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.
NursesGeneral NursingArticle
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.
