Physician smiling with two nurses behind her

Communicating Critical Information: A Risk Management Case Study

A 39-week pregnant patient presented to Labor & Delivery at 2300 complaining of contractions since 1800. After she was examined by the physician, Pitocin was started at 2mu/minute. Prolonged decelerations in the fetal heartbeat were noted at 0100 and the Pitocin was turned off. At 0130, the physician ruptured the patient’s membranes and deceleration was noted with an immediate return to a baseline of 140-150 BPM.

The Pitocin was restarted at 0200 at 4mu/minute. Between 0240 and 0340, the Pitocin was turned down to 2mu/minute when frequent contractions with an unstable baseline, decelerations, and minimal variability were noted. From 0354 to 0404 there were more decelerations and absent variability with a baseline of 170-180 BPM. At 0405 the physician was called.

The infant was born 25 minutes later via emergency cesarean section. She was blue, flaccid, with a nuchal wrap x4, low and unstable blood pressure, and a cord pH of 6.6. She was intubated, resuscitated, transfused and given medications to elevate her blood pressure. The infant remained in the neonatal intensive care unit for one month before being discharged home. She was diagnosed with cerebral palsy and experienced developmental delays.

The family sued the physician and the nurse, alleging that the delay in delivery resulted in profound brain damage. They argued that the nurse failed to properly monitor and evaluate the patient and appropriately notify the physician.

The Nurse’s Position:

“When working as a nurse on the night shift, I would often need to exercise my clinical judgment about a change in a patient’s status. After my initial assessment of the situation, I decided to text page the physician that there was a problem. After 30 minutes without a response, I attempted once more. I finally called to report fetal distress and he arrived immediately thereafter.”

The Obstetrician’s Position:

“When working as an intern at night, I relied on the assessment skills of the nurses and hoped they knew when to call. Many messages are received daily but critical information warranted direct communication, not a text message. The text page did not describe an emergency situation. After receiving the nurse’s call, I came immediately.”

After unfavorable expert reviews, the case was settled for more than $3 million, with the nurse bearing primary responsibility.

An analysis of this case highlights two areas of concern: Failure to communicate and failure to document. Failed communication between nurses and physicians is a major source of patient injury and professional liability litigation. When critical information is being transmitted to the physician, direct discussion can avoid delay in treatment. While reports not requiring urgent attention are generally sent through routine channels, urgent communications require extra effort to ensure they are received.

In this case scenario, the nurse recognized a pattern consistent with the fetus responding to hypoxia and sent the physician a text page that was not responded to in a timely manner. It would have placed a little burden on the nurse to call instead of paging the physician with that information. Because of the communication failure, the delivery of this high-risk fetus was delayed. It is best practice to personally communicate critical information to the physician and thoroughly documents that discussion.

Lack of Documentation is the second area of concern in this case study. Regardless of a nurse’s recollection of an event, the chart is still the best evidence as to what was done to and for the patient. In this case, there were a few places on the fetal monitoring strip where the nurse had documented “Report,” but no indication as to what was reported or to whom. The nurse was adamant she had reported fetal distress to the physician much earlier, but lack of documentation compromised her testimony and defense.

If the nurse notified the physician there was a problem when she gave the report, she should have documented the details of that communication thoroughly and immediately. Moreover, if the doctor did not respond appropriately, she should have documented the response and gone further through the hospital chain of command.

The nurse was charged with the responsibility of being the patient’s advocate, and as such is required to evaluate the condition of the patient and timely notify the physician if a problem is identified. In many cases, particularly in obstetrics, the window of time for an intervention may be very narrow and the nurse must act promptly.

In this case, the documentation does not suggest that the nurse promptly recognized signs of distress or undertook any measures to assist with the alarming fetal condition demonstrated on the fetal monitoring strips. There was no documentation as to why the Pitocin was increased after the first prolonged deceleration or why the Pitocin was later only decreased instead of being turned off. The records do not show that supplemental oxygen was ever applied, or that proper attempts were made to reach the physician.

As patient advocates, nurses must uphold their duty to properly monitor and evaluate each patient and appropriately notify the physician of changes in the patient’s condition. 

After 10 years of nursing experience specializing in high-risk women’s health and education, Aida Van Herk, RN, received her Juris Doctor. Combining her nursing and law degrees, she began working at a boutique medical malpractice firm, assisting in the defense of some of the country’s most prominent healthcare systems. Today, she is responsible for handling professional liability matters and is a subject matter expert of clinical loss control at AMN Healthcare. She is a licensed attorney in California.