Was an MI patient sent to the waiting room? It is highly possible an ED nurse failed to convey important information, as multiple malpractice cases make clear.
“Nurses in the emergency department are in a critical position to enhance the diagnostic process in recognizing and treating cardiovascular disease,” says Penny Greenberg, MS, RN, CPPS, senior program director for patient safety services at CRICO Strategies.
A recent analysis of medical claims and lawsuits in the national Comparative Benchmarking System dataset found that in 155 diagnostic-related error cases from 2007 to 2016, nursing was identified as the primary responsible service. Of these cases, 28 involved cardiovascular disease.1 More than half of the misdiagnoses of cardiovascular disease resulted in a patient death, according to the analysis. Diagnostic errors are “the deadliest and most harmful of medical errors,” says Kelly Gleason, RN, PhD, the study’s lead author and an assistant professor at Johns Hopkins School of Nursing. ED nurses must be prepared and trained to play a role in the diagnostic process.
“If we do not fully own that role, the consequences can be devastating,” Gleason warns. It is perceived commonly that nurses scope of practice laws limit them from fully engaging in diagnosis. “In fact, state scope of practice laws contain little language guiding what nurses can or cannot do related to medical diagnosis,” Gleason explains.
The fact that ED nurses are named as the primarily responsible service in many diagnosis-related malpractice claims “demonstrates that nurses are recognized as having a responsibility in the diagnostic process,” Gleason adds. A recent successful malpractice lawsuit hinged on an inaccurate assumption made by an ED nurse. The case involved an 83-year-old woman who was brought to the ED with obvious stroke symptoms. The triage nurse noted confusion, garbled speech, and facial droop. Due to an incorrect assumption that the patient was not a candidate for thrombolytics, the nurse directed the patient to the waiting room. Despite new onset of right-sided paralysis, the patient waited more than an hour for evaluation by an EP.
Upon admission, an MRI showed acute posterior temporal lobe and basal ganglia infarctions. The patient sued the triage nurse, claiming that a delay in diagnosis and treatment of an acute stroke led to permanent neurologic damage. The case settled.
Here are risk-reducing “lessons learned” for EDs, which also are applicable to delayed STEMI diagnosis and treatment:
- The nurse failed to recognize and alert EPs of an evolving stroke, reflecting a knowledge deficit;
- The nurse based the triage score, in part, on the current ED resources. “Triage designations should be independent of the current state of the department,” Greenberg says;
- The patient’s daughter perceived the ED staff to be unconcerned about her mother’s condition. The absence of anyone checking on her mother in the ED waiting area put the burden on the daughter to alert ED personnel of clinical changes. “Further delays after her mother suffered another stroke in the waiting area, because there were ‘many other sicker patients,’ certainly could be perceived as callous,” Greenberg notes;
- ED staff made written and verbal comments blaming other providers. In the ED chart, an EP noted that the patient’s near-total right-sided paralysis could have been avoided by a timely evaluation. Additionally, an ED nurse reportedly told the family that the bad outcome could have been avoided. Such concerns should be addressed in other forums, Greenberg says: “Sparring in the chart or in front of families can increase patient confusion and the risk of a malpractice lawsuit.”
In malpractice claims that name ED nurses, a frequently seen contributing factor is communication with providers. “ED nurses’ role in transferring important information is paramount,” Greenberg says. The authors of another recent study examined communication-related medical malpractice.2 Thirty-two percent of all nursing cases involved a communication failure. “The majority of these cases expose gaps in verbal and documented communication with other providers about the patient’s condition,” Greenberg notes. During a recent malpractice case, it became apparent that the EP was never notified of an 81-year-old man’s ECG changes and high cardiac troponin levels. “The nurses did not communicate status changes to the provider,” Gleason says.
This can happen for many reasons. ED nurses may be swamped with tasks on a busy night shift or do not understand what information necessitates immediate reporting to the EP. Other times, ED nurses do report concerns, but they go unheeded. An ED nurse might report a patient’s sudden drowsiness, only to be told by the EP that it is due to recently administered pain medication. Both EPs and ED nurses “need to get on the same page about what information the physician wants to best guide decisions,” Gleason says.
Regardless of the reason for poor communication between ED nurses and EPs, says Gleason, “if we think of it through the lens of keeping our patients safe, then it is logical for nurses to prioritize participating in the diagnostic process.”