A NURSE'S ABILITY to recognize and respond to changes in a patient's condition is a crucial element of professional nursing practice. Failure to respond appropriately to clinical changes can lead to complications and even death.1 In a study that investigated the impact of communication in malpractice lawsuits, communication failure was a factor in 32% of cases involving nurses, with most involving poor communication with other healthcare professionals about the patient's status. These cases often result in huge financial consequences in cost of care and legal damages.2 Such was the case in a recent judgment that illustrates the human and financial costs of failing to communicate clinical changes to the appropriate practitioner.3 While physicians were also implicated in the case, only elements related to RNs are discussed here.
Facts of the case
On February 22, 2005, Mary Trout* was admitted to the hospital with an abscess that caused swelling in the floor of the mouth, her neck, and her airway related to Ludwig's angina (a bilateral infection of the submandibular space). The abscess was successfully drained and a tracheotomy was performed on February 23.
The following day, the tracheostomy site started to bleed and Ms. Trout complained of a choking sensation, but the bleeding resolved over several days.
On February 27, bleeding resumed. Judith Massey, RN, redressed the site. A few hours later, the nurse observed “bloody, watery” drainage from the tracheostomy but she did not notify a physician.
While performing a procedure on February 28, the physician observed persistent bleeding from the patient's stoma. He cauterized it and packed it with gauze. The patient was returned to the medical/surgical unit, where she was cared for by Doris Fox, RN.
Sometime during the shift, Ms. Trout's sister alerted the nurse that Ms. Trout was bleeding from the tracheostomy site. Upon assessing the patient, Nurse Fox observed blood trickling from the stoma and blood stains on the hospital gown. She handed some gauze to the patient's sister and asked her to press it against the tracheostomy. When the gauze was thoroughly soaked and the bleeding worsened, Nurse Fox gave the sister towels to soak up the blood. She then contacted a physician, who ordered two units of red blood cells (RBCs) and four bags of fresh frozen plasma (FFP).
Nurse Fox was relieved by Nurse Joan Duke at 1900. Nurse Duke testified that during the shift, she administered the RBCs and FFP as prescribed, reinforced the dressing, and suctioned the tracheostomy all night.
At 2300, Ms. Trout was coughing blood with clots. She also communicated that she was in pain and that the blood clots were choking her. Nurse Duke contacted the resident physician on duty, who examined the patient but did not make a notation in the medical record. At trial, the resident said she did not document the visit because the patient was stable and she did not observe active bleeding.
After a second page at midnight, the resident paged another physician. While the second physician was examining Ms. Trout, she lost consciousness. Although she was eventually resuscitated, she was deprived of oxygen for 20 to 25 minutes. When she was discharged about a month later, she had suffered anoxic brain damage and was partially paralyzed. The patient sued the hospital for malpractice, alleging that negligence by the hospital's nurses and physicians had allowed a clot to occlude the patient's tracheostomy tube, leading to respiratory arrest and severe brain injury.
At trial, the hospital's nurse expert witness testified that the nurses caring for the plaintiff met the standard of care for tracheostomy management and were not required to call a physician any sooner than they did. In contrast, the plaintiff's expert witness testified that the standard of care is to keep the stoma clean and the airway clear with regular suctioning, and that an occlusion in the tracheostomy requires a nurse to contact a physician promptly. It was her opinion that the nurses who did not contact the physician as soon as they observed bleeding failed to meet the minimum standard of care required for tracheostomy management and that this led to the clot formation and subsequent respiratory arrest.
The patient died after the case was submitted to the jury but before a verdict was returned. The patient's daughter was appointed as a representative of the estate to receive the jury's verdict.
The jury returned a verdict in favor of Ms. Trout in the amount of $22,185,598.90, with $15,007,965.68 of this for future damages. The hospital appealed the verdict.
In its decision, the appellate court accepted the testimony that Ms. Trout had bled from the tracheostomy site and that the blood entered the tracheostomy, clotted, and obstructed her airway. The court also accepted the testimony that if nurses had informed a physician sooner that the bleeding was continuing, a clot would not have formed and the patient's airway would have remained clear. The court sustained the jury's award for 7,177,632.82, deducting the $15,007,965.68 awarded for future damages because Ms. Trout had passed away.3
The communication of patient status has been the focus of much attention and research and has been determined to be problematic and sometimes stress-inducing for nurses.4 Various communication frameworks have been generated to facilitate clinical communication among healthcare professionals about patient status.5,6 Widely used examples include SBAR (situation, background, assessment, and recommendation) and ISBARR (introduction, situation, background, assessment, recommendation, and read back).
The events in this case, however, were not about the nurses' ability to communicate with physicians. Rather, they were about the lack of competence and decision-making skills that enable a nurse to assess a patient's condition and determine the appropriate intervention, including when to escalate care and seek the expertise of appropriate personnel.
Another aspect of incompetence demonstrated relates to impermissible delegation. In this case, one nurse handed gauze and towels to a patient's relative to staunch bleeding from a tracheostomy. By asking a patient or family member to perform nursing tasks, an RN not only compromises the patient's safety, but also violates the principles of delegation, which include the nurse's responsibility for ensuring that the delegatee possesses the appropriate skills, training, and validated competence. In this case, nothing indicated that the patient's sister was in any way prepared for the task she was assigned. And even if she had been a nurse and/or hospital employee, her role as family member excluded her from the pool to which such a task may be delegated.
In addition, an RN may not delegate the nursing process. Appropriate delegation requires the delegatee to assess the bleeding and plan what to do about it, when to intervene, and how to intervene. This requires nursing judgment, which cannot be delegated to anyone who is not a nurse.7
Barriers to communication
Many factors can play into why nurses may not communicate a patient's status promptly or at all. These include a busy schedule, a reluctance to “bother” the physician, or a failure to recognize the circumstances under which a physician should be notified due to a lack of clinical competence.2 The details of this case did not include any specific information about how busy the shift was or whether nurses were reluctant to call the physician. What is apparent is that the nurses did not recognize the severity and emergent nature of the patient's condition.
One nurse testified that she suctioned copious amounts of blood for hours before paging a physician. Coughing blood clots from a tracheostomy site from which blood was suctioned “copiously” for hours is an emergency. The nurse's failure to recognize an emergency indicates a lack of competence in nursing fundamentals and a lack of knowledge about the possible physiologic consequences. This gap in knowledge contributed to a catastrophic deterioration in the patient's condition.
Critical thinking extends beyond mere information, attentiveness, and assessment. How do nurses acquire the decision-making and critical-thinking skills necessary for their practice? The clinical competence needed to make decisions, especially in acute situations, develops over time as the nurse advances from novice to expert.8 In this case, nurses gave their patient a great deal of attention, but the patient's needs required a higher level of competence in tracheostomy care.
Implications for practice
Nurses and healthcare employers are obligated to maintain patient safety by ensuring nursing practice meets professional standards. The implications of this case affect managers who assign nurses to patients, employers who are responsible for the processes and the culture under which nurses practice, and nurses themselves.
To determine appropriate interventions and recognize when it is necessary to escalate care, nurses must:
- accept only patients that they are capable of caring for.9
- develop the education and skills necessary to recognize when the interventions they initiate are not effective.1
- escalate the patient's care to a more experienced nurse or the healthcare provider when they find that a patient's status change is beyond their capability.10
- follow the facility's chain of command. In a situation such as this, the nurse's vigilance, recognition of an urgent situation, evaluation of changes in the patient's condition, and steps taken to escalate appropriately should be evident in the medical record.11 Documentation should include the persons consulted and the actions that resulted from the consultation.12
- be aware that, as in this case, nurses can be held legally liable for actions they omit as well as actions they fail to take in a timely manner.10
Guidelines for practice
When documenting adverse events, follow your facility's policies and procedures. The record should be objective, including only clinical facts without any guesses, assumptions, speculations about the cause of the event, or personal opinions.13
In addition, keep these general guidelines in mind:
- Listen to family members' concerns. They are often at the bedside much longer than the clinical staff. They know the patient and are likely already engaging in the care of the patient at home. They are a valuable source of information and their concerns should be taken seriously.14
- Nurses should consider carrying their own liability insurance, both for the purposes of legal liability and for any disciplinary actions taken by the board of nursing.15
- Healthcare employers are obligated to create processes and policies to ensure that nurses are equipped to handle their patient assignments and tasks. Those processes must include ways in which nurses may be helped to determine when more experienced or more qualified help is required.2 For example, because tracheostomy care is not a routine task for many nurses, those who may care for patients with tracheostomies should receive specific and targeted training. Minimally, it should be confirmed that the staff can both recognize and manage common complications of tracheostomy care.16 Developing appropriate processes and policies requires agency-wide and multidisciplinary cooperation.
The crux of the matter is that failure to report changes in a patient's condition can have serious health consequences for the patient as well as legal and financial implications for all involved in the care of the patient. But by meeting the standards of professional nursing care, nurses can and should avoid these costly consequences.