Presentation title

Name/Credentials

Organization

Date

Authors: Linda M Hess, RN, MN, CNS

Jere O’Brien-Kinne, RN, MN, CNS. CPNP

Chris Cooper, BSN, RNC, MBA

Updated 2012: Kimberly Cooper, RN

Neonatal Patient Safety, Documentation and Legal Issues

Objectives

• Discuss the legal implications associated with working in the perinatal/neonatal arena

• Describe recent trends in nursing negligence/malpractice

• Describe most common charges against nurses• Discuss how the National Patient Safety Standards

affect you• Describe how you can protect yourself• Discuss the importance of clear, concise

documentation• Review the most common documentation issues• Identify the need to utilize the “Ladder of Hierarchy”

for issues and principles of professional communication.

Our Attitudes

• Burdensome, excessive, of little use

• Low priority• After thought, something to finish

before leaving

Definitions:• JCAHO defines NEGLIGENCE as a “failure to use

such care as a reasonably prudent and careful person would use under similar circumstances.”

• JCAHO defines MALPRACTICE as “improper or unethical conduct or unreasonable lack of skill by a holder of a professional or official position; often applied to physicians, dentists, lawyers, and public officers to denote negligent of unskillful performance of duties when professional skills are obligatory.”

6 Major Categories of Negligence that Result in

malpractice Lawsuits

• Failure to follow standards of care

• Failure to use equipment in a responsible manner

• Failure to communicate

• Failure to document

• Failure to assess and monitor

• Failure to act as a patient advocate

Several factors have contributed to the increase in the number of malpractice

cases against nurses…

• Delegation. Cost-containment efforts and HMO’s

• Early Discharge. Nurses may be sued for not providing care, making appropriate referrals, or communicating pt condition in a timely manner.

• Nursing Shortage. Greater workloads increase likelihood of error.

• Advances in Technology. Nurses must keep abreast of constantly changing technologies & methods.

• Better-informed Consumers. More likely to recognize insufficient or inappropriate care.

NICU: A High Risk Place

• High Mortality• High Morbidity• Cutting Edge• Pushing the Envelope• Innovation

The Unique Neonatal Patient

• Symptoms change quickly and without warning

• Opportunity for major drug errors is great

• Enormous variability in reactions to care and treatment

• Clearly the most fragile population

When Things Go Wrong in the Nursery

• Often permanent disabilities/injuries

• Plaintiffs are sympathetic• Projected expenses are large• Difficult to sort out “cause” and

“effect”

Why Do People Sue?

• Unmet expectations leading to anger and disappointment

• Unexpected death• Want answers to

clinical questions• Enormous expenses

Washington State Statute of Limitations

• Professional Malpractice: Medical malpractice actions may be filed within three years of the date of the act or omission giving rise to the injury, or within one year of the date the injury was or reasonably should have been discovered, whichever is later. However, no medical malpractice action may be filed more than eight years after the date of the act or omission giving rise to the injury.

• Personal Injury: 3 years.• Fraud: 3 years.• Libel / Slander / Defamation: 2 years.• Injury to Personal Property: 3 years.• Product Liability: 3 years from the date of

injury, or within three years of the date the injury was or reasonably should have been discovered.

• Contracts: Written, 6 years; Oral, 3 years.

• Special Rules for Minors • Except in cases or wrongful death or

where a parent has knowledge of a medical malpractice injury, the statute of limitations begins to run on the minor’s 18th birthday.

In Washington State…• “The RN shall document, on essential client

records, the nursing care given and the client’s response to that care”

• “The RN shall communicate significant changes in the client’s status to appropriate members

of the health team”• “Communication is defined as…common system

of speech, symbols, and written communication…”– WAC 246-840-700: standards of nursing

conduct or practice

NANN

• Neonatal nurses are skilled professionals in newborn care who demonstrate expertise in a variety of roles and activities.

• All newborns and their families have the right to optimal care.

• As specialists in nursing practice, neonatal nurses recognize and accept their responsibility and duty to ensure the delivery of this care

Duties of Nurses Include:• Duty to monitor, observe, and report

changes in patient status• Duty to challenge or clarify physician’s

orders before carrying them out• Duty to anticipate events that might

harm a patient• Duty to administer medications

properly• Duty to document care

Reducing Potential Liability

• Maintain open, honest, respectful relationships and communication with patients and family members.

• Maintain competence in your specialty area of practice

• Know legal principles and incorporate them into everyday practice

• Practice within the bounds of professional licensure

• Know your strengths and weaknesses

Why Worry About Charts?

• The medical record is a witness that never lies, never dies and never moves

• Poor medical records are the leading non-medical reason a medically defensible case is settled or lost at trail

• Memories fade…even if you don’t think you could ever forget “that night”

Documentation

• Documentation is a means to:– Demonstrate contributions to quality health

care– Demonstrate contributions to client outcomes– Demonstrate contributions to fiscal outcomes

• Documentation must be seen as a critical component of nursing practice, not an after thought

Washington State Statute of Limitations

• Professional Malpractice: Medical malpractice actions may be filed within three years of the date of the act or omission giving rise to the injury, or within one year of the date the injury was or reasonably should have been discovered, whichever is later. However, no medical malpractice action may be filed more than eight years after the date of the act or omission giving rise to the injury.

• Personal Injury: 3 years.• Fraud: 3 years.• Libel / Slander / Defamation: 2 years.• Injury to Personal Property: 3 years.• Product Liability: 3 years from the date of

injury, or within three years of the date the injury was or reasonably should have been discovered.

• Contracts: Written, 6 years; Oral, 3 years.

• Special Rules for Minors • Except in cases or wrongful death or

where a parent has knowledge of a medical malpractice injury, the statute of limitations begins to run on the minor’s 18th birthday.

In Washington State…• “The RN shall document, on essential client

records, the nursing care given and the client’s response to that care”

• “The RN shall communicate significant changes in the client’s status to appropriate members

of the health team”• “Communication is defined as…common system

of speech, symbols, and written communication…”– WAC 246-840-700: standards of nursing

conduct or practice

NANN

• Neonatal nurses are skilled professionals in newborn care who demonstrate expertise in a variety of roles and activities.

• All newborns and their families have the right to optimal care.

• As specialists in nursing practice, neonatal nurses recognize and accept their responsibility and duty to ensure the delivery of this care

Duties of Nurses Include:• Duty to monitor, observe, and report

changes in patient status• Duty to challenge or clarify physician’s

orders before carrying them out• Duty to anticipate events that might

harm a patient• Duty to administer medications

properly• Duty to document care

Reducing Potential Liability

• Maintain open, honest, respectful relationships and communication with patients and family members.

• Maintain competence in your specialty area of practice

• Know legal principles and incorporate them into everyday practice

• Practice within the bounds of professional licensure

• Know your strengths and weaknesses

Why Worry About Charts?

• The medical record is a witness that never lies, never dies and never moves

• Poor medical records are the leading non-medical reason a medically defensible case is settled or lost at trail

• Memories fade…even if you don’t think you could ever forget “that night”

Purpose of Documentation

• Document the Nursing Process – Assess, Plan, Implement, Evaluate

• “Tell the story”• Legal • Adhere to National, State, Professional

Organization, and Hospital regulations and policies

Four C’s of Documentation

• Critical thinking• Communication• Chain of

command• Charting

Frequency of “Mistakes”

• 3.7% of all hospitalized patients suffer an adverse event

• 27.6% of adverse events are due to negligence

• 1% of all hospitalized patients will be injured due to negligence

Recurring Problems With Claims

•Documentation•Medication errors•Chain of command

Other Common Themes…

• “Jousting” health professionals saying or implying something negative about prior care

• Practitioners making decisions or taking actions beyond their training and experience

What Do the Lawyers Look

for?

• Clear breach of established standards• Violation of hospital’s own standards• Criticism of care in medical record• Frustration with other providers in the

medical record

Medical Records Must Be:

•Complete•Objective•Consistent•Accurate

If Something Was Not Recorded

• It was not done• It was not important• It was no considered

Typical Problems with

the Medical Record• Conflicting documentation between

doctors & nurses• No documentation that an MD was notified

of significant changes in patient condition• Time gaps in nursing documentation• Missing vital signs• Failure to Chart Specifics (Saying after the fact

that a patient was monitored appropriately is useless without chart notes to back it up)

Good Charting Requires

• Persistence• Attention to

detail• Focus on the

big picture

Some Charting Do’s and Don’ts…

• Document facts, impressions, clinical judgments and treatments objectively

• Be specific (no generalizations)• Chart all nursing interventions, advice given

and patient's and families’ responses• Chart only the care you provided, observed, or

supervised• Chart promptly after and never before care is

given• Record any negative reaction to care or

treatment• Chart any potentially contributing patient or

family acts

Keep Focused

• Stay focused on health problem for which you are providing care. Avoid extraneous information that will not be used in providing care of the patient– “Paged Dr Jones again. Third attempt this

morning. He is probably on the golf course with his pager turned off”

• Initiate “chain of command” if providers are unresponsive. Charting failure to respond will not improve patient care or speed up the process

Phone Calls

• Name of person calling or called

• Date and time of call• Nature of conversation• Any changes in plan of

care resulting from conversation

Medication Errors

• 76.7 % of those total errors reached the patient but did not do harm

• 3.2 % reached the patient and did harm

• 0.03% caused a death• National Medication Error Reporting

program states that medication errors kill one person per day in the USA

Errors, Omissions and Corrections

• Errors: draw single line through error, date and initial the correction

• Omission: add information by identifying entry as “late entry”, or “addendum”. Sign, date and time

• Avoid obliterations, erasures, or alterations

• Once the accuracy of the medical record is questioned, the integrity of the entire record is questioned

Documentation in Difficult Situations

• Remain objective• Avoid judgment, remain factual• Do not omit important facts, even if they

are not the “best” facts• If you don’t want to see it blown up to

poster size, don’t write it• Sometimes documentation is not enough-

do not substitute a chart for patient/family communication

Adverse Events/Errors

• Do not chart any QA forms filled out, or calls to risk management– No: “called risk management about

overdose”– Yes: “baby appears to have received

high dose of vancomycin. Pharmacy and Dr Jones notified”

• Do not chart events associated with peer review or quality assurance activities

Who Sees the Chart?

• Patients/parents• Peer review• Quality

assurance• Payers• Surveyors• Attorneys• Auditors

Control What They See

•Today is the first day of the rest of

your charts!

Medication Administration

• Administer drugs in accordance to drug demonstration guidelines, orders

• Not protected from liability just because you followed an MD order. You are accountable for your own actions

• Expected to be patient advocate, which includes becoming familiar with the medications you administer

Neonatal Considerations

• Weight based dosing: more calculations than with adult patients

• Medications often must be diluted• Patient often cannot communicate about

adverse effects• May have limited reserves to tolerate or

compensate for errors

Anatomy of a Medication Error

• Never intentional• Usually systems based• Usually multidisciplinary• Often fails at several steps in the

system• Latent failures versus active failures

Common NICU Errors

• Decimal points (ten-fold, 100-fold errors)

• Converting numbers between units (milligram to microgram, etc)

• Weight based dosing• Dilution of medications

High Risk for Neonatal Error…

• Total parenteral nutrition• Neuromuscular blocking agents• Narcotics/opiates, IV and oral• Moderate sedative agents, IV (midazolam)• Hypoglycemics• Heparin, IV, subcutaneous• Insulin, subcutaneous, IV• Magnesium sulfate injection• Potassium chloride

Medication Errors

• 76.7 % of those total errors reached the patient but did not do harm

• 3.2 % reached the patient and did harm

• 0.03% caused a death

Barriers• Increase

awareness & openness

• Increase reporting• Perceptions

(punitive)• Time constraints

Organizational/Nursing Actions That Lead to

Improved Patient Outcomes• Practice good telephone etiquette• Have professional and appropriate appearance• Good Patient handoffs - SBAR• Provide safe, age appropriate, care• Appreciate and celebrate staff for jobs well done• Positive Attitude. Perform random acts of

kindness• Sense of Ownership and Accountability• Involve patient & family in their care• Follow-up to see if they have other

questions/needs

References• Boes, L, & Munson, D. (2002). Defensive Documentation and the

Law, Iowa department of Correction. Downloaded 1/26/05.• Croke, E.M. (2003). Nurses, Negligence, and Malpractice: An

Analysis Based on More Than 250 Cases Against Nurses. AJN, 103(9), 54-63.

• DeMilliano, M. (1992, July). Eight Common Charting Mistakes to Avoid. NSO Advisor.

• DiVarco, S. (2002). Documentation and Legal Issues in the NICU. Lecture Notes from National Neonatal Nurses Conference, Chicago.

• Eskires, T. (1998). Seven Common Pitfalls in Nursing. AJN, 98(4), 33-40.

• JCAHO 2008 National Patient Safety Goals• Maxfield, D., Grenny, J., McMillan, R., Patterson, K., & Switzer, A.

Vitalsmarts Industry Watch, Executive Summary (2005). Silence Kills: The Seven Crucial Conversations in Healthcare

• Monarch, K. (2007, July). Documentation, Part 1: Principles for Self-Protection. AJN, 107(7), 58-60.

• Shinn, L., et al (2001). The Nursing Risk Management Series II. Retrieved Jan 26, 2004 from http://nursingworld.org/mods/archive/mod311/cerm2ful.html

• Washington Administrative Code (2004). The Law Relating to Nursing Care and Regulation of Health Professions-Uniform Disciplinary Act. WA State Department of Health.