Tips for keeping plaintiffs out of your deep pockets

Susan Chmieleski, APRN, JD, CPHRM, director of health care risk management with the Chubb Group of Insurance Companies in Simsbury, CT, offers these tips for keeping the plaintiff’s hands out of the hospital’s pockets:

  • Hospital liability often results from the failure of the nurses to document use of suprapubic rather than fundal pressure.
  • Encourage physicians to document management plans. "Have them write down what they’re thinking. Most of the time they’ve got something worked out in their heads for what they’ll do if something happens, but it makes a huge difference if they write it down and show that they were thinking about it," Chmieleski says.
  • The OB department should have standby anesthesia and surgery staff.
  • Adjust staffing ratios to ensure adequate staffing.
  • For family practitioners and midwives in the labor and delivery unit, make sure you have their credentials on file and have established what they can and can’t do. Make sure this information is readily available to the labor and delivery staff; they don’t have time to get on the phone and find out what the midwife is credentialed to do.
  • Document all dystocia maneuvers in real time. The record will be more accurate, complete, and credible if it is created in real time, rather than a nurse trying to remember the maneuvers even a few minutes later. Chmieleski acknowledges that documentation can be challenging when the dystocia is a sudden, unexpected event and everyone in the room is responding to the emergency.

"But sometimes the shoulder dystocia is a reasonably predictable outcome and you can prepare," she says. "When possible, have another nurse step in solely to document the maneuvers. I realize that’s not easy with staffing shortages, but it might be something you can do when you see this situation coming. It really can win the day when you have to defend the case."

  • "Because the doctor said to" is not a valid defense for the hospital.
  • Enforce all policies you enact. Juries generally believe that failure to follow hospital policies and procedures equals negligence.
  • Document all communication between the doctor and nurse. "I generally encourage nurses to use quotations when documenting what the physician said. Doctors don’t like it when I say that, but it is a way for hospitals to protect themselves."
  • Teach nurses to clearly state the need for a physician. When they call physicians, Chmieleski encourages nurses start the conversation by saying something like, "Dr. Smith, the purpose of this call is to inform you that your patient is bleeding and you need to come to the hospital immediately." The point is to convey clearly and quickly what is needed from the physician, and then offer further information if necessary.
  • Conduct emergency cesarean drills. This is particularly important in small hospitals that don’t do a lot of cesareans. The OB staff and physicians must make sure they can meet the necessary criteria for time and patient safety.
  • Nurses must have somewhere to go and report that care is not being provided or is being provided in a way that may harm the patient. "It is crucial that it be nonpunitive, even if afterward the investigation determines that her concerns were unfounded," she says. "If there’s even a slap on the wrist for reporting that concern, it will be all over the hospital in a flash, and you’ll never get anyone speaking up again."