations reveal the balloon sheath lodged in the artery and it is surgically removed. The patient experiences post-operative complications and is left with a significant scar.

Think about it

  • What are some of the risks associated with working with unfamiliar equipment or in unfamiliar environments?
  • What are some of the barriers to effective team function?

Lessons learned

There are a number of risks and barriers associated with this case.
  • Lack of orientation in the use of the new equipment.
    In this case, the radiologist and nurse did not familiarize themselves with the new catheter.
  • Inadequate information sharing, faulty assumptions, defensiveness.
    In this case, the nurse did not indicate she could not find the sheath as she assumed it had fallen under a drape or onto the floor.
  • Complacency, failure to monitor each other's performance, lack of situational awareness.
    In this case, the radiologist accepted assurances the sheath had been removed even though it could not be found.
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Case: Psychiatric team caring for a suicidal patient
Young male in mental distress

Background

An 18-year-old student is depressed and has suicidal ideation. He is admitted to a psychiatric facility for treatment following an examination by the psychiatrist.

The physician prescribes an anti-depressant medication and orders close observation which means the young man will be seen every 30 minutes. A team comprising a psychologist, nurses, a social worker, and the psychiatrist will be caring for the patient.

As is often the case, it is extremely busy on the psychiatric ward. The hospital policy states that an "intake conference," intended to orient all of the team members to a patient, should occur for each admitted patient, but this does not happen.

Background continued

The patient's room is at the end of the corridor, away from the nursing station, so it is difficult for nurses to observe his behaviour.  

The patient refuses to take the oral anti-depressant and generally does not communicate with the team members.

While any member of the team could increase the level of observation to "constant," and although they are all concerned, none of the team members does so.

The patient's aunt alerts the duty nurse that the patient has told her how he could commit suicide while in the hospital. She neither records this information in the medical record, nor alerts other members of the team.

Outcome

The next day the teenage patient crashes through the glass window of his hospital room, runs across the parking lot and is hit by a car.

He is left paraplegic and requires continuous care.

Think about it

What are some of the barriers to the effective functioning of the team that might have played a role?

Legal action

The family launches a lawsuit, naming each member of the team.

The allegations include:

  • incorrect diagnosis
  • failure of the team to hold an intake conference
  • failure to increase the level of observation
  • inadequate strength of the window glass in the facility

Female nurse looking for electronic file

Legal outcome

  • The psychiatrist was found negligent for having misdiagnosed the severity of the patient's psychiatric condition.
  • Each member of the team was found negligent for failing to increase the level of observation of the patient.
  • Each member of the team was held accountable in the failure to hold the intake conference.

The judge was also critical about the lack of documentation in the medical record.

Lessons learned

This case highlights several issues in healthcare:  
  • workload and resource issues: lack of beds close to the nursing station, distractions among the team
  • lack of documentation
  • lack of communication of critical information between team members
  • lack of coordination of care across the team: each team member had the ability to increase the level of observation of the patient, but no one did
  • inadequate hospital policy: while the policy stipulated an "intake conference" should occur, it did not specify who was to arrange the conference, and this lack of clarity resulted in no one arranging the meeting
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Case: "This isn't a surgical problem"
Male surgeon in mask

Background

A patient with a past history of Crohn's disease develops abdominal pain. Specialists in medicine, gastroenterology and surgery assess him. CT scanning is initially reported to be inconclusive. The resident in surgery declares that "this isn't a surgical problem."

The patient continues to deteriorate, but the first-year resident cannot convince the surgical service to reassess him.

The internist does not respond to the resident's pleas, and also has great difficulty getting the attention of the surgical service.

Outcome

Only when the resident becomes more forceful and demanding that a surgeon attend, does the surgeon arrive and it becomes clear that this is indeed a surgical problem.

The patient subsequently has a stormy post-operative course but survives.

Lessons learned

The assertiveness by the resident and the internist that the patient needs urgent intervention is an example of appropriate advocacy on behalf of the patient that should be respected and trigger a suitable response.
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A culture of patient safety actively encourages everyone involved in patient care to ask whatever questions are necessary to ensure optimum care. It also encourages others to respectfully listen and respond to such questions.

For more information see patient safety.