New Graduate Nursing Residency

• Presented by: Margaret McGahern, BSN UCLA Health Department of Risk Management

Risk Management

The role of the UCLA Health Risk Management

Department is to advise, recommend, and consult.

Our focus is identification and prevention of risk

exposures.

When an injury occurs and Risk Management is

notified, attempts made to mitigate further risk. This requires the cooperation and participation of

the involved department(s) to Identify, Assess and

Reduce the risk to prevent future events that could

result in costly claims and lawsuits.

Risk Management is Insurance Management

CLAIMS MANAGEMENT – PROFESSIONAL LIABILITY

Claims: Any demand for payment from an entity or individual, including a

UCLA employee, which is disputed in whole or in part. A “claim” is defined

to include:

Potential Liability Exposure:

An adverse event or complication resulting in an unanticipated outcome, including death, brain damage, permanent paralysis, sensory deficits, partial or complete loss of hearing or sight, birth injury or disability, or other catastrophic damage or permanent disability; an incident that has produced an actual, potential or perceived injury or potential claim.

Updated April 2018

When To Alert Risk ManagementSurgery & Invasive Procedures

Iatrogenic complications, Air Embolism,

Burns, Retained Foreign Objects, Instrument

Fragment, Needle(s), Guide Wire Drains,

Sponge(s) , Pt. Injury from a device

Never Events

Wrong site, procedure or patient, Infant

abduction, Missing pt, Suicide, Physical Assault

on staff or patient

Maternal Complications

Death, Eclampsia, Hysterectomy,

Postpartum Hemorrhage, Symptomatic

uterine rupture, Sterilization w/o consent.

Infant Complications

Apgar <3, Brachial Plexus Palsy, Cord pH

<7.0, Fractured skull, Meconium aspiration,

Air Embolism (amniotic fluid)

Updated April 2018

Control Loss

Adherence to Policies and Protocols Medication Safety – independent verification

Universal Protocol

National Patient Safety Goals

Equipment Malfunction – Sequester even if no harm

Scope of Practice

Communication Handover Report

Chain of Command

Time Out for all invasive procedures – PICC insertions

Patient, family or surrogate with proper documentation (HIPAA)

Transparency through Apology and Disclosure

Updated April 2018

Control Loss

Documentation

Should tell a story

Complete and Accurate

Reflect clinical interventions and responsescalling or paging residents, fellows or attending physicians

reasons for – and results of – x-rays, lab tests, procedures

Individualize care plans

Family / Team conferences

Goals of Care Tab

Updated April 2018

Consent

Informed Consent is a process, Not completing a form.

Failing to obtain consent may result in punitive damages /Assault and Battery

Informed Refusal -

Surrogate Decision Makers

Durable Power of Attorney Health Care – Spouse, children

Must show proof (legal documentation) before or at the time of signing consent

Conservatorship, Court Orders, Third Party

Unrepresented patients

No family, estranged, involve Social Services on admit

Updated April 2018

Consent - Informed Refusal

There are some patients who refuse to receive information about their surgery, procedure or anesthesia and that is acceptable.

Decision makers including surrogates have the right to withdraw consent.

Consequences of the decision maker’s refusal Must be explained and clearly documented by the physician in Care Connect

Updated April 2018

(LPS) Conservatorship

Consenting A Patient For Surgery

There is no such thing as two (2) physician consent. It’s a Myth!

Physician must document in the Progress Notes

Treatment of a medical emergency may be provided without consent where the provider reasonably believes that a medical

procedure should be undertaken immediately and there is insufficient time to obtain consent.

Document in Care Connect ALL attempts made to contact family (Office of the Public Guardian -“OPG”

Document patient’s inability to consent due to: Trauma, TBI , Stroke, Coma, Conservatorship. Court Order etc..

Conserved (Mental Health - LPS)

OPG does not have the authority to make medical /surgical decisions with LPS Conservatorships

Could take 4-6 weeks resulting in delay of surgical/medical treatment

Updated April 2018

Patient Death

Ways To Decrease Liability

Early intervention avoids escalation to litigation

Learn about issues happening and intervene before they escalate

Do the right thing as quickly as possible

Encourage providers to alert Risk Management when a patient is harmed.

Ex: burns, lasers, compartment syndrome-fasciotomies, wrong procedure/wrong

patient, medication events – death, falls/restraints lead to loss of function or death,

equipment malfunction (Guide wire breakage, catheter sheared off, PICCs, IAB

rupture – Save All Packaging – Event Report

Updated April 2018

Equipment / Medical Supply Malfunction

Device/Equipment Malfunction while in use on a Pt. MUST:

1. Notify Clinical Risk Manager immediately

2. Sequester device, ALL attachments/ plugs, cords, fibers, consoles including IV

bags and tubing, pressure cables, transducers. Patient Name and MRN

3. Any device, equipment, catheters, implant, prosthetic that malfunction can be

released to a vendor or Rep. without Consent of the Clinical Risk Manager pager

4. Complete SOFI with ALL identifiers, sequester location, Name / MRN, contact

person and phone number

Equipment Malfunction Cont….

5. HS Policy 0331- Incidents Related to Medical

Equipment

6. Vendor must come to our facility for the initial

investigation.

7. Whether or Not there was harm to the patient,

we are required to make a report to FDA Medsun

within 10D.

14

FDA Requires Acute Hospitals Report

• Medical Devices: range from simple tongue depressors and bedpans to complex

programmable pacemakers with micro-chip technology and laser surgical devices, VADs, GI

scopes

• Medical Devices: include electronic radiation emitting products with medical application and

claims meet the definition of medical device. Examples: MRI, diagnostic ultrasound, x-ray

machines, medical lasers, specialty beds.

• Medical Supplies: include PICC Lines, drains, HD/ Triple lumen catheters, Guidewires, Intra-

Aortic Balloon catheters, Breast Milk and Tissue / Device Implants

Operating Room – Device Overload

Updated April 2018

Equipment Case (OPE)

Office of the Patient Experience e-mailed Risk Management on 12.8.2017

• We received a letter from a patient is alleging that the XYZ device implanted on 2/27/2017

malfunctioned, causing her injury (electrical shocks), and had to be removed.

• Would you kindly review and provide a brief summary? Patient is demanding that her

outstanding balances ($5,000+) be waived, and that she be reimbursed for all monies

paid out-of-pocket for these surgeries.

• I see in Care Connect her attorney called the RM office on 10/18/17 demanding a

conference call.

• Do we have liability?

• What words stand out?

17

Equipment Case cont….

1. Implant device removed on 8.21.17

2. Implant sent to Pathology 8.21.17

3. RM is informed of patient complaint on 12.08.17.

4. Clinical Risk Manager never informed of implant failure / removal on 3.31.17

5. Report to FDA/ Medsun on device malfunctions is a requirement for UCLA

6. Failure to report on time (within 10 days)

7. Deadline missed by 235 days

Any concerns identified?

18Updated April 2018

Equipment –Implant – RM Review

1. Implant device removed on 8.21.17

2. Implant sent to Pathology 8.21.17

3. RM is informed of patient complaint on 12.08.17.

4. Clinical Risk Manager never informed of implant failure / removal on 3.31.17

5. Report to FDA/ Medsun on device malfunctions is a requirement for UCLA

6. Failure to report on time (within 10 days)

7. Deadline missed by 235 days

Any concerns identified?

19Updated April 2018

Equipment – Implant Case

• What ones concerned you the most?

• Were there delays, If so, Why did they occur?

• Were they preventable? How?

• Was the delay a result of a person or system?

Updated April 2018

Equipment – Implant Case

1. 12.8.2017 RM receives E-mail from OPE

2. Implant Surgery was 02.27.17

3. Alleges injury

4. Implant was removed

5. Demanding money in excess of $5000

6. Wants fees waived

7. Has an Attorney

Updated April 2018

Goals of Care Documentation

Called Mr. K’s son and spoke with him around 1140 am. Updated Mr.

K’s son that pt. is stable from a medical standpoint & ready for

discharge to a SNF. He has been accepted to two SNFs K.( SNF near

Cedars at request of son). Son was upset that SNF’s were contacted

and he doesn’t want dad to go to either SNF. “I want more information

about the SNFs”. Physician explained to son that “Social Worker and

Case-manager coordinate SNF placement. You need to speak with

them directly. They are more knowledgeable in this regard and this

their area of expertise.”

Goals of Care – Cont.

What is the purpose of the Goals of Care (GoC) note?

A Goals of Care note documents discussions and decisions about future medical treatments including conversations to enhance prognostic awareness, discussions leading to or failing to yield a completed advance directive, patient preferences concerning future health states and treatments, conversations leading to a POLST, and nuanced discussions about future care goals or health states.

What other information can you find in the GoC note?

Nursing Clinical Note

I entered patient's room to help my CP with the patient. The husband started yelling for

reasons unclear to us. He was very irate, called his son, on speaker phone to talk to us. Both

yelling at the same time while I tried to explain what we’re doing. Son asked "what's going

on?“. I tried to explain, He interrupted me "you stop talking & f--c-ng listen to ME!." I told him,

“don't talk to me using that language”. The yelling continued while we finished up. The charge

RN tried to speak with the husband and the son (on the phone) since they were so upset.

Security & Nursing supervisor came and tried to talk & explain the situation but the son would

not listen. Nursing supervisor advised Security to stop any visitors that come to floor and escort

them out. The family's interference, interruption, verbal abuse & threatening behaviors prevent

the clinicians from providing care.

Manipulative Families

Set limits! Patient / family; give them a copy of limits

Use the Chain of Command – ANII, UD, CNS

Key clinicians address concerns and communicate to the team

Clinical conferences prepare team to be consistent w/ communication

Document “limits” in EMR or under Goals of Care

Do NOT allow requests for procedures that are NOT needed.

Consistent communication from the clinicians is Key.

Documenting your explanations is crucial. Do Not copy and paste.

Case Discussion

• This is titled “Nursing Clinical Note”

• Do you think the clinicians felt like they had to listen to

the father and son.

• Are you in any way concerned about this note? Why?

• CiCare

Getting to “No” Your Patients

Encouraging patients to become engaged may result in assertive and

demanding patients requesting care that is unsupported by good clinical

judgment.

Physicians worry that saying “No” may increase their risk of being

dismissed, sued or reported to the CA Medical Board.

Clinicians must combine the right clinical judgment, bedside manner and

address “Evidence Based Medicine” to communicate that “No” is in their

best interest to prevent them from unnecessary - or unsafe testing or

treatment.

Getting to “No” Your Patients

Explaining the reason behind “No” takes time and patience but leaves the clinician less vulnerable to allegation of malpractice.

Accurate documentation is the best support for your decision to say “No”.

Jack Hoffman, CRICO 2012

Use Of Patient’s Personal, HS 1342

Medications brought by the patient to the hospital are immediately delivered to pharmacy where

they will be stored until discharge. A patient's personal medication may be administered in hospital

under the following circumstances:

A.The physician writes an order in the patient's medical record indicating that the patient's personal supply of medication be

used; and

B.The medication ordered is not on UCLA Medical Center's Drug Formulary, and the medication containers are labeled

according to State Board of Pharmacy regulations; and

C.The pharmacist can make a positive identification of the medication by verifying the product's physical shape, size, color, and

manufacturer's imprinted identification number. Oral liquids, intravenous solutions, ophthalmic drops, topical agents and other

products, which have the potential to have additional additives and/or adulterants and cannot be identified short of chemical

analysis cannot be administered to patients.

The Magic Word

• It can reduce the risk of claims and medical litigation if

the record is complete and accurate.

• Demonstrates to patient and family that the

appropriate interventions were carried out timely.

• Assists the Expert Witness when testifying

• Assists with Regulatory Compliance (The Joint

Commission (TJC) and CDPH.

• It helps answer questions the family have about the

adverse / medication or fall events.

DOCUMENTATION

WORKS

SOFI

1900: Received pt A/Ox3 (to person, place, and time), reoriented to situation, lethargic appearing (this has been patient's

baseline as per day shift RN; T team aware of patient's status; pt. screened positive for sepsis in the day shift; blood cultures

and lactate drawn, lactate was 13, no new interventions). Pt had intermittent episodes of anxiety throughout shift. Tachypneic

and labored breathing noted at rest and with exertion. Pt remained in SR with HR in the 70s - 90s with occasional PACs,

scheduled diltiazem and flecainide given. SpO2 >93% on 1 L NC. Cool/heated aerosol set up with face tent O2 at 6L on 30%

FiO2 to provide comfort. Pt states this helps with her mouth breathing, moistens the back of her throat. Respiratory Therapist

did scheduled Pneumovest treatment, pt. states this helps bring up secretions. Moderate thick brown/white sputum/secretions

noted, pt. independently uses Yankeur to suction and was assisted as needed with suctioning. Nausea well managed with

Zofran IVP x1 overnight, no nausea noted since.

SOFI:

Cont. Neuro checks done when repositioning pt .Q2 hours, pt. is able to assist with turning, does appear lethargic and frail,

A/Ox 3-4. Pt last turned at 0500 in supine position, pt is awake and able to participate in turning, pt A/Ox4, appears lethargic

and tired. Tolerating TF Peptamen 1.5 with Prebio at goal rate of 70 ml/hr, no residual. J-tube remains sluggish, papaya

enzyme given to improve patency. Accucheks done Q6 hours. NGT flushed as per order, remains to gravity drainage.

Fall/safety/aspiration precautions maintained at all times. Hourly rounds performed. At 0640, three doctors from T team

including residents arrived at bedside. Pt appeared lethargic, arousable to tactile stimuli. Vital signs: BP 126/59, temp 37.1,

respirations 24, spO2 98 on 1L NC. Team ordered stat ABG x2 and suspected aspiration PNA. Orders placed to transfer pt to

XICU for HLOC. Around 0715, Pt transferred to XICU, Lab called with critical ABG, notified Dr. GK en route to XICU . Pt

intubated in the XICU

SOFI: Short & to the point

1900: Received pt A/Ox3 reoriented to situation, lethargic appearing (this has been patient's baseline as

per day shift RN; T team aware.pt. screened positive for sepsis in the day shift; lactate was 13, no new

interventions). Tachypneic and labored breathing noted at rest and with exertion. Moderate thick

brown/white sputum/secretions noted. Does appear lethargic and frail. At 0640, T team including residents

arrived at bedside. Pt appeared lethargic, arousable to tactile stimuli. Team ordered stat ABG x2 and

suspected aspiration PNA. Lab called with critical ABG. pH 7.24 / PCO2 97/ PO2 70/ Bicarb 41/ BE 9. Pt

intubated in the XICU.

Comments on scenario above?

Nursing Clinical Note vs SOFI Entry

FACTS about a negative situation can be

documented in the Legal Medical Record.

Fall, Medication, Adverse Event, Incorrect test or

procedure (X-ray /MRI), Behavioral / Disruptive

family /visitor, Security

Document interventions

Outcome of situation

UDs, Nurse Supervisors, CNS document if they

intervene with a family/patient.

Resident paged x3 10 -1115AM decreasing O2 Sats

SOFI: provide specific details that should not

go into the EMR.

What actually occurred – Challenging family

What happened – verbal threats, foul language,

aggressive behavior, will sue you!

Why/How did it happen? MCSW spoke of D/C

plans now refuses to leave.

Recommendations ideas for improvement

Do NOT Copy or Paste from the EMR

DOCUMENTATION

EXAMPLES

How Good Is Your Documentation?

Proper documentation is essential to protecting yourself in your nursing

career and essential to patient safety. It must be truthful, legible, and

above all, comprehensive.

Attorneys will scrutinize looking for any mistake or inconsistency.

Regulatory organizations such as TJC, CMS, CDPH, Leapfrog, PSO will

review your documentation to see if you are providing quality healthcare.

You can never be too thorough, and no event is too small or

inconsequential to include in your charting.

Should I Document

Documenting what happened is important, But… sometimes documenting

what didn’t happen can be more important.

missed attempts on intubation,

missed respiratory treatments,

attempted CVC, IV, and IO insertions

Who is affected

RCPs – NPs - Resident – Fellows - Nurses

Nursing Documentation Do a thorough assessment. Objective and Subjective

Make sure you refrain from your own theories about what is going on. Don’t

speculate. Facts

Describe your interventions and the patient’s response.

Include essential conversations with other clinicians, especially the doctor.

Include with whom you consulted, what you told them and what their

responses were. Include any diagnostic tests arising from your

assessment.

Evaluate your actions.

Evaluate and list the effectiveness of your interventions by describing the

patient's response.

Documentation - Refusal

End of Shift Summary: Pt has been resistant and requires extended time to

educate/convince to comply with nursing routines/MD orders (i.e: blood draws,

radiology). X-ray bone completed. Blood draw canceled due to multiple refusals by

pt. Pt. reports pain at 9/10 to BLE and joints however is seen turning self in bed

without grimacing/guarding, no changes in HR, no changes in breathing patterns

noted. Pt is highly anxious and emotionally labile. Started on PO pain med regimen

with IV Dilaudid for btp.

Question: What stands out in the above note?

Identified Risk Issues

Ambiguous documentation of positioning

(what is expectation, who documents, several places)

Wound Care Consultation – is it done timely?

Failure to notify physician of breakdown

Physician documentation lacking regarding assessment or plan of care

Assessment at discharge or transfer lacking or not precise

Lack of follow-up and coordination of care on discharge

The Challenge –

Non - Compliance

An ethical response to making mistakes in

professional practice.

Prevention will decrease errors in healthcare but that’s not all we can do.

When a mistake or an Adverse Event occurs, how we manage the situation

can affect how we feel as well as the patient and family affected.

We may not know how to respond properly

We may lack sufficient support to make a healthy recovery from the mental anguish

and emotional suffering that can accompany making mistakes

• PERC – Post Event Recovery Communication

PERC

Post Event Recovery

Communication

What Is An Unanticipated Event?

“A negative or unexpected result stemming from a diagnostic test,

medical judgment or treatment, surgical intervention, or from the

failure to perform a test, treatment or intervention.

It is not necessarily the result of medical error or professional

negligence”.

Following An Event……

Begin investigation immediately following the event to achieve the best outcome.

Notify Management/Administration using the Chain of Command

Initiate an Event Report

Involve Risk Management if necessary (When to ALERT Risk Management)

Questions to answer:

Did (Attending MD/Unit Director) verbally offer an Apology

Was the event disclosed and documented in the EHR by the attending?

Nursing leadership to review documentation and identify potential vulnerabilities.

Could anything have been done to prevent or minimize harm?

Were policies followed?

Disclosure - Apology

Should be done within hours post event and no longer than 24 hours Respond in a timely fashion – Delays can look like a cover up Apologize to patient/family. “I’m sorry you and your family have to go

through this.” Demonstrate a caring, concerned attitude Consider the personalities and communication skills of the family

spokesperson and primary communicator (clinician) Familiarize yourself with the facts prior to meeting Focus and listen to the concerns of the patient /family Avoid becoming defensive or offensive Do not admit fault Initiate an Event Report

California Apology Law: CA Evid. 1160

(a) The portion of statements, writings, or benevolent gestures expressing sympathy or a

general sense of benevolence relating to the pain, suffering, or death of a person involved in

an accident and made to that person or to the family of that person shall be inadmissible as

evidence of an admission of liability in a civil action. A statement of fault, however, which

is part of, or in addition to, any of the above shall not be inadmissible pursuant to this

section. (b) For purposes of this section: (1) "Accident" means an occurrence resulting in

injury or death to one or more persons which is not the result of willful action by a party. (2)

"Benevolent gestures" means actions which convey a sense of compassion or

commiseration emanating from humane impulses. (3) "Family" means the spouse, parent,

grandparent, stepmother, stepfather, child, grandchild, brother, sister, half-brother, half-

sister, adopted children of parent, or spouse's parents of an injured party.

Why Disclose?

Goal: To dispel anger, confusion and distrust

Talk about how the patient’s care will be managed

Arrange for appropriate consultants

Advise family of identity of contact person

Inform risk management and sequester equipment /supplies involved

With assistance from RM, address bills for follow-up care (need approval)

Ensure follow-up —disclosure may be an ongoing process

Document the discussion and the disclosure (includes all clinicians, UD, CNS,

AHS, ANII)

Advise other staff e.g., nurses, residents, Hospitalists of the plan for disclosure

Message to patient/family has to be consistent

Surgical “Burn”

Operative Notes by Surgeon, MD at 08/28/14 @ 1831 “ The soft tissue was then irrigated with saline. We noted small

amount of skin denudement (2 cm area) around the midline incision

from the saline irrigant at the end of the operation. The surrounding

skin (3 cm area) appeared mildly erythematous. Bacitracin was

applied. Dry sterile dressings were applied.”

MD called Risk Management regarding the above event and stated

she “placed a consult to Plastic Surgery.”

Is there anything else to do for the patient?

What are the next steps or are you done?

Surgical “Burn” – Disclosure

Progress Notes by Surgeon, MD at 08/2014 @ 1831

“I discussed with the patient and her family (brother) this afternoon that the

saline irrigation that we used for the soft tissue at the end of the operation prior

to skin closure was noted to be perhaps too warm. We noted a small area of

skin denudement and mild skin erythema in the operating room. In the PACU,

the skin was noted to be more erythematous and is blistered. We consulted

the plastics surgery team for evaluation and treatment recommendations. They

will continue to follow the patient, and we will follow their recommendations. All

questions were answered to their satisfaction.”

Physician Disclosure – Surgical Injury

…….during the operation, point unknown, the sigmoid colon was injured likely

from the left lower quadrant ports. This was not noted at the time of surgery and

aside from the pts being a larger gentleman with a large diastasis with the

hernias within it, the operation was entirely uneventful. I had put in an extra port

on the right side to make sure that we could see on the left side and watch all of

our ports as well as introduce the mesh through that site. I have discussed the

colon injury with his parents at length both over the phone from out of the

country and in person, my regrets and have explained that this is an

exceedingly rare complication of laparoscopy (1.3 per 1000).

Criticisms of Care

Failure to weigh and monitor intake and order relevant labs and give

appropriate nourishment

Failure to reposition on multiple occasions

Failure to do dressing changes as needed

Failure to carry out wound care consult - Ordered – 4 days over holiday

Failure to medicate patient which precluded repositioning

LOW FREQUENCY/ HIGH RISK

T-TUBE

• Patient with complicated history of severe tracheal stenosis, previous admits.

• Undergoes a Stage 1 Laryngotracheoplasty with placement of a Montgomery Tracheal T-tube (“T-tube”), first of three

procedures.

• Initially stable. T-tube capped during the day - suctioning by nursing/son.

• Floor RN responds to noise. Son suctioning patient - distressed.

• RN attempted to calm the patient. No improvement; RN suctions but only small amount of mucus.

• Calls RT and resident stat. RT not familiar with T-Tube, although he attempted to provide the patient with oxygen.

• Code called – Anesthesia team not familiar either but able to ventilate patient.

• Patient transferred to MICU - irreversible global anoxic brain injury.

RISKS IDENTIFIED

• Risk 1 - Appropriate protocols and practices regarding care of

the patient with unusual-Tubes not in place.

• There were no specific protocols or procedures which addressed

the care of patients with these unique T-tubes. There was only a

brief mention of T-Tube care in the General Trach Care nursing

policy.

NOTE: There was an ambiguous policy confusing to staff

RISKS IDENTIFIED

• Risk 2 - There was confusion regarding the need for and

type of Adaptor and how to respond to an emergency

which was not addressed adequately by Leadership.

• Not stocked on floor

• Low frequency – high severity device. Although the procedure had been done for several years, Leadership failed to recognize that device was not implanted with sufficient frequency to afford the nurses comfort in caring for the patients during a respiratory crisis. Case at issue night shift during a weekend.

RISKS IDENTIFIED

• Risk 3 - There was a communication breakdown in failing to coordinate the care of patients with this type of tube with another essential department.

• An internal investigation determined that RT had not been included in the management of these patients on the nursing unit, and as such were not familiar with the unique device.

LESSONS TO BE LEARNED

• When introducing a new piece of equipment or medical device, make sure that there is a thorough

evaluation of workflow before implementation.

• Are all those who could potentially be involved in caring for patients with the equipment/device included

in the informational, investigational and educational processes.

• Don’t assume anything. Here, a critical department was not involved.

• In developing the process, evaluate all potential scenarios, and complications to ensure necessary

equipment is readily available to address identified concerns. In this case, a complete occlusion of a T-

Tube had not been considered.

• Suctioning had been utilized successfully in the past for instances of partial occlusion. Hence, it was

not anticipated that suctioning would not be able to work in this case.

LESSONS TO BE LEARNED

• If the device is not frequently utilized, ensure resources are

available and steps in place to help familiarize staff. If there is the

possibility of high severity, consider designating trainers who are

responsible for refreshers and educational tools for bedside use or

available to access in the EMR.

• Ongoing monitoring and assessment with retooling as necessary.

• Ensure policies/protocols or educational tools accurately reflect the

process.

Case – Neuro Event

Two (2) 40 yr. old M, same initials arrived in ED within 1 hour. One male

fell off a crane on his head, other male had severe H/A & new seizures.

Two different RNs involved. Brain CTs performed. Escort gave reports to

ED clerk.

Impression: One patient had lg. intracranial bleed; other pt.. showed

signs of a stroke.

Intervention: Neurosurgeon called for intracranial bleed; Stroke Team

paged.

Case – Neuro Event cont.

Event 1: Impending stroke patient, mistakenly taken to OR.

Surgeon said “let’s go!” Upon opening the skull…….. No

intracranial bleed!

Event 2: Stroke team immediately realized they were assessing

the intracranial bleed patient and called OR.

Case - Neuro – RM Questions

Were these preventable events?

Is the organization liable?

What processes failed?

Do you feel staff wanted to speak up in the OR?

What prevents staff from “Speaking Up”?

Case –Neuro – RM Review. Departments affected:

• Emergency staff / physicians; Radiologist; Perioperative staff; Stroke Team;

Transportation; Neurosurgeon; Anesthesiologist; Residents; Billing, Quality

Management; Risk Management and Finance.

What went wrong:

• No Patient Identification NPSG #1; Universal Protocol – HS 1344; Hand Off

HS1395: communicate patient-specific information when transferring care of a patient

between or among providers

• Effective Communication - NPSG #2; Distractions - Patient Identification –

Placement Of ID Bands HS 1301

Case Outcome

Identify the current policies or practices:

Universal Protocol – HS 1344

NPSG #1 - Name Identification

Chain of Command Policy - HS 1405

OUTCOME: Both men suffered neurological impairments; Disclosure involved 2

families; cases reported to CDPH (included hospital fines); Families filed lawsuits.

LEGAL OR RISK?

Litigated Cases

Type of Cases Involving Nursing Care:

• OB

• Falls

• Pressure Ulcers

• IV infiltrations

• Assessment – Chain of Command/Escalation

• Discharge

• Peripheral cases – nursing documentation significant

Negligence Defined

A failure to use reasonable care to prevent

harm.

You can be negligent by acting or by failing to

act (an omission).

You are negligent if you do something that a

reasonably careful person would not do in the

same/similar circumstance.

You are negligent if you fail to do something

that a reasonably careful person would do.