EPs diagnose patients, but ED nurses are held legally responsible for their role in the process, according to an analysis of malpractice claims.1
“The idea that it is not within the nurses’ scope of practice to contribute to diagnosis is both dangerous and wrong,” says Kelly Gleason, PhD, RN, the study’s lead author.
Gleason and colleagues analyzed a database of malpractice claims from 2007 to 2016 related to diagnosis (139 claims) and physiological monitoring (647 claims) that named nurses as the primary responsible party. The claims involved various settings, including the ED.
“The contributing factors were similar across all settings, with communication with providers listed as a contributing factor for over half of cases,” says Gleason, an assistant professor at Johns Hopkins School of Nursing.
- In the 139 claims related to diagnosis, there was a much higher likelihood of death if communication among providers was a contributing factor;
- In the 647 cases involving physiologic monitoring, there was a greater likelihood of death, and also higher expenses and indemnity, if communication among providers was a contributing factor.
In some claims involving communication breakdowns, the plaintiff’s chief complaint was a fall injury. The patient sustained only minor lacerations. However, at triage, the patient mentions feeling dizzy before the fall. The patient assumes that since the triage nurse knew about the dizziness, the rest of the clinical team is aware.
But the ED nurse did not share this concerning piece of information, which suggests the fall might have happened because the patient suffered a stroke. After finding no significant injuries, the EP discharges the patient home. “The patient is later readmitted with a stroke, which potentially could have been caught had the clinical team realized that dizziness led to the fall,” Gleason offers.
Viewing ED nurses as key members of the diagnostic team “is essential to optimizing patient outcomes,” Gleason adds. ED nurses communicate patient information to the clinical team. They also ensure the patient understands and agrees with the diagnosis. “Ensuring that nurses are aware that it is not just within their scope of practice to participate in the diagnostic process, but also expected of them as part of their job, is important,” Gleason stresses.
John C. West, JD, MHA, DFASHRM, CPHRM, has seen multiple ED misdiagnosis claims that started with premature closure (the EP decides what something is without running all the necessary diagnostic tests) or anchoring (the EP hits on a diagnosis and sticks to it despite conflicting test results or symptoms).
“My feeling is that nurses set the stage, or point to a path for the physician to go down,” says West, principal at West Consulting Services, a Signal Mountain, TN-based risk management and patient safety consulting firm.
If an ED nurse tells an EP that a patient with “back pain” is ready to be seen, this conveys that the problem is back pain as opposed to something else. “The physician works the patient up for musculoskeletal issues, when the patient has a dissecting aortic aneurysm,” West notes.
Often, there is no legal recourse taken against the ED nurse in most misdiagnosis cases. The nurse’s attorney will try to paint the EP or the hospital as the real culprit. From a legal standpoint, says West, “the ultimate responsibility to make a proper medical diagnosis is the sole responsibility of the physician.”
Compared to EPs, nurses spend a great deal of time with patients, and often obtain history and physical findings that were missed. “Data discovered by nurses can be combined with physician assessment and lab or imaging data to solve the potential mystery of what is wrong with a patient,” says Martin Huecker, MD, an associate professor and research director in the department of emergency medicine at the University of Louisville.
ED nurses learn about a new medication the patient is on, an obscure symptom nobody mentioned to the EP, or a mild mechanism of trauma the EP did not factor in during the assessment. Information like that can save a patient from a missed diagnosis, but EHRs make it difficult to find. “Nursing notes are comprised of default information that is often not relevant to the diagnosis. Each iteration of medical record systems seems to bury the crucial, unique patient information,” Huecker laments.
Since the EP is not seeing the whole picture, it is easier to make the wrong diagnosis. “Face-to-face communication remains valuable in the ED setting,” Huecker adds.
- Gleason KT, Jones RM, Rhodes C, et al. Evidence that nurses need to participate in diagnosis: Lessons from malpractice claims. J Patient Saf 2020; Mar 25. doi: 10.1097/PTS.0000000000000621. [Online ahead of print].