Anil Chopra, MD Shirley Strachan-Jackman, NP

Emergency Medicine, UHN

I am not a lawyer (they make more money!) ICRC of CPSO Medicolegal consultant with BLG, CMPA Hospital quality reviews

I am not a doctor…Chopra makes more money! medicolegal consultant for CNO, as well as law

firms in Toronto and Southwestern Ont. (Aviva, Rogers Partners, Lerners LLP)

Discuss: Risky business!

To offer some advice to try to keep you out of trouble with the College, your employer and lawyers!

Two large downtown academic EDs 110,000 patients 100 nurses 70 ED docs 4 NPs 1 PA Millions of trainees!!

Communication/Professionalism

Care

CP x 4 hours, resolving Px: VSS, tender left ant chest Dx: MSK CP Rx: Tyl #3 F/U prn

Nursing notes: chest pressure with sweating Worried about heart attack as father died of MI

“I didn’t have time to write everything down!” “Do you want me to look after sick patients or

write essays!” “I’m sure I did that even if I didn’t write it

down.” “It looks like 60/40 in my notes, but I meant to

write 160/40.” “I scribbled it out because I wrote on the

wrong chart”

Standard of Care* You are expected to find time to write concise,

legible, timely notes documenting what you found out, what you did and what you think.

Legal Interpretation If you wrote it down, that’s the facts. *PHA, RHPA, CPSO, CNO, Accreditation, hospital

Sharing information Continuity of care Measure of quality of care Legal protection

Case 2

26 year old female sent in by her GP Presented with signs of slight confusion/

difficulty ambulating Bloodwork- Na 112 mmol/L Admitted to GIM- hyponatremia Order- correct sodium slowly @ 125 cc/ hr

The patient remains in the ED d/t no beds The infusion was started- the nurse went

back to check on the patient and realized that 1 litre had been infused in one hour

The family claimed that this rapid infusion of sodium led to permanent brain damage known as central pontine myelinolysis

Medication Errors

“The Canadian Adverse Events Study: The Incidents of Adverse Events in Hospital Patients in Canada” ▪ 1 in 19 adults will be given the wrong medication or

wrong medication dose ▪ 24% of preventable adverse events were related to

medication errors

Statistics Canada

Medication errors increase when nurses work longer hours and excessive amounts of overtime

Among nurses who work OT- 22% reported medication errors compared to 14% of those who did not work OT

Almost ¼ of medical errors are caused by medication mistakes

UHN Medication Incidents

In 2013- 885 medication incidents were reported

Total 46 came from the Eds

< 10% result in measurable harm

Top Reasons Why Nurses Get Sued

Medication errors Communication errors Failure to monitor and assess Failure to properly advocate for the patient Working while impaired whether by

inadequate sleep or controlled substances Negligent or inappropriate delegation and

supervision

In 2013, CNO received 285 public complaints and 993 reports

Total Membership: -112,582 RNs - 41,996 RPNs - 2,242 NPs In 2013- 1,072 nurses were being monitored

Normal interpretation of films and patient discharged home

Talus # Dx 3 weeks later: ORIF, chronic pain/arthritis/disability

CXR: rapid growth of lung malignancy diagnosed 4 months later: patient died

CT head: patient decompensated next day All successful legal action

Clear written discharge instructions to patient and family/caregiver not given

Discrepant findings on imaging: - ?MRP - timely notification: PACS, phonecall, fax - redundancy: ordering MD, FD, ED

Knowledge deficit: eg. missed dissection Failure to take adequate Hx: eg. AMI Failure to perform adequate Px: eg. ischemic leg Failure to consider DDx: eg. PE Failure to order/interpret tests: eg. ECG, CT **Failure to diagnose: eg. torsion *Failure to treat: eg. sepsis Failure to consult: eg. glaucoma Failure to admit: eg. chest pain Failure to communicate: eg. discharge instructions

Duty of care Breach of duty Harm or injury Causation

New matters: 3497 ICRC: 1256: - 59% NFA - 21% Advice - 10% Written Caution* - 4% Verbal Caution* - 2% Discipline - 3% SCERP - 1% Undertaking *Homework

So, how to save yourself…. and the patient

Be pleasant with your patients: why piss them off? (leave your ego at home)

Talk to patients and the annoying people who show up with them!... Are there any red flags?

A physical exam involves touching the patient …no telemedicine in the ED

Write it down!! : +’ves & -’ves Call a friend when you need help Discharge = last chance to save yourself & the

patient

Case 3

18 month old presented to ED with a 2 day history of fever

Temp 39.5 degrees C at home; vomited x 1; cough and runny nose for one week; drinking fluids on and off

Tylenol given at home

Temp on arrival to the ED was recorded at 40.1 rectally, HR 180, RR 34, 02 sat 98%

Received Tylenol; repeat temp 39.0 rectally Received ibuprophen one hour later- CXR 3 hours later child was discharged home- no

repeat set of v/s were done The only documentation by the nurse was

“saline lock discontinued”

Next day child returns via ambulance seizuring

Diagnosis: bacterial meningitis

Abnormal Vital Signs

“What looks like bronchitis could be a pneumonia”

“A high fever in a 2 year old could be a treatable flu, or it could be meningitis”

Discharge Documentation

Red Flags to Lawyers

Crowding or squeezing entries above a signature or between lines

Erasures Change in slant of hand writing Using different pens Notes on different days in same colour ink from

same pen Typed entry followed by handwriting Missing original records that have been replaced by

photocopies

Case 4

32 year old male NFA- found sleeping in the hallway- had ingested 40 mg oxycontin

Known drug abuser and had previous ED visits for illicit drug use

No SI/ HI Alert and co-operative- patient wanted to see

“crisis” “wanted a warm place to sleep” v/s were documented normal except he had a

temp of 39.8

Pt was put on a stretcher, not undressed and crisis was called

Patient seen by crisis- brief assessment by physician- released

Pt returns next morning complaining of pain in his right arm

Dx: necrotizing fasciitis- underwent an amputation of his right arm below the shoulder

EMS Report

Documented abscesses on both arms- multiple sites

??? Reported to the triage/ primary nurse

Patient claims had he been undressed and assessed- seen degree of infection

Summary

Avoid a lawsuit is to be aware of the standard of nursing practice

Nurses are at high risk for compassion fatigue Maintain competence in your speciality area

of practice Know your legal principles and incorporate

into everyday practice Practice within your boundaries