Authors: Linda M Hess, RN, MN, CNSJere O’Brien-Kinne, RN, MN, CNS. CPNP Chris Cooper, BSN, RNC, MBAUpdated 2012: Kimberly Cooper, RN

Neonatal Patient Safety, Documentation and Legal Issues

OBJECTIVES

Discuss the legal implications associated with working in the perinatal/neonatal arena

Describe recent trends in nursing negligence/malpractice

Describe most common charges against nurses Discuss how the 2013 National Patient Safety

Standards affect you Describe how you can protect yourself Discuss the importance of clear, concise

documentation Review the most common documentation issues Identify the need to utilize the “Ladder of Hierarchy”

for issues and principles of professional communication.

OUR ATTITUDES

Burdensome, excessive, of little use Low priority After thought, something to finish before

leaving

TREND…

More and more nurses are being named as defendants in malpractice lawsuits.

This trend shows no signs of stopping.

Documentation is an essential part of a defense against any eventual litigation alleging negligence or malpractice.

THE NUMBER OF ADVERSE ACTIONS REPORTED TO NPDB RELATED TO NURSES IN 2011 WAS NEARLY DOUBLE THAT FOR 2002 (21,586 VS. 11,029 RESPECTIVELY). THE NUMBER OF REPORTS INCREASED STEADILY BETWEEN 2002 AND 2006 AND THEN REMAINED RELATIVELY STABLE THROUGH 2009 (FIGURE 12). BETWEEN 2009 AND 2011, THE NUMBER OF ADVERSE ACTIONS REPORTED TO NPDB RELATED TO NURSES INCREASED 32 PERCENT, POSSIBLY REFLECTING THE IMPLEMENTATION OF SECTION 1921. FIGURE 12: NURSES ADVERSE ACTION REPORTS 2002 – 2011

Figure 12: Nurses Adverse Action Reports 2002 – 2011

MALPRACTICE CASES BY AREA

Medical-Surgical Nurses have the highest rate.

Guess who’s second!

NURSING NEGLIGENCE ALLEGATIONS

Acute care facilities are 60% of all nursing negligence allegations.

DEFINITIONS: JCAHO defines NEGLIGENCE as a “failure to

use such care as a reasonably prudent and careful person would use under similar circumstances.”

JCAHO defines MALPRACTICE as “improper or unethical conduct or unreasonable lack of skill by a holder of a professional or official position; often applied to physicians, dentists, lawyers, and public officers to denote negligent of unskillful performance of duties when professional skills are obligatory.”

6 MAJOR CATEGORIES OF NEGLIGENCE THAT RESULT IN MALPRACTICE LAWSUITS

Failure to follow standards of care

Failure to use equipment in a responsible manner

Failure to communicate

Failure to document Failure to assess and

monitor Failure to act as a

patient advocate

SEVERAL FACTORS HAVE CONTRIBUTED TO THE INCREASE IN THE NUMBER OF MALPRACTICE CASES AGAINST NURSES…

Delegation. Cost-containment efforts and HMO’s

Early Discharge. Nurses may be sued for not providing care, making appropriate referrals, or communicating pt condition in a timely manner.

Nursing Shortage. Greater workloads increase likelihood of error.

Advances in Technology. Nurses must keep abreast of constantly changing technologies & methods.

Better-informed Consumers. More likely to recognize insufficient or inappropriate care.

NICU: A HIGH RISK PLACE High Mortality High Morbidity Cutting Edge Pushing the Envelope Innovation

THE UNIQUE NEONATAL PATIENT

Symptoms change quickly and without warning

Opportunity for major drug errors is great Enormous variability in reactions to care and

treatment Clearly the most fragile population

WHEN THINGS GO WRONG IN THE NURSERY

Often permanent disabilities/injuries Plaintiffs are sympathetic Projected expenses are large Difficult to sort out “cause” and “effect”

WHY DO PEOPLE SUE?

Unmet expectations leading to anger and disappointment

Unexpected death Want answers to

clinical questions Enormous expenses

WASHINGTON STATE STATUTE OF LIMITATIONS

Professional Malpractice: Medical malpractice actions may be filed within three years of the date of the act or omission giving rise to the injury, or within one year of the date the injury was or reasonably should have been discovered, whichever is later. However, no medical malpractice action may be filed more than eight years after the date of the act or omission giving rise to the injury.

Personal Injury: 3 years. Fraud: 3 years. Libel / Slander / Defamation: 2

years. Injury to Personal Property: 3 years. Product Liability: 3 years from the

date of injury, or within three years of the date the injury was or reasonably should have been discovered.

Contracts: Written, 6 years; Oral, 3 ars.

Special Rules for Minors Except in cases or wrongful

death or where a parent has knowledge of a medical malpractice injury, the statute of limitations begins to run on the minor’s 18th birthday.

IN WASHINGTON STATE… “The RN shall document, on essential client

records, the nursing care given and the client’s response to that care”

“The RN shall communicate significant changes in the client’s status to appropriate members of the health team”

“Communication is defined as…common system of speech, symbols, and written communication…”WAC 246-840-700: standards of nursing

conduct or practice

NANN Neonatal nurses are skilled professionals in

newborn care who demonstrate expertise in a variety of roles and activities.

All newborns and their families have the right to optimal care.

As specialists in nursing practice, neonatal nurses recognize and accept their responsibility and duty to ensure the delivery of this care

DUTIES OF NURSES INCLUDE:

Duty to monitor, observe, and report changes in patient status

Duty to challenge or clarify physician’s orders before carrying them out

Duty to anticipate events that might harm a patient

Duty to administer medications properly Duty to document care

REDUCING POTENTIAL LIABILITY

Maintain open, honest, respectful relationships and communication with patients and family members.

Maintain competence in your specialty area of practice

Know legal principles and incorporate them into everyday practice

Practice within the bounds of professional licensure

Know your strengths and weaknesses

WHY WORRY ABOUT CHARTS?

The medical record is a witness that never lies, never dies and never moves

Poor medical records are the leading non-medical reason a medically defensible case is settled or lost at trail

Memories fade…even if you don’t think you could ever forget “that night”

DOCUMENTATION

Documentation is a means to: Demonstrate contributions to quality health care Demonstrate contributions to client outcomes Demonstrate contributions to fiscal outcomes

Documentation must be seen as a critical component of nursing practice, not an after thought

PURPOSE OF DOCUMENTATION

Document the Nursing Process Assess, Plan, Implement, Evaluate

“Tell the story” Legal Adhere to National, State, Professional

Organization, and Hospital regulations and policies

FOUR C’S OF DOCUMENTATION

Critical thinking Communication Chain of command Charting

FREQUENCY OF “MISTAKES”

3.7% of all hospitalized patients suffer an adverse event

27.6% of adverse events are due to negligence

1% of all hospitalized patients will be injured due to negligence

RECURRING PROBLEMS WITH CLAIMS

DocumentationMedication errorsChain of command

OTHER COMMON THEMES…

“Jousting” health professionals saying or implying something negative about prior care

Practitioners making decisions or taking actions beyond their training and experience

WHAT DO THE LAWYERS LOOK FOR?

Clear breach of established standards Violation of hospital’s own standards Criticism of care in medical record Frustration with other providers in the

medical record

MEDICAL RECORDS MUST BE:

CompleteObjectiveConsistentAccurate

IF SOMETHING WAS NOT RECORDED

It was not doneIt was not importantIt was no consideredIf you didn’t document, you can’t prove it was done.

TYPICAL PROBLEMS WITH

THE MEDICAL RECORD

Conflicting documentation between doctors & nurses

No documentation that an MD was notified of significant changes in patient condition

Time gaps in nursing documentation Missing vital signs Failure to Chart Specifics (Saying after the

fact that a patient was monitored appropriately is useless without chart notes to back it up)

GOOD CHARTING REQUIRES

PersistenceAttention to detail

Focus on the big picture

SOME CHARTING DO’S AND DON’TS…

Document facts, impressions, clinical judgments and treatments objectively

Be specific (no generalizations) Chart all nursing interventions, advice given

and patient's and families’ responses Chart only the care you provided, observed,

or supervised Chart promptly after and never before care is

given Record any negative reaction to care or

treatment Chart any potentially contributing patient or

family acts

KEEP FOCUSED

Stay focused on health problem for which you are providing care. Avoid extraneous information that will not be used in providing care of the patient “Paged Dr Jones again. Third attempt this morning.

He is probably on the golf course with his pager turned off”

Initiate “chain of command” if providers are unresponsive. Charting failure to respond will not improve patient care or speed up the process

PHONE CALLS

Name of person calling or called

Date and time of call Nature of conversation Any changes in plan of care

resulting from conversation

THE JOINT COMMISION 2013 HOSPITALNATIONAL PATIENT SAFETY GOALS

The purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on problems

in health care safety and how to solve them.

This is an easy-to-read document. It has been created for the public. The exact language of the goals can

be found at www.jointcommission.org. Identify patients correctly Prevent infection Improve staff communication Identify patient safety risks Prevent mistakes in surgery Use medicines safely

BANNED ABBREVIATIONS

Use commonly accepted abbreviations, institution approved

The Joint Commission Official “Do Not Use” List

BANNED ABBREVIATIONS

MEDICATION ERRORS

76.7 % of those total errors reached the patient but did not do harm

3.2 % reached the patient and did harm 0.03% caused a death National Medication Error Reporting program

states that medication errors kill one person per day in the USA

ERRORS, OMISSIONS AND CORRECTIONS

Errors: draw single line through error, date and initial the correction

Omission: add information by identifying entry as “late entry”, or “addendum”. Sign, date and time

Avoid obliterations, erasures, or alterations

Once the accuracy of the medical record is questioned, the integrity of the entire record is questioned

DOCUMENTATION IN DIFFICULT SITUATIONS

Remain objective Avoid judgment, remain factual Do not omit important facts, even if

they are not the “best” facts If you don’t want to see it blown up to

poster size, don’t write it Sometimes documentation is not

enough-do not substitute a chart for patient/family communication

ADVERSE EVENTS/ERRORS

Do not chart any QA forms filled out, or calls to risk management No: “called risk management about overdose” Yes: “baby appears to have received high dose of

vancomycin. Pharmacy and Dr Jones notified”

Do not chart events associated with peer review or quality assurance activities

WHO SEES THE CHART?

Patients/parents Peer review Quality

assurance Payers Surveyors Attorneys Auditors

CONTROL WHAT THEY SEE

Today is the first day of the rest of

your charts!

CASE #1 Infant born via emergent C/S after a long

labor complicated by decelerations Cord wrapped tightly around the neck,

Apgars 2, 3 and 7. Resuscitation with bag & mask, brief

intubation. Transferred to nursery for supplemental

O2. Placed in open warmer on chemical

warming pad RN had obtained from a recent conference

CASE #1 - CONT.

Infant’s temp rose to 102.3 an hour later, when warming pad was removed

During a sponge bath was noted to be deep red from neck to sacrum with 2 blisters on upper back

Required debridement and plastic surgery

Permanent scarring and “neurological injury”

CASE #2

Patient admitted with irregular contractions. Regular OB on vacation, therefore covering MD was called.

FHT monitor placed and began to show decelerations at 3:30pm.

MD called at 8:10pm and told mother not in labor, FHT reassuring. MD ordered FHT monitor to be discontinued.

CASE #2 - CON’T.

Next morning, MD examined patient Infant delivered via C/S, Apgars low (no

respirations, cyanosis, hypoxia) Infant has severe cerebral-palsy, mental

retardation, and spastic quadriplegia Plaintiff contends RN staff failed to notify

MD of decelerations and negligently followed order to discontinue monitoring

Plaintiff argued MD deviated from standard of care by not seeing patient until the next day

This suit was filed 19 years after the fact

MEDICATION ADMINISTRATION

Administer drugs in accordance to drug demonstration guidelines, orders

Not protected from liability just because you followed an MD order. You are accountable for your own actions

Expected to be patient advocate, which includes becoming familiar with the medications you administer

NEONATAL CONSIDERATIONS

Weight based dosing: more calculations than with adult patients

Medications often must be diluted Patient often cannot communicate

about adverse effects May have limited reserves to tolerate

or compensate for errors

ANATOMY OF A MEDICATION ERROR

Never intentional Usually systems based Usually multidisciplinary Often fails at several steps in the system Latent failures versus active failures

COMMON NICU ERRORS

Decimal points (ten-fold, 100-fold errors) Converting numbers between units

(milligram to microgram, etc) Weight based dosing Dilution of medications

HIGH RISK FOR NEONATAL ERROR…

Total parenteral nutrition Neuromuscular blocking agents Narcotics/opiates, IV and oral Moderate sedative agents, IV

(midazolam) Hypoglycemics Heparin, IV, subcutaneous Insulin, subcutaneous, IV Magnesium sulfate injection Potassium chloride

MEDICATION ERRORS

76.7 % of those total errors reached the patient but did not do harm

3.2 % reached the patient and did harm 0.03% caused a death

BARRIERS

Increase awareness & openness

Increase reporting Perceptions (punitive) Time constraints

CASE #1: WRONG DOSE GIVEN

Nine month old in NICU had a drop in potassium level.

Order obtained for potassium chloride, but administered at 4 times the prescribed dose

Infant had a cardiac arrest which took 50 minutes to re-establish vital signs

Overdose was not noted until 2 days later when an incident report was completed.

KCL was not in the hospital’s list of medications that could be administered IV by an RN

CASE #2: WRONG BLOOD

Two infants each had an order to receive PRBC transfusion

The two units of blood were received from the blood bank at the same time for the two patients

Blood was not checked at the bedside against a patient ID

CASE #3: WRONG DILUTION OF MEDICATION

Infant required insulin injection, ordered from pharmacy

Dose error of 100 fold dilutionFound multiple dilutions available in

pharmacyStarted with the wrong dilution, checked by

pharmacist, labeled correctly, sent to unitDifference in dilution not noted, medication

given

ORGANIZATIONAL/NURSING ACTIONS THAT LEAD TO

IMPROVED PATIENT OUTCOMES Practice good telephone etiquette Have professional and appropriate

appearance Good Patient handoffs - SBAR Provide safe, age appropriate, care Appreciate and celebrate staff for jobs

well done Positive Attitude. Perform random acts

of kindness Sense of Ownership and Accountability Involve patient & family in their care Follow-up to see if they have other

questions/needs

REFERENCES

Boes, L, & Munson, D. (2002). Defensive Documentation and the Law, Iowa department of Correction. Downloaded 1/26/05.

Croke, E.M. (2003). Nurses, Negligence, and Malpractice: An Analysis Based on More Than 250 Cases Against Nurses. AJN, 103(9), 54-63.

DeMilliano, M. (1992, July). Eight Common Charting Mistakes to Avoid. NSO Advisor.

DiVarco, S. (2002). Documentation and Legal Issues in the NICU. Lecture Notes from National Neonatal Nurses Conference, Chicago.

Eskires, T. (1998). Seven Common Pitfalls in Nursing. AJN, 98(4), 33-40.

JCAHO 2013 National Patient Safety Goals Maxfield, D., Grenny, J., McMillan, R., Patterson, K., & Switzer, A.

Vitalsmarts Industry Watch, Executive Summary (2005). Silence Kills: The Seven Crucial Conversations in Healthcare

Monarch, K. (2007, July). Documentation, Part 1: Principles for Self-Protection. AJN, 107(7), 58-60.

Shinn, L., et al (2001). The Nursing Risk Management Series II. Retrieved Jan 26, 2004 from http://nursingworld.org/mods/archive/mod311/cerm2ful.html

Washington Administrative Code (2004). The Law Relating to Nursing Care and Regulation of Health Professions-Uniform Disciplinary Act. WA State Department of Health.