Lessons Learned as an Expert Nurse Witness

In the past couple of years I have been asked to serve as an expert nurse witness for several medical-legal cases. The downside of consulting for medical-legal cases is that the cases are almost always extremely sad, involving the untimely death of a patient. The upside is, the lessons I’ve learned reviewing these cases has made me more meticulous in my own nursing practice. Many of these lessons can be applied to nursing care on any unit.

Lessons Learned as an Expert Nurse Witness

I never planned to become an expert nurse witness for medical cases. I didn't go to any class to do this. I'm a pediatric ER nurse and a clinical instructor. However due to my expertise in pediatric triage and assessment, identified through some of my work experiences and professional organization involvements, I have recently been asked to take on the role of pediatric expert nurse witness for several medical-legal cases. I have to admit, it is pretty interesting work. Reviewing these cases has opened my eyes to common errors in nursing judgment and documentation. I'd like to share a few of these "lessons learned":

"If you didn't document it, you didn't do it".

Ring a bell? It is something I've heard countless times since becoming a nurse. But reviewing the charts of medical cases has driven it home. Here are some common documentation omissions that I've observed:

  • No pulse oximetry recorded for a child who came to a pediatric ER for a respiratory complaint (cough and fever).
  • No continuous vital sign monitoring recorded for a child who EMS reported had O2 sats in the 80's. Until she coded 8 hours later.
  • No documentation of provider notification for changes in patient status (which includes behavior- more on that later).
  • No documentation of which nurse was assigned to and responsible for a patient. When a patient has a bad outcome, this raises a major red flag.
  • No documentation of transfer of care between RN's. Same point as above.

Don't be so overloaded by documentation that you forget to document what matters most.

Sometimes we are so busy checking boxes for the countless screening tools and care plan goals, we may forget to document some key parts of our assessment. We can't let that happen. We have to be careful to address all pertinent parts of our nursing assessment and vital signs, period. When a patient comes in for a cardiac or respiratory complaint, for example, our assessment documentation should reflect the fact that we actually touched and assessed our patient and didn't simply rely upon machines and monitors for information.

Always touch your patient when you assess them.

Look, listen and feel. I can't say that enough. Vital signs are NOT a full assessment; they are simply a tool to aid in the assessment. Very sick patients (especially children) can sometimes compensate for a long time before their vital signs tank.

Don't be afraid to consider Intraosseous (I/O) access!

I/O access is not nearly as scary or difficult as it sounds, and it can literally save a life when time is of the essence. Find someone trained to do it when it matters. In one case I reviewed, a very dehydrated child went 6 hours with no access (IV and central line attempts were unsuccessful). She compensated until she couldn't anymore. If she had received IV fluids just hours earlier she likely would have survived her illness.

Don't assume changes in behavior are behavioral in nature.

The lesson here is, always ASSESS, never ASSUME. Yes, kids and teenagers can be anxious, dramatic, even combative. But if there is a change in behavior or mental status, don't take it at face value; think critically and explore it. In a pediatric patient, any change in mental status should be considered to be a result of hypoxia until proven otherwise1. A full reassessment (which includes actually touching the patient, auscultating breath and heart sounds, lifting the shirt and observing work of breathing) and vital signs should be performed.

Always notify the physician after changes in patient status.

This one is an extension of the previous. It is something we usually do, but don't always remember to document. Notify the physician /provider of any change in status and document this notification. If the patient needs to be reassessed by a provider we must be patient advocates and ensure this happens, even if it means going up the food chain until someone listens to us.

References

1. Emergency Nurses Association (2012), Emergency Nursing Pediatric Course. Emergency Nurses Association, Des Plaines, Ill.

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ElizabethStoneRN

About ElizabethStoneRN

I'm a pediatric emergency nurse of 12+ years and a clinical instructor for UNC-Chapel Hill's School of Nursing.

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Specializes in dealing w/code browns and blues.

Wow - great article! Thanks for sharing.

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Would you have to make an argument for I/O ? From what I have seen of that procedure it looks like something that would be difficult to convince someone to consent to unless someone seemed obviously in peril?

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Thanks for writing this. It certainly reinforces the importance of documenting correctly.

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I know this article is geared more towards hospitalized care,but i am in homecare.

On the last point of notifying the physician,many parents do not want the nurses to call the Doctor.

What should we do other than document it?

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Specializes in ICU.
I know this article is geared more towards hospitalized care,but i am in homecare.

On the last point of notifying the physician,many parents do not want the nurses to call the Doctor.

What should we do other than document it?

I don't work in home care, so somebody else's opinion may be more pertinent, but... the parents don't have a nursing license to lose, YOU do. I would call the doctor if I thought I needed to. If you don't, and something goes wrong with the child, I don't think the parents would hesitate to throw you under the bus. "The NURSE knew something was wrong but she didn't call the doctor!!!!" From what I understand, failure to rescue is a pretty common reason to get sued.

OP - How exactly do you go about becoming an expert witness? Who is it that approached you - hospital legal team? An outside lawyer? I always thought it sounded fascinating and that it was something I'd be interested in doing.

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Specializes in Case mgmt., rehab, (CRRN), LTC & psych.
OP - How exactly do you go about becoming an expert witness? Who is it that approached you - hospital legal team? An outside lawyer? I always thought it sounded fascinating and that it was something I'd be interested in doing.
Some colleagues of mine have been approached by plaintiff's attorneys who have asked if they would serve as expert witnesses. They've all refused, and so would I.

Even if another nurse made a mistake or failed to rescue, I would not point out their errors or deviations in the standard of care. To me, serving as an expert witness feels like I would be throwing another nurse under the bus, so I will not do it.

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Specializes in Adult and Pediatric Vascular Access, Paramedic.
Would you have to make an argument for I/O ? From what I have seen of that procedure it looks like something that would be difficult to convince someone to consent to unless someone seemed obviously in peril?

IO is indeed used as a last resort; however the reported child died, so I would have considered that child in peril. Kids can be in peril way before we realize it, since as the OP said they compensate and then crash.

IO is actually minimally painful to insert, its the actual infusion of fluid/medication that causes the pain. Pre-hopsital we administer Lidocaine for that pain if the patient is awake enough, which seems to help a little. Pain is better than dead, remember that. You can also give 2-3 boluses as needed through the IO and then look again of PIV or central line access since it may be easier once the patient is less dehydrated.

If you educate the parents in the case of a child, I am going to assume they would agree to it, especially if it means their child will get the help they need. In the case mentioned the patient was sick enough to warrant trying central line access.

Annie

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Interesting article. It is good for us to see that side of a lawsuit. It is a good reminder to document EVERYTHING. If you did the work you better give yourself the proof of it. Also it is a reminder that we are sometimes the advocate that makes the difference between a patient living and dying.

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Specializes in ICU.
Some colleagues of mine have been approached by plaintiff's attorneys who have asked if they would serve as expert witnesses. They've all refused, and so would I.

Even if another nurse made a mistake or failed to rescue, I would not point out their errors or deviations in the standard of care. To me, serving as an expert witness feels like I would be throwing another nurse under the bus, so I will not do it.

That's a good point - I hadn't thought about it like that. I've just always thought about it along the lines of it being something somebody has to do, so if somebody just has to make that extra money without working an extra bedside shift, it might as well be me one day.

Besides, you could always be an expert witness for the defense instead of the prosecution. That would be helping another nurse to save her job instead of throwing her under the bus. :)

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Some colleagues of mine have been approached by plaintiff's attorneys who have asked if they would serve as expert witnesses. They've all refused, and so would I.

Even if another nurse made a mistake or failed to rescue, I would not point out their errors or deviations in the standard of care. To me, serving as an expert witness feels like I would be throwing another nurse under the bus, so I will not do it.

I respectfully disagree. To me this sounds like "the White Wall of Silence". If a nurse makes a mistake or fails to rescue and this results in a patient being harmed or killed the nurse in my opinion has accountability. To what degree needs to be assessed. Aiding in covering something like that up goes against everything I believe in. What happens when the mistakes or failing to rescue isn't a one-off, but part of a pattern?

If the nurse's mistakes were due to (wholly or partly) to substandard staffing, equipment, training, protocols or any other organizational failure it's the nurse's attorney's/representative's job to expose that. No nurse should ever have to take

the fall for the failures of an organization, but patients deserve protection from incompetent healthcare professionals. While I believe that the vast majority of incidents in healthcare are to be blamed on a chain of events/circumstances and poorly managed organizations and seldom on a lone individual, the occasional incompetent nurse or physician do exist, and should in my opinion be re-trained

when appropriate or weeded out when necessary.

Another advantage of an expert witness is that they actually understand a lot more and can likely explain that providing nursing/medical care isn't as black-and-white as

a layman would imagine. Patients don't always present with the same signs and symptoms. I think that if people who are medically "ignorant" were to judge by themselves that judgment would many times be harsher than when the complexities of the human body and disease process are explained to them.

I come from a different healthcare culture as I am a Scandinavian nurse. Healthcare professionals don't get sued in a court of law (but we can be reported to healthcare authorities and investigated) and I realize that your reality is different. My stance on this matter presupposes that your judicial system actually works and that blame and accountablity will be justly attributed. If it doesn't then you have a big problem, because a system that punishes the individual wrongfully but won't hold the organization accountable, is a system set up to protect those individuals who are in fact incompetent.

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Specializes in Case mgmt., rehab, (CRRN), LTC & psych.
Aiding in covering something like that up goes against everything I believe in.
I wouldn't engage in a cover-up; however, I will never testify against another nurse. The legal team will need to look elsewhere because I will never participate in another nurse's fall from grace.

If that sounds bad, so be it.

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