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LEGAL CLINIC

Editors note: This is the first in a series about real litigation involving nurses and what they could have done differently to avoid the situation.

Lessons Learned from Litigation: The Case of Eric Decker


Did nurses actions result in infant harm?
On July 17, 1996, Robin Decker gave birth to a fullterm infant at Carson City Hospital, a small rural hospital in Michigan. Fetal distress or maternal fatigue necessitated a vacuum extraction, but Eric Deckers Apgar scores were normal. The following day, the infants bilirubin was elevated and he demonstrated a reluctance to feed. A pediatrician, unaware of the fetal distress or vacuum extraction, discharged him to home. At home, Erics reluctance to feed continued and he was becoming lethargic. He was returned to the hospital on July 19. His elevated bilirubin was accompanied by jaundice, and he was diagnosed with persistent hypoglycemia. Eric was airlifted to Helen DeVos Childrens Hospital in Grand Rapids, Michigan, and admitted to the pediatric ICU. When he arrived, he was taken off fluids, including a glucose infusion, for approximately 20 minutes. When his glucose level was checked, it was discovered to be dangerously low at 4 mg/dL. A central line was inserted for glucose administration. His glucose level remained low, and seizure activity was observed. On July 20, a computed tomographic scan of the brain revealed extensive hypoxic ischemia with hemorrhage. Eric continued to decompensate and ultimately suffered a cardiac arrest. During resuscitation, it was determined that the central line wasnt in the subclavian vein, which had resulted in cardiac tamponade and a large pneumothorax. A second central line was inserted, and he was stabilized. He was discharged from the hospital on September 3, with developmental delays, sensory deficits, and blindness. Eric was diagnosed with cerebral palsy resulting from the early anoxia. Robin Decker filed suit against both of the hospitals, the obstetrician, and the pediatrician.1 The claims against the hospitals were related to nursing management. The suit alleged that the nurses were liable for Erics injuries because they didnt appropriately monitor and maintain his glucose level. Specifically, it alleged that the nurses failed to properly monitor Erics glucose levels and the status of the central line, in light of his medical history and condition.
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provide the necessary care to Eric. record the changes in Erics condition and report them to physicians and other providers completely or in a timely fashion. seek consultations with or provide referrals to qualified specialists. Despite orders for hourly glucose levels at Helen DeVos Childrens Hospital, the medical record demonstrated that no glucose levels were obtained between 1:13 pm and 4:01 pm (on July 19). The suit alleged that glucagon, potassium, and glucose boluses werent administered as ordered or in a timely fashion. The medical record indicated that at 3:04 am (on July 20) the nurses observed bradycardia(with a heart rate ranging from the 130s [beats per minute] to the 100s), hypopnea (with a respiratory rate ranging from the 30s [breaths per minute] to the teens), and reduced oxygen saturation (percentages in the 70s). But there was no indication that these findings had been communicated to a physician, nor was there documentation showing that the nurses had communicated difficulties drawing from the central line or that Eric was exhibiting seizure activity. Between 4 am and 5:07 am Erics glucose level dropped from 90 mg/dL to 48 mg/dL. Between 5 am and 5:50 am his glucose level fell farther, to 37 mg/dL. The medical record did not indicate that these dangerous levels were communicated to a physician. To prevail (be the winning party) in a medical malpractice case, the party bringing the suit (the plaintiff or plaintiffs) must prove four elements: duty breach cause harm First, the plaintiff must prove that the party being sued (the defendant or defendants) owed a legal duty to the plaintiff. The duty providers owe to patients is the duty of reasonable care. Although the elements are defined differently in different jurisdictions, a nurses duty is generally meant to reflect the level of
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ELEMENTS OF A MALPRACTICE LAWSUIT

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By Edie Brous, JD, MS, MPH, RN

care that a reasonably prudent nurse would have provided under the same or similar circumstances. The second element, breach, means the defendant or defendants departed from the generally accepted standard of practice. A defendant breaches her or his duty when deviating from those standards. By doing something a reasonably prudent nurse would not have done, or by not doing something a reasonably prudent nurse would have done, a nurse departs from generally accepted standards and breaches her or his duty to the patient. Third, the plaintiff must prove that the defendants breach of duty was a cause of the plaintiffs harm. Causationor proximate cause or cause in fact, as it may be calledis determined by a but for or substantial factor test: the plaintiff would not have been harmed but for the defendants breach of duty and the harm caused to the plaintiff was a foreseeable result of the defendants departure from the standards of care; similarly, the departure was a substantial factor in allowing the harm to reach the plaintiff. The plaintiff must state the manner in which the breach of the standard of practice or care was the proximate cause of the injury claimed. Its not sufficient merely to state that the defendants negligence caused the harm. Finally, the plaintiff must demonstrate actual harm, that she or he has indeed been damaged by the defendants breach of duty. A plaintiff cannot prevail by demonstrating only potential injuries. In a medical malpractice case, this harm can be physical, emotional, or financial. To prevail in the Decker case, the plaintiff, Robin Decker, needed to demonstrate that the nurses owed a duty to Eric Decker (the duty of reasonable care); that they breached that duty (by departing from the standard of practice); that the departure from standards was a cause of Erics injury; and that he, in fact, suffered actual injury. Regarding the nurses duty and breach, the plaintiffs expert nursing witness testified that central lines must be monitored and evaluated for patency, as well as used correctly. individualized care must be given to a patient on the basis of the patients medical condition. physician orders must be followed. nurses must record significant changes in a patients condition and report them to physicians and other providers; they must also record such verbal communications. Regarding causation, Robin Deckers complaint alleged that Eric Deckers injuries were a result of the failure of the nurses to take those actions identified by the expert witness. Regarding injuries, the complaint stated that the failure of the nursing staff to
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practice in accordance with generally accepted standards of practice caused Eric to suffer from cerebral palsy, developmental delays, difficulty walking, limited use of his extremities, articulation delays, sensory deficits, and blindness. The case didnt go to trial, and all parties settled for an undisclosed amount. Nurses are the safety net in health care. It is the nursing staff that monitors patients for foreseeable complications. It is the nursing staff that intervenes and notifies physicians when those complications occur. And it is the nursing staff that prevents harm as vigilant patient advocates. When patients experience threats to their safety, it must be the nurses who rescue them from those dangers. When that doesnt happen, adverse events can lead to catastrophic harm. People who choose nursing as a career accept enormous responsibility for the well-being of others. Its hoped that indifference to that responsibility is rare. The reasons nurses dont always prevent the kind of harm that Eric suffered are varied. Insufficient staffing, inadequate training, unsupportive management, organizational constraints, system failures, and abusive hierarchies may all contribute. Here are some steps you can take to prevent harm and reduce your own liability exposure in the process: Develop effective interpersonal skills. More than any other single factor, the nature of the
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LESSONS TO BE LEARNED FROM THIS CASE

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Illustration by Janet Hamlin.

LEGAL CLINIC

providerpatient relationship determines whether you will be named in a suit. Keep liability concerns in context. The fear of liability far exceeds the reality for nurses; most nurses will never be individually named in a lawsuit. Obtain the necessary education and training for the specialty in which you work. For example, adult and pediatric nurses arent interchangeable. Maintain clinical proficiency, and keep current with professional-organization membership and professional-journal subscriptions. Bring staffing concerns to management in writing and to the bargaining table if you work in an organization with a collective bargaining agreement. Carefully monitor patients for foreseeable complications. Immediately notify a physician of worrisome clinical status changes. Remember that the medical record is the best, and sometimes the only, available evidence if you must defend your actions. Document all clinical observations and critical diagnostics.

Document conversations with other providers regarding patient issues. Document which specific physician was notified of which specific concerns at what specific time. Document that the chain of command has been engaged when necessary. Make sure the medical record reflects that you pursued your concerns to resolution. Maintain a professional liability insurance policy; dont rely solely on your employer for coverage. Do what you think is in the best interests of the patient, not what you think will reduce liability exposure. Be the advocate we pride ourselves on being.

Edie Brous is a nurse and attorney in New York City and the coordinator of Legal Clinic: ediebrous@aol.com. The author has disclosed no potential conflicts of interest, financial or otherwise.

REFERENCE
1. Decker v. Rochowiak, 287 Mich. App. 666 (2010) 791 N.W.2d 507.

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