Transcript Presentation title

Presentation title
Name/Credentials
Organization
Date
Neonatal Patient Safety,
Documentation and Legal Issues
Authors: Linda M Hess, RN, MN, CNS
Jere O’Brien-Kinne, RN, MN, CNS. CPNP
Chris Cooper, BSN, RNC, MBA
Updated 2012: Kimberly Cooper, RN
Objectives
• Discuss the legal implications associated with working in the
perinatal/neonatal arena
• Describe recent trends in nursing negligence/malpractice
• Describe most common charges against nurses
• Discuss how the National Patient Safety Standards affect yo
• Describe how you can protect yourself
• Discuss the importance of clear, concise documentation
• Review the most common documentation issues
• Identify the need to utilize the “Ladder of Hierarchy” for
issues and principles of professional communication.
Our Attitudes
• Burdensome, excessive, of little use
• Low priority
• After thought, something to finish before
leaving
Definitions:
• JCAHO defines NEGLIGENCE as a “failure to use such
care as a reasonably prudent and careful person would
use under similar circumstances.”
• JCAHO defines MALPRACTICE as “improper or unethical
conduct or unreasonable lack of skill by a holder of a
professional or official position; often applied to
physicians, dentists, lawyers, and public officers to
denote negligent of unskillful performance of duties
when professional skills are obligatory.”
6 Major Categories of Negligence that
Result in malpractice Lawsuits
• Failure to follow
standards of care
• Failure to use
equipment in a
responsible manner
• Failure to
communicate
• Failure to document
• Failure to assess and
monitor
• Failure to act as a
patient advocate
Several factors have contributed to the increase in the
number of malpractice cases against nurses…
• Delegation. Cost-containment efforts and HMO’s
• Early Discharge. Nurses may be sued for not providing care, making
appropriate referrals, or communicating pt condition in a timely manner.
• Nursing Shortage. Greater workloads increase likelihood of error.
• Advances in Technology. Nurses must keep abreast of constantly
changing technologies & methods.
• Better-informed Consumers.
insufficient or inappropriate care.
More likely to recognize
NICU: A High Risk Place
• High Mortality
• High Morbidity
• Cutting Edge
• Pushing the Envelope
• Innovation
The Unique Neonatal Patient
• Symptoms change quickly and without warning
• Opportunity for major drug errors is great
• Enormous variability in reactions to care and
treatment
• Clearly the most fragile population
When Things Go Wrong
in the Nursery
• Often permanent disabilities/injuries
• Plaintiffs are sympathetic
• Projected expenses are large
• Difficult to sort out “cause” and “effect”
Why Do People Sue?
• Unmet expectations
leading to anger and
disappointment
• Unexpected death
• Want answers to
clinical questions
• Enormous expenses
Washington State
Statute of Limitations
•
•
•
•
•
•
•
Professional Malpractice: Medical
malpractice actions may be filed within three
years of the date of the act or omission
giving rise to the injury, or within one year of
the date the injury was or reasonably should
have been discovered, whichever is later.
However, no medical malpractice action
may be filed more than eight years after the
date of the act or omission giving rise to the
injury.
Personal Injury: 3 years.
Fraud: 3 years.
Libel / Slander / Defamation: 2 years.
Injury to Personal Property: 3 years.
Product Liability: 3 years from the date of
injury, or within three years of the date the
injury was or reasonably should have been
discovered.
Contracts: Written, 6 years; Oral, 3 years.
•
•
Special Rules for Minors
Except in cases or wrongful death or
where a parent has knowledge of a
medical malpractice injury, the statute
of limitations begins to run on the
minor’s 18th birthday.
In Washington State…
• “The RN shall document, on essential client records, the
nursing care given and the client’s response to that care”
• “The RN shall communicate significant changes in
the
client’s status to appropriate members of the
health team”
• “Communication is defined as…common system of
speech, symbols, and written communication…”
– WAC 246-840-700: standards of nursing conduct or practice
NANN
• Neonatal nurses are skilled professionals in
newborn care who demonstrate expertise in a
variety of roles and activities.
• All newborns and their families have the right to
optimal care.
• As specialists in nursing practice, neonatal
nurses recognize and accept their responsibility
and duty to ensure the delivery of this care
Duties of Nurses Include:
• Duty to monitor, observe, and report changes
in patient status
• Duty to challenge or clarify physician’s orders
before carrying them out
• Duty to anticipate events that might harm a
patient
• Duty to administer medications properly
• Duty to document care
Reducing Potential Liability
• Maintain open, honest, respectful relationships and
communication with patients and family members.
• Maintain competence in your specialty area of practice
• Know legal principles and incorporate them into
everyday practice
• Practice within the bounds of professional licensure
• Know your strengths and weaknesses
Why Worry About Charts?
• The medical record is a witness that never lies,
never dies and never moves
• Poor medical records are the leading nonmedical reason a medically defensible case is
settled or lost at trail
• Memories fade…even if you don’t think you
could ever forget “that night”
Documentation
• Documentation is a means to:
– Demonstrate contributions to quality health care
– Demonstrate contributions to client outcomes
– Demonstrate contributions to fiscal outcomes
• Documentation must be seen as a critical component
of nursing practice, not an after thought
Washington State
Statute of Limitations
•
•
•
•
•
•
•
Professional Malpractice: Medical
malpractice actions may be filed within three
years of the date of the act or omission
giving rise to the injury, or within one year of
the date the injury was or reasonably should
have been discovered, whichever is later.
However, no medical malpractice action
may be filed more than eight years after the
date of the act or omission giving rise to the
injury.
Personal Injury: 3 years.
Fraud: 3 years.
Libel / Slander / Defamation: 2 years.
Injury to Personal Property: 3 years.
Product Liability: 3 years from the date of
injury, or within three years of the date the
injury was or reasonably should have been
discovered.
Contracts: Written, 6 years; Oral, 3 years.
•
•
Special Rules for Minors
Except in cases or wrongful death or
where a parent has knowledge of a
medical malpractice injury, the statute
of limitations begins to run on the
minor’s 18th birthday.
In Washington State…
• “The RN shall document, on essential client records, the
nursing care given and the client’s response to that care”
• “The RN shall communicate significant changes in
the
client’s status to appropriate members of the
health team”
• “Communication is defined as…common system of
speech, symbols, and written communication…”
– WAC 246-840-700: standards of nursing conduct or practice
NANN
• Neonatal nurses are skilled professionals in
newborn care who demonstrate expertise in a
variety of roles and activities.
• All newborns and their families have the right to
optimal care.
• As specialists in nursing practice, neonatal
nurses recognize and accept their responsibility
and duty to ensure the delivery of this care
Duties of Nurses Include:
• Duty to monitor, observe, and report changes
in patient status
• Duty to challenge or clarify physician’s orders
before carrying them out
• Duty to anticipate events that might harm a
patient
• Duty to administer medications properly
• Duty to document care
Reducing Potential Liability
• Maintain open, honest, respectful relationships and
communication with patients and family members.
• Maintain competence in your specialty area of practice
• Know legal principles and incorporate them into
everyday practice
• Practice within the bounds of professional licensure
• Know your strengths and weaknesses
Why Worry About Charts?
• The medical record is a witness that never lies,
never dies and never moves
• Poor medical records are the leading nonmedical reason a medically defensible case is
settled or lost at trail
• Memories fade…even if you don’t think you
could ever forget “that night”
Purpose of Documentation
• Document the Nursing Process
– Assess, Plan, Implement, Evaluate
• “Tell the story”
• Legal
• Adhere to National, State, Professional Organization,
and Hospital regulations and policies
Four C’s of Documentation
• Critical thinking
• Communication
• Chain of command
• Charting
Frequency of “Mistakes”
• 3.7% of all hospitalized patients suffer an
adverse event
• 27.6% of adverse events are due to negligence
• 1% of all hospitalized patients will be injured
due to negligence
Recurring Problems With Claims
•Documentation
•Medication errors
•Chain of command
Other Common Themes…
• “Jousting” health professionals saying or
implying something negative about prior care
• Practitioners making decisions or taking
actions beyond their training and experience
What Do the Lawyers
Look for?
• Clear breach of established standards
• Violation of hospital’s own standards
• Criticism of care in medical record
• Frustration with other providers in the
medical record
Medical Records Must Be:
•Complete
•Objective
•Consistent
•Accurate
If Something Was Not Recorded
•It was not done
•It was not important
•It was no considered
Typical Problems with
the Medical Record
• Conflicting documentation between doctors & nurses
• No documentation that an MD was notified of
significant changes in patient condition
• Time gaps in nursing documentation
• Missing vital signs
• Failure to Chart Specifics (Saying after the fact that a patient was
monitored appropriately is useless without chart notes to back it up)
Good Charting Requires
•Persistence
•Attention to detail
•Focus on the big
picture
Some Charting Do’s and Don’ts…
• Document facts, impressions, clinical judgments
and treatments objectively
• Be specific (no generalizations)
• Chart all nursing interventions, advice given and
patient's and families’ responses
• Chart only the care you provided, observed, or
supervised
• Chart promptly after and never before care is given
• Record any negative reaction to care or treatment
• Chart any potentially contributing patient or family
acts
Keep Focused
• Stay focused on health problem for which you are
providing care. Avoid extraneous information that
will not be used in providing care of the patient
– “Paged Dr Jones again. Third attempt this
morning. He is probably on the golf course with
his pager turned off”
• Initiate “chain of command” if providers are
unresponsive. Charting failure to respond will not
improve patient care or speed up the process
Phone Calls
• Name of person calling or
called
• Date and time of call
• Nature of conversation
• Any changes in plan of care
resulting from conversation
Medication Errors
• 76.7 % of those total errors reached the patient
but did not do harm
• 3.2 % reached the patient and did harm
• 0.03% caused a death
• National Medication Error Reporting program
states that medication errors kill one person per
day in the USA
Errors, Omissions and Corrections
• Errors: draw single line through error, date and initial
the correction
• Omission: add information by identifying entry as “late
entry”, or “addendum”. Sign, date and time
• Avoid obliterations, erasures, or alterations
• Once the accuracy of the medical record is
questioned, the integrity of the entire record is
questioned
Documentation in Difficult Situations
• Remain objective
• Avoid judgment, remain factual
• Do not omit important facts, even if they are not the
“best” facts
• If you don’t want to see it blown up to poster size,
don’t write it
• Sometimes documentation is not enough-do not
substitute a chart for patient/family communication
Adverse Events/Errors
• Do not chart any QA forms filled out, or calls to
risk management
– No: “called risk management about overdose”
– Yes: “baby appears to have received high dose
of vancomycin. Pharmacy and Dr Jones
notified”
• Do not chart events associated with peer review
or quality assurance activities
Who Sees the Chart?
• Patients/parents
• Peer review
• Quality assurance
• Payers
• Surveyors
• Attorneys
• Auditors
Control What They See
•Today is the first day of
the rest of your charts!
Medication Administration
• Administer drugs in accordance to drug
demonstration guidelines, orders
• Not protected from liability just because you
followed an MD order. You are accountable for
your own actions
• Expected to be patient advocate, which includes
becoming familiar with the medications you
administer
Neonatal Considerations
• Weight based dosing: more calculations than with
adult patients
• Medications often must be diluted
• Patient often cannot communicate about adverse
effects
• May have limited reserves to tolerate or compensate
for errors
Anatomy of a Medication Error
• Never intentional
• Usually systems based
• Usually multidisciplinary
• Often fails at several steps in the system
• Latent failures versus active failures
Common NICU Errors
• Decimal points (ten-fold, 100-fold errors)
• Converting numbers between units
(milligram to microgram, etc)
• Weight based dosing
• Dilution of medications
High Risk for Neonatal Error…
• Total parenteral nutrition
• Neuromuscular blocking agents
• Narcotics/opiates, IV and oral
• Moderate sedative agents, IV (midazolam)
• Hypoglycemics
• Heparin, IV, subcutaneous
• Insulin, subcutaneous, IV
• Magnesium sulfate injection
• Potassium chloride
Medication Errors
• 76.7 % of those total errors reached the patient
but did not do harm
• 3.2 % reached the patient and did harm
• 0.03% caused a death
Barriers
• Increase awareness
& openness
• Increase reporting
• Perceptions
(punitive)
• Time constraints
Organizational/Nursing Actions That
Lead to Improved Patient Outcomes
• Practice good telephone etiquette
• Have professional and appropriate appearance
• Good Patient handoffs - SBAR
• Provide safe, age appropriate, care
• Appreciate and celebrate staff for jobs well done
• Positive Attitude. Perform random acts of kindness
• Sense of Ownership and Accountability
• Involve patient & family in their care
• Follow-up to see if they have other questions/needs
References
• Boes, L, & Munson, D. (2002). Defensive Documentation and the Law, Iowa
department of Correction. Downloaded 1/26/05.
• Croke, E.M. (2003). Nurses, Negligence, and Malpractice: An Analysis Based on
More Than 250 Cases Against Nurses. AJN, 103(9), 54-63.
• DeMilliano, M. (1992, July). Eight Common Charting Mistakes to Avoid. NSO
Advisor.
• DiVarco, S. (2002). Documentation and Legal Issues in the NICU. Lecture
Notes from National Neonatal Nurses Conference, Chicago.
• Eskires, T. (1998). Seven Common Pitfalls in Nursing. AJN, 98(4), 33-40.
• JCAHO 2008 National Patient Safety Goals
• Maxfield, D., Grenny, J., McMillan, R., Patterson, K., & Switzer, A. Vitalsmarts
Industry Watch, Executive Summary (2005). Silence Kills: The Seven Crucial
Conversations in Healthcare
• Monarch, K. (2007, July). Documentation, Part 1: Principles for Self-Protection.
AJN, 107(7), 58-60.
• Shinn, L., et al (2001). The Nursing Risk Management Series II. Retrieved Jan
26, 2004 from http://nursingworld.org/mods/archive/mod311/cerm2ful.html
• Washington Administrative Code (2004). The Law Relating to Nursing Care and
Regulation of Health Professions-Uniform Disciplinary Act. WA State
Department of Health.