Communicating Critical Information: A Risk Management Case Study
By Aida Van
Herk, RN, JD, Risk Management - AMN Healthcare
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 a deceleration was noted
with immediate return to 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
The obstetrician’s position: “When working as an intern at nights, 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
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 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 document that
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
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. To refresh
your skills in professional communication and documentation, review RN.com’s
Communication: Speak Up, Speak Well and Professional
Documentation: Safe, Effective and Legal.
© 2014. AMN Healthcare, Inc. All Rights Reserved.
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.