Case
Study #1: Failure to adequately assess and monitor the
patient post operatively resulting in the patients death
NOTE: There were multiple co-defendants in this
claim who are discussed in this scenario.
While there may have been errors/negligent acts on the part of other
defendants, the case, comments, and recommendations are limited to the actions
of the defendant; the nurse.
The
decedent/plaintiff was a 67 year old male who underwent a right total knee
replacement. Following the procedure,
the plaintiff was treated in the post-anesthesia care unit where an epidural
catheter was inserted for postoperative pain management.
Following
one episode of hypotension which was treated successfully with ephedrine, the
plaintiff was discharged to an inpatient medical-surgical care nursing unit
with the epidural in place. Although the
defendant nurse customarily worked on the post-acute critical care unit, she
had been re-assigned to the medical-surgical nursing care unit. The defendant nurse stated that she
understood her assignment at the time of the plaintiffs admission to this unit
was to provide oversight of the patient care on the entire floor for that
shift.
The
defendant nurse assessed the plaintiff upon his admission to the unit and found
him to be stable. The defendant nurse
understood that the direct care of the plaintiff was assigned to a c-defendant
licensed practical nurse (LPN).
Approximately three hours after arriving on the unit, the plaintiff was
unable to tolerate ordered respiratory therapy due to nausea and vomited
shortly thereafter. According to the
defendant nurse, approximately ten minutes after the episode of vomiting, the
LPN found the plaintiff cyanotic and unresponsive and immediately called a
code.
The
defendant nurse responded, as did the code team, and the plaintiff was
intubated and transferred to ICU. This
account of events was disputed by the LPN and two other staff on the unit who
understood that the defendant nurse was responsible for the direct care of the
plaintiff.
The
LPN stated that it was the defendant nurse who found the plaintiff to be
unresponsive at some point after the episode of vomiting and called the code
herself. The elapsed time between the
episode of vomiting and the code is also disputed. The eventual diagnosis was anoxic
encephalopathy due to the time that elapsed before CPR was initiated. The prognosis was poor and life support was
withdrawn. The plaintiff breathed
independently and was transferred to hospice care where he subsequently
expired.
Ordered
vital signs and checks of the xyphoid process were not documented. The fact that the plaintiff had experienced
hypotension in the recovery room should have warranted even closer
observation. The episode of nausea and
vomiting should have resulted in additional observation and notice to the
physician.
Resolution
Experts determined that the defendant
nurse had breached the standard of care.

Discussion
1.
Summarize
the case and the verdict.
2.
Based
on your review and summation, do you agree with the courts decision?
Defend/discuss your answer.
3.
What
practice-related legal and/or ethical issues as they pertain to Health Care management
were breached? How? By whom? Include the nurse as well as ALL other possible
defendants. DEFEND your answer.
4.
Identify
and document a risk management action plan to prevent this type
of issue(s) from reoccurring.
Case
Study #1: Failure to adequately assess and monitor the
patient post operatively resulting in the patients deathNOTE: There were multiple co-defendants in this
claim who are discussed in this scenario.
While there may have been errors/negligent acts on the part of other
defendants, the case, comments, and recommendations are limited to the actions
of the defendant; the nurse.The
decedent/plaintiff was a 67 year old male who underwent a right total knee
replacement. Following the procedure,
the plaintiff was treated in the post-anesthesia care unit where an epidural
catheter was inserted for postoperative pain management.Following
one episode of hypotension which was treated successfully with ephedrine, the
plaintiff was discharged to an inpatient medical-surgical care nursing unit
with the epidural in place. Although the
defendant nurse customarily worked on the post-acute critical care unit, she
had been re-assigned to the medical-surgical nursing care unit. The defendant nurse stated that she
understood her assignment at the time of the plaintiffs admission to this unit
was to provide oversight of the patient care on the entire floor for that
shift. The
defendant nurse assessed the plaintiff upon his admission to the unit and found
him to be stable. The defendant nurse
understood that the direct care of the plaintiff was assigned to a c-defendant
licensed practical nurse (LPN).
Approximately three hours after arriving on the unit, the plaintiff was
unable to tolerate ordered respiratory therapy due to nausea and vomited
shortly thereafter. According to the
defendant nurse, approximately ten minutes after the episode of vomiting, the
LPN found the plaintiff cyanotic and unresponsive and immediately called a
code.The
defendant nurse responded, as did the code team, and the plaintiff was
intubated and transferred to ICU. This
account of events was disputed by the LPN and two other staff on the unit who
understood that the defendant nurse was responsible for the direct care of the
plaintiff.The
LPN stated that it was the defendant nurse who found the plaintiff to be
unresponsive at some point after the episode of vomiting and called the code
herself. The elapsed time between the
episode of vomiting and the code is also disputed. The eventual diagnosis was anoxic
encephalopathy due to the time that elapsed before CPR was initiated. The prognosis was poor and life support was
withdrawn. The plaintiff breathed
independently and was transferred to hospice care where he subsequently
expired.Ordered
vital signs and checks of the xyphoid process were not documented. The fact that the plaintiff had experienced
hypotension in the recovery room should have warranted even closer
observation. The episode of nausea and
vomiting should have resulted in additional observation and notice to the
physician. ResolutionExperts determined that the defendant
nurse had breached the standard of care. Discussion1.
Summarize
the case and the verdict.2.
Based
on your review and summation, do you agree with the courts decision?
Defend/discuss your answer.3.
What
practice-related legal and/or ethical issues as they pertain to Health Care management
were breached? How? By whom? Include the nurse as well as ALL other possible
defendants. DEFEND your answer.4.
Identify
and document a risk management action plan to prevent this type
of issue(s) from reoccurring.