Merit in an Upside Down World

As practicing nurses, we take care of the sick, observe them for declines in condition, and rectify the wrongs done by others as a matter of course.  If we put our patients first on a busy shift, our hands are literally full – too full, sometimes, to pick up a pen and document the care we have given.

The result of a horrible day may be a life saved and a catastrophe averted, but if we did not write it down, it simply did not occur years later when our work is reviewed.

This was brought home to me in a case I recently reviewed for merit.  The lack of documentation clearly provided legal support for negligence.  Did I truly believe this patient had gone four hours in the emergency room without one vital sign being taken?  No, I did not.  But two years after the fact, no one can prove those vital signs were taken.

I did know that at the end of those four hours, the patient had crashed.  His first recorded systolic was in the 60’s, he was bleeding out, and he was on a stretcher with the head of his bed elevated to at least 75 degrees.  This was a breach in the standard of care.

The second breach of care was less of a breach and more of an accident – the kind that can occur with any outpatient colonoscopy – but which nonetheless resulted in massive internal bleeding.

The third breach occurred as his circulatory system was overloaded with too much fluid over too short a time for a person with heart disease.  Failure to recognize this resulted in congestive heart failure and pulmonary edema.

The fourth negligent act was failure to recognize the signs of internal perforation with resulting crepitus. Think Michelin Man as he was wheeled off to emergency surgery two hours later.

Any nurse would be appalled and sympathetic to the plight of this helpless patient.

However, as legal nurse consultants, we must step beyond what was done wrong, and focus on the event that definably resulted in permanent damages.  Without those permanent damages, patients are not reimbursed for near-fatal events and a medmal attorney will not take this case.   

Of all the things that happened to this patient, ultimately only one event will matter.  The gap in vital signs that could have deprived his brain of oxygen will account for his residual cognitive deficits.  Deficits mean a loss of earning capacity and a formula by which to assess damages.  That gap of time during which care probably was given but was not charted is the critical event on which this case will proceed, if at all.  A cautionary tale for all of us, and doesn’t that feel a bit upside down?

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