DO no harm: legal potpourri for neonatal nurses

1. DO no harm: legal potpourri for neonatal nurses Amy J. Jnah, DNP, APRN, NNP-BC

2. disclosures Relevant financial relationships • Director for the Center for Neonatal Nursing Education, LLC • Paid medical malpractice expert witness

3. Learning objective

4. Medical liability American Medical Association Liability Report • 95 liability claims filed (per 100 MDs) • 61% of all MDs have been named in a lawsuit • Defendant prevailed in 90% of all cases National Practitioner (APRN/RN) Data Bank Liability Report (2003-2013) • *1,458 APRNs named in a suit (FL highest) • *100,709 claims against RNs (NJ highest) • Defendant prevailed (indemnity payment made) in 3.7% of all cases *Increasing trends! Indemnity payment – Monies paid on behalf of an insured nurse in the settlement or judgment of a claim.

5. Why the increase in lawsuits against nurses? • Increased complexity of responsibility • Higher standards of care • Increased patient/family expectations (and pressure for higher satisfaction scores) • Increased patient load • Litigious society

6. “CARDIOPULMONARY RESUSCITATION ON TELEVISION: Miracles & Misinformation” TV influence Diem SJ, Lantos JD, Tulsky JA. Cardiopulmonary Resuscitation on Television — Miracles and Misinformation. The New England Journal of Medicine. 1996;334:1578-1582.

7. Malpractice & neonatology“we are special” Challenges: • Diagnostic errors (albeit unintentional) can cause life-long (and severe) injuries • Lifetime medical costs associated with injuries are HUGE • Juries sympathize with parents/families

8. Malpractice & neonatology“we are special” Challenges: • Cannot obtain patient history (from the baby) and sometimes from the mother • “Last Minute” calls to attend deliveries or emergencies and no verbal sign-out • No time to establish trusting relationship with family (often unexpected “code pink” call to delivery room) • Prolonged hospitalization = parental stress/fatigue, mistrust • Most meds we give babies are NOT approved by the FDA for use in NICUs • Most meds we give babies are intended for adult use (10-fold risk for error) – weight adjustment issues • Statute of Limitations is LONG (we often forget details and have to rely on charting come time for deposition, but the family definitely does not forget details)

9. Indemnity payments

10. Indemnity payments https://aonaffinity-blob-cdn.azureedge.net/affinitytemplate-dev/media/nso/images/documents/cna-nurse-claim-report-101615.pdf

11. Severity by allegation https://aonaffinity-blob-cdn.azureedge.net/affinitytemplate-dev/media/nso/images/documents/cna-nurse-claim-report-101615.pdf

12. Patient assessment • Failure to assess the NEED for medical intervention (60.5%) • Failure to properly or fully complete the patient assessment (19.8%) • Failure to consider/assess patient symptoms (11.6%) • Failure to reassess patient after a change of status (4.7%) • Delayed/untimely patient assessment (3.5%)

13. Patient monitoring • Failure to monitor/report changes in patient’s condition (in ICUs) (52.6%) • Failure to monitor/report changes in patient’s medical condition to the practitioner (21.1%) • Failure to monitor/report vital signs in timely manner (11.8%) • Failure to monitor/report blood levels for medications in timely manner (11.8%) • Failure to monitor results of ordered tests/consults/referrals or report to the practitioner (2.6%) https://aonaffinity-blob-cdn.azureedge.net/affinitytemplate-dev/media/nso/images/documents/cna-nurse-claim-report-101615.pdf

14. Treatment & care https://aonaffinity-blob-cdn.azureedge.net/affinitytemplate-dev/media/nso/images/documents/cna-nurse-claim-report-101615.pdf

15. Medication administration https://aonaffinity-blob-cdn.azureedge.net/affinitytemplate-dev/media/nso/images/documents/cna-nurse-claim-report-101615.pdf

16. Type of injury https://aonaffinity-blob-cdn.azureedge.net/affinitytemplate-dev/media/nso/images/documents/cna-nurse-claim-report-101615.pdf

17. Statute of limitations & Minor children • Definition: deadline for filing a personal injury claim • Unique to each State • North Carolina = 3 years after the child’s 18th Birthday

18. Litigation hot spots (neonatology) • NRP • Hyperbilirubinemia • Hypoglycemia • Sepsis • The Late Preterm (LPT) Infant • Neonatal Safety

19. NRP • Issues related to neonatal resuscitation may include the following: • Failure to provide appropriate neonatal resuscitation, including timely chest compressions. • Failure to use appropriate and necessary resuscitation equipment. • Failure to demonstrate adequate specialty knowledge and competency.

20. Hyperbilirubinemia Issues related to hyperbilirubinemia may include the following: • Failure to consult with the physician regarding an increased transcutaneous bilirubin or physical assessment. • Failure to recognize risk factors associated with hyperbilirubinemia. • Failure to document physical assessment, laboratory values, and teaching.

21. hypoglycemia Issues related to hypoglycemia may include the following: • Failure to recognize the at-risk infant • Failure to initiate glucose monitoring in a timely manner • Failure to properly hydrate infant who is at-risk or clinically hypoglycemic • Failure to monitor before and after treatments for hypoglycemia • Failure to reassess infant after interventions • Failure to administer the correct dose of glucose bolus

22. sepsis Issues related to sepsis may include the following: • Failure to recognize infant’s change in status • Failure to document change in infant status • Failure to consult with appropriate provider regarding change in infant status • Failure to reassess infant in a timely manner

23. Neonatal safety • Patient handling errors • Patient advocacy • Patient monitoring and communication errors • Medication and transfusion errors • Failure to monitor • Medication errors

24. Protect yourself • Document contemporaneously • Maintain record of continuing education (do not stagnate) • Communicate frequently with neonatal team and & document conversations in EMR • Do not “notify and tune out” – advocate, use chain of command, think for yourself! • Disclose mistakes (Just Culture) and apologize • Avoid paternalism – transparency with parents is VERY IMPORTANT …for not suing me

25. Did I mention documentation? • Observations, complaints, conversations or concerns AND instructions given to parents • Sensory method used when assessing an infant • Changes in infant’s condition AND intervention • Utilization/activation of the chain of command • Don’t write “MD/APRN notified” (need to state what happened, why, when, and what action you took as the RN)

26. Have resources on hand(and use them!)

27. Case study • Baby Ryan is a term (40 week EGA) infant delivered vaginally. At the time of birth, mother was a 27-year-old G1P4. • Mother’s blood type was A negative, and her other prenatal lab results included Hep B negative, RPR nonreactive, HIV negative, GBS negative, Rubella immune. • Labor was electively induced, with ROM approximately 85 minutes prior to delivery of a viable male infant. The vaginal delivery was uncomplicated. • Baby Ryan weighed 6lbs 12oz at birth (3016 grams—27%tile), head circumference 34.3cm (26%tile), length 50.2cm (59%tile). Per the WHO chart for growth, Ryan was of appropriate size for gestational age (AGA). • Ryan’s blood type was recorded as A negative, Coombs negative.

28. Case study • The first 24-hours of Ryan’s hospitalization proceeded normally. • Ryan was breast feeding and supplementing with formula, per mother’s wishes. • Ryan was voiding and stooling. • As is routine and customary, Ryan was weighed at 24-hours of life, and additional screening tests and lab work was obtained. Ryan weighed 2990 grams (2.3% below birth weight) and Ryan’s total serum bilirubin (TSB) at 24hrs of life was 8.7mg/dL and direct bilirubin = 0.3mg/dL.

29. Case study • A repeat TSB was ordered for 30 hours of life. • The TSB level at 30 hours of life was 9.5mg/dL. • Ryan was thereby discharged to home with his parents, at approximately 7:30pm on Friday 9/13/2019. • Discharge instructions: follow-up on Saturday 9/14/2019 in the hospital emergency room, for repeat TSB.

30. Case study • On Saturday 9/14/2019, the family returned to the emergency room, as directed. • Ryan’s TSB level at that time, (55 hours of life) was 14.4mg/dL. • The NNP on duty, and a neonatal RN, were called to the emergency room to see the patient and interpret lab results. The NNP subsequently discharged Ryan to home with an order for outpatient pediatric follow-up on Monday 9/16/2019 (48hrs later) for repeat TSB testing. • The neonatal RN executed the discharge, as ordered.

31. Case study • On Monday 9/16/2019, Ryan’s parents reported to the pediatrician as recommended. • Dr. DoNoHarm noted that Ryan was visibly jaundiced (skin and eyes) and ordered a TSB level to be obtained and analyzed by LabCorp, in a nearby office. • The repeat TsB was obtained at 103 hours of life, with an order for routine processing.

32. Case study • The TsB was analyzed on Tuesday 9/17/2019. Result = 31.8 mg/dL • Dr. DoNoHarm was thereby notified and called the parents. Ryan was subsequently directly admitted to the nearby hospital for intensive phototherapy and management of severe neonatal hyperbilirubinemia. • Ryan’s TSB at 126 hours of life, while receiving intensive phototherapy, rose to 38.9mg/dL. • Ryan demonstrated clinical manifestations consistent with acute bilirubin encephalopathy including progressive neurologic irritability, opisthotonos, posturing, and decerebrate movements of the right arm. • On 9/18/2019, Ryan’s TSB rose to 41.9mg/dL (direct bilirubin 3mg/dL); on that same date, a single copy of the allele-allele G6PD X-linked gene was identified. • Subsequent management included two (2) double volume exchange transfusions, the administration of IVIG, albumin, and phenobarbital for suspected seizures.

33. case study • Identify Risk Factors • Assign Neurotoxicity Risk Category • Assess phototherapy threshold • Assign hour-specific risk category for severe hyperbilirubinemia • Determine “when” the bilirubin level should be repeated • Compare your information to what was done • Determine if there were breaches in the standard of practice

34. Breaches in the standard of care • Ryan’s TsB at 24 hours of life was 8.7mg/dL, which was at the ≥95th percentile (high-risk zone). • Ryan’s TsB at 30 hours of life increased to 9.5mg/dL, again at the 95th percentile (high-risk zone). • Ryan’s TsB at 55 hours of life was 14.4mg/dL, which was at the 95th percentile (high-risk zone). His phototherapy treatment threshold at that time was a TsB ≥15.9mg/dL.

35. Breaches in standard of care

36. Thank you! Contact me: CFNNEducation@gmail.com or APNConsult@gmail.com