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Summary: Registered Nurses in their training cover each of the accepted areas that a new graduate might be expected to work in. Once in the field, it is expected that additional and specific training to a Department or Specialty will be obtained. In this case, the Psychiatric nurses did not pick up on a festering infection in a patient that had tried to commit suicide. Was the fact that they were Psychiatric nurses a valid excuse?The patient was admitted to the facility after he had tried to commit suicide. He had taken a loaded gun, covered his abdomen with a pillow and shot himself. Emergency Medical Services were summoned and the patient was transported to a nearby Emergency Department.
"Suicide Facts:
• Over 32,000 people in the United States kill themselves every year accounting for 1.4% of all deaths, suicide is the 9th leading cause of death in the U.S..
• A person commits suicide about every 15 minutes in the U.S. but it is estimated that an attempt is made about once a minute.
• 60% of all people who commit suicide kill themselves with firearms.
• There are 4 male suicides for every female one however, at least twice as many females as males attempt suicide.
• 3/4 of all suicides are committed by white males."2The patient was examined and stabilized. After Assessment by the Emergency Department physician, a consult with a surgeon was ordered.
His condition was considered serious and transfer to the Intensive Care Unit was performed.
The ICU surgeon arrived and examined the patient's wound. It was clearly a wound into the abdomen with portions of the pillow "stuffing" imbedded inside the body.
No surgical intervention was performed at that time for the patient's self-inflicted gunshot wound. From the date of admission till discharge from the Psychiatric Unit, the patient would receive only a single dose of Intravenous Antibiotics.
During the patient's stay, signs/symptoms of an active infection were noted from the gunshot wound. It is unclear if this was brought to the attention of the physician. It was not documented by the Nursing staff.
What is clear, is that on discharge, the patient was seen by his family physician and was immediately put on antibiotics to treat an active abdominal infection.
Later at home, the patient and his wife had "removed" pieces of the pillow still intact in the patient's wound from the time of the gunshot wound.
A surgeon would again be consulted and a series of three operations to debreed and remove foreign bodies from the patient's abdomen followed.
The surgeon stated plainly, that all of the material present could have been removed when the patient was seen in the hospital initially.
The delay in treatment of the patient's injury clearly had led to both an active infection and the need for further debreeding. The surgeon stated also that further operations still may be required for the wound to heal properly.
The question would arise of "why wasn't the patient treated when initially seen."
The patient sued the hospital, the nursing staff and the physicians who had initially treated him in the hospital. An Emergency Department Physician witness for the plaintiff offered testimony as to standards of care to be observed in this case. The defense moved to have his testimony disallowed.
Questions to be answered:
1. Was the standard of care for a patient admitted for a gunshot wound breached by either the hospital staff, nurses or physicians during the patient's admission.
2. Was either the physician, psychiatrist or nursing staff negligent in their diagnosis/observation of a potentially life threatening infection during the patient's hospital stay in the Psychiatric Unit?
3. Did the documented delay in treatment cause harm to come to the patient and necessitate further medical treatment/attention.
The Emergency Department Physician in his testimony stated clearly that foreign material present in a gunshot wound presented an imminent danger of infection and sepsis. He questioned why it had not been removed initially.In his discussion of the medical and nursing care in the Psychiatric Unit, he made the following observations.
The sole order written to address a potential infection was a single dose of IV antibiotics.
During the stay the wife and patient noted purulent drainage and foreign material still intact in the wound. They claimed to have brought this to the attention of the Nursing staff. Examination of the charting and documentation in the Nurses Notes revealed no such observation.
A medical chart including nurses notes have long been recognized as legal records. The fact that the patient's abdominal wound was not mentioned in the documentation, strongly reinforced the argument that negligent nursing care had been rendered. This omission of observation demonstrated a significant breach of applicable Nursing Standards.
It should be noted that the lack of thorough documentation of the patient's wound by the nurse significantly strengthened the plaintiff's case. Often testimony by "witnesses" can be dismissed or invalidated by an opposing attorney. Clear and concise documentation in a medical chart by a nursing professional, when available, carries much more weight.
The patient's infection was likewise not addressed in the physicians or psychiatrists progress notes.
"When an injured patient seeks legal advice about filing a medical malpractice lawsuit, the attorney's first task is to review the medical records. The attorney is looking for specific acts of negligence and at the overall quality of the record. The strongest medical malpractice lawsuits are based on well-documented, specific acts of negligence. In most cases, however, the negligence is inferred from documented and undocumented events."3
The observation of the patient and duty to report any actual or potential change in condition is a basic nursing standard. The prudent nurse, that is a nurse in any department or specialty with experience similar to the psychiatric nurses in this case, at the first sign of a potential infection of an open wound, would be expected to notify the physician. The next logical step would be to obtain an order to culture the purulent material to identify the organism and it's susceptibilities.
An argument was made and dismissed that because the nurses caring for the patient were not Medical Surgical, Emergency or nurses experienced in Wound Care that their potential liability should be lessened.
It is clearly defined the in nurse practice acts of each state that a licensed "nurse" will be competent to perform certain basic duties. This is regardless of where or under what specialty that nurse is practicing in. Failure to perform these duties will be grounds for disciplinary action against a nurse's privilege to hold a license.
The duty to the patient of observation, accurate charting and documentation, and duty to report to a phsyician (or psychiatrist in this case) significant changes in condition was breached.
The consequences of the delay in treatment were apparent and documented well by the patient's family physician and surgeon performing the three sucessive surgeries.
The main question raised by the defense was the "appropriateness" of a Emergency Physician documenting on the performance of duties of another physician, the surgeon and the nursing staff.
It was ruled that as an Emergency Physician, familiar with standards of care in the Emergency Department, he could give satisfactory testimony on the alleged negligence of both the Medical and Nursing staff.
He stated unequivocally that the patient should not have left the Emergency Room or Intensive Care Unit until arrangements had been made for surgical intervention to treat the patient's gunshot wound and remove the clearly evident foreign bodies.
The simple fact that the patient's condition went untreated both initially and well into his admission merited a finding of negligence on the part of each party involved in the patient's stay.
Related Nursing Link Sections:
Abuse: Domestic, Physical, Verbal Links, Direct Patient Care on: The Nurse Friendly
http://www.nursefriendly.com/nursing/directpatientcare/abuse.htmClinical Charting and Documentation, Nurses Notes:
http://www.nursefriendly.com/nursing/directpatientcare/clinical.documentation...Courtroom Directory:
http://www.legalnursingconsultant.org/legal.nurse.consultants.lnc/courtrooms....Direct Patient Care Links on: The Nurse Friendly:
http://www.nursefriendly.com/nursing/linksections/directpatientcarelinks.htmEthics:
http://www.nursefriendly.com/nursing/directpatientcare/ethics.htmMedical Legal Consulting Nurse Entrepreneurs:
http://www.nursefriendly.com/nursing/ymedlegal.htmPhysical and Mechanical Restraints, Direct Patient Care Links on: The Nurse Friendly:
http://www.nursefriendly.com/nursing/directpatientcare/physical.mechanical.re...Psychiatric Nurses:
http://www.nursefriendly.com/nursing/directory/spec/psych.htmlPsychiatric Links, Direct Patient Care on: The Nurse Friendly
http://www.nursefriendly.com/nursing/directpatientcare/psychiatric.htmSuicide, Psychiatric & Mental Health, Direct Patient Care on: The Nurse Friendly:
http://www.nursefriendly.com/nursing/directpatientcare/psychiatric/suicide.htmViolence & Violent Patients:
http://www.nursefriendly.com/nursing/directpatientcare/violence.violent.patie...Related Nursing Malpractice Cases:
August 22, 1999: Psychiatric Nurse, Sued By hospital After Developing Relationship With Client?
Wright v. Mercy Hosp. Of Janesville - 557 N.W. 2d 846 - WI (1996)
Summary: Doctors and Nurses by nature of their positions deal with patients when they are vulnerable, off-balance and emotionally needy. When the population includes the psychiatric patient, the potential exists for a client to develop "feelings" for the caregiver. In this case, a sexually abused mother of three was admitted for multiple mental disturbances. During the course of the treatment, a relationship developed and led to sexual encounters following discharge. When it came to light, the patient successfully sued. The hospital would attempt to recover damages against the nurse following her testimony in defense of the facility. This is commonly called a Subrogation action.
http://www.nursefriendly.com/nursing/clinical.cases/082299.htmAugust 15, 1999: Violent Psychiatric Patient Attacks Nurse,
No Legal Recourse Against Facility or Psychiatrist?
Charleston v. Larson, 696 N.E. 2d 793 – IL 1998
Summary: It would seem absurd, that if a physician admits and facility assigns a nurse to care for a known violent patient, that it has no legal obligation to protect that nurse against violence. In this case, a psychiatric patient sought admission to facility. On admission, he threatened to attack a nurse. When the patient would follow through on his threat, the nurse was denied legal recourse against the psychiatrist who could have taken precautions against the attack.
http://www.nursefriendly.com/nursing/clinical.cases/081599.htmAugust 1, 1999: Nursing Duty To Patient, "Does Not Guarantee" Safety Or Quality Of Care.
Summary: When a nurse accepts report and responsibility for the care of a patient a duty to the patient is also accepted. This duty is to provide a reasonable standard of care as defined by the Nurse Practice Act of the individual state and the facility Policy & Procedures. In this case, a post-op abdominal aneurysm repair patient was injured after falling from his bed to the floor. When a lawsuit was filed the court initially mistook expert testimony to imply the role of the nurse includes a guarantee of safety.
Downey v. Mobile Infirmary Med. Ctr. - 662 So. 2d 1152 (1995).July 4, 1999: Diabetic Coronary Artery Bypass Patient, Septic & Noncompliant. Nursing Duty and Responsibility Questioned.
Patient noncompliance can present serious challenges to nurses and physicians providing care. If aware of the proper measures to be taken, what happens when the patient does not agree or comply with the course of treatment? In this case, a patient after having a coronary artery bypass grafting developed a sternal infection. When advised by a nurse to return for treatment, the patient refused.
Kind v. State Ex Rel. Dept. of Health, 728 S.o. 2d 1027 -LA (1999).
http://www.nursefriendly.com/nursing/clinical.cases/070499.htmJune 27, 1999: Elderly Patient Repeatedly Injured In Nursing Home "Accidents." Negligence, Coincidence or Abuse?
As the elderly population continues to increase, more and more families are faced with the decision to place loved ones in nursing homes. When a family member is placed in a facility, a certain standard of care is expected. In this case, a resident was injured repeatedly while under their care. When the patient died a few days after being "dropped" the family sued.
Brickey v. Concerned Care of Midwest Ince. 988 S.W. 2d 592 MO (1999)
http://www.nursefriendly.com/nursing/clinical.cases/062799.htmJune 6, 1999: Emergency Department Nurse Verbally Abused, Physician History Well Documented
Official tolerance for verbal abuse and sexual harassment is approaching zero. It is clear that both are still prevalent in healthcare settings today. Enforcing and reporting instances of abuse are critical to an end being put to the situation. In this case, a physician had a "history" of verbal abuse in the facility involved. It was the documentation of previous events that made formal action and administration of a suspension feasible.
http://www.nursefriendly.com/nursing/clinical.cases/060699.htm
Gordon v. Lewiston Hospital, 714 A.2d 539 – PA (1998)May 30, 1999: Patient Left Unrestrained, Patient Injured. Nurses Judgement Call
The decision to use or not use restraints must be made with caution and good judgement. Their intended purpose must be to protect either the patient or others who may be injured by the patient including the staff caring for the client. The ultimate determination of necessity is left with the physician. Often, the moment to moment necessity is determined by the nurse. In this case a nurse did not feel restraining the patient was necessary. When an injury occurred, the patient sued.
Gerard v. Sacred Heart Medical Center - 937 P. 2d 1104 (1997)Sources:
1. 40 RRNL 5 (October 1999)
2. American Foundation for Suicide Prevention. 1996. Suicide Facts. Retrieved October 24, 1999 from the World Wide Web: http://www.afsp.org/suicide/facts.html
3. Richards, Edward P. Medical Records as a Plaintiff's Weapon. Retrieved June 13, 1999 from the World Wide Web: http://plague.law.umkc.edu/Xfiles/x188.htm
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http://www.nursefriendly.com/nursing/clinical.cases/101799.htmSend comments and mail to Andrew Lopez, RN Created on November 1, 1999
Last updated by Andrew Lopez, RN on Monday, January 25, 2010
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