Courtroom Insider Lessons Learned from Malpractice Cases
By: Wendy L. Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP
Timely Documentation is Essential I have seen numerous cases where charting is not completed for weeks after seeing the patient. The standard of care is three days to close the encounter. The EHR system provides a timestamp of when the chart is signed. For many of us, it can be hard for us to remember everything we said/did yesterday, let alone two weeks later. Work hard to ensure you stay on top of your charting and documentation. When I review a case and the documentation is completed after the patient has suffered an event, this does not look good for any jury or defense. Take proactive steps to protect yourself and your patients from harm. These tales from the courtroom can do just that.
Over the past 28 years, I have had the opportunity to review and work on somewhere between 100 to 125 malpractice cases involving NPs, MDs, and RNs. I spend about 80% of my time reviewing cases on behalf of the defense team, and about 20% for the attorneys representing the plaintiff. Of the cases I have been asked to review, I have declined to support or further participate in approximately 50% of these cases. But why? In some instances, there does not appear to be enough evidence to move forward on the case. Seasoned attorneys want honest and accurate evaluations of the case at hand and are often grateful when experts point out the lack of merit in a particular case. Conversely, there are other cases where it is very clear that a breach in the standard of care occurred and that I cannot provide the type of defense that will be needed. In these cases, I often advise the attorney to figure out a settlement agreement, since there was clear harm or wrongdoing. I have noticed some recurrent patterns or themes in malpractice cases. My goal is to prevent other NPs from finding themselves involved in a malpractice case. Pulmonary Emboli are Rising I have seen approximately five to six cases of diagnostic failure of pulmonary embolus. Studies
Warfarin is Not Your Friend I have been asked to review approximately four to five cases involving a patient taking warfarin. Warfarin has many drug interactions that can either increase or decrease the clearance of this drug. If a patient is on warfarin, you must always take caution when adding a new medication to their regimen, even something as simple as a routine antibiotic. Additionally, from a system perspective, protocols must be set to ensure that patients taking warfarin are monitored regularly. Typical INR monitoring varies between every week to every month. I have seen cases where the INR is ordered every three to four months. This is way too long! If you are the prescribing NP, you are responsible for ensuring that the patient is monitored. Does your clinic have have shown that the numbers of emboli are increasing, and some literature propose that the rise is due to the pathogenesis of COVID. Regardless of the cause, NPs must always consider a pulmonary embolus in the patient who presents with acute onset of shortness of breath, chest pain, tachycardia, near syncope or full syncope, wheezing, dizziness, and/or pleuritic chest pain. Get a stat D-dimer and CTA urgently. If you are not able to accomplish this workup in an outpatient setting, an ED referral is essential. Delaying this diagnosis can be fatal.
a system in place to ensure the patient is getting INRs? We put them on the schedule when they are due for an INR and / or set a reminder in the EHR system to ensure the patient is adherent. If, despite multiple attempts to improve patient adherence with monitoring, the patient still does not get the INR, the NP should consider sending a certified letter with return receipt and a copy of the letter mailed through standard mail to the patient. This letter should contain information alerting them of the risks of failure to monitor and agree to provide medication for 30 days while they find another provider to prescribe their warfarin. In today’s environment, while we certainly want to avoid terminating care with a patient, we cannot put our license at risk for those who are not willing to adhere to standard of care recommendations. Drug Interactions are Increasing Opioids and benzodiazepines are not a safe combination. It is estimated that up to forty percent of accidental overdoses occur with the opioid/benzodiazepine combination. You do not have to continue the practice of others if you deem that the practice is unsafe or does not conform to the current standard of care. You must, however, provide a safe tapering process. If the patient does not agree with this recommendation, the NP should provide emergency care for 30 days until this patient finds another provider.
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