A nurse and the system to deal with medical errors

by Mary Lynn Summer

I am a nurse. Like most medical practitioners, I am afraid of malpractice attorneys and view them as a threat to my nursing license. Every hospital has a system in place to deal with medical errors and patient complaints. I used to think they worked, but now I don’t.

My mother, in her late 80s, recently broke her hip. She has dementia so is unable to appropriately express her needs. On night two after her surgery I went home to sleep and was woken by a call from a nurse. “Your mother bottomed out after we gave her a pain pill, so we’re moving her to telemetry.” When I arrived at the hospital she was barely responsive.

I pushed the blood pressure monitor to see what her vital signs were. Her blood pressure was 68/36.  I asked if a CBC was ordered after her blood pressure plummeted. The answer was no.

Her blood levels were very low, and 3 units of blood were ordered and given.

My mother’s vital signs returned to normal and she once again became alert.

What did not return to normal was her pain control. All pain medication was stopped because the original nurse documented that she had a negative reaction to it. Multiple studies have shown that how quickly a patient is up walking after hip surgery directly affects their final outcome. Physical Therapy could not get my mother out of bed because of pain. The hospitalist didn’t listen when I said I believed she needed something for pain. When I asked the floor nurses to get an order to re-institute pain control, each and every nurse said something similar to, “Well, you’ll need to go talk to the doctor because you know how they are—they don’t listen to us.”

I spoke with the hospitalist again. He didn’t listen. My mother’s hospital stay was prolonged four days due to her immobility secondary to pain.

Within an hour of arriving at rehab she had pain medicine, and a week and a half after surgery, was finally free of pain.

I spoke with the person in charge of risk management. I asked for an opportunity to speak with the physician who was my mother’s hospitalist. I asked to speak to him off-the-record in a non-punitive environment so he might actually hear me. She agreed it was an excellent course of action and that is was unfortunate the floor nurses felt they could not communicate their opinions.

I never heard from her again. I never spoke to the doctor again.

I believed in the internal reporting process. I thought I took the most constructive action to get the doctor’s attention and to prevent future episodes of the same. But now, months later, I’m having second thoughts. Apparently, the risk management person who spoke to me only wanted to assess the threat of a lawsuit since she did not follow up with our agreed-upon course of action.

Had I hired an attorney, I am certain I would have met with the doctor and we would have reviewed the sequence of events that left my mother in pain and immobile. So now I am left to wonder if self-policing works and if sometimes legal action is morally the right thing to do.

Mary Lynn Summer is a nurse.

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  • Primary Care Internist

    As you know, the interface between patients’ families and the doctor is the floor nursing staff. It’s unfortunate that they felt they couldn’t speak directly to him/her, but i wonder if that was really true, or were they just lazy? Leaving a simple message for the MD saying that they need something prn for pain is not too hard. I bet the hospitalist didn’t even know it was an issue.

    The hospitalist is probably covering dozens of patients all over the hospital, while the nursing staff is just on that one floor. I can’t tell you how many times families and patients have told me “your doctor didn’t order xyz, so i can’t give it even though you’ve been using it every day for years. You’ll have to ask the doctor.” Why on earth wouldn’t the nurse call the doctor right away about that?

    Do you really think the doctor just wanted your mother to be in pain? I don’t know any doctors who would object to a prn tylenol order.

    • Penny Steers

      First as a NP who was a hospital RN for over 25 years, I object to the characterization of the floor nurses as “lazy”.
      Second: It is obvious that the hospitalist knew the situation and did want the patient to have adequate blood pressure which meant to him that she would not have adequate pain medicine.
      Third: That prn tylenol order is tantamount to given someone with a raging UTI one macrodatin 100 mg once daily. Just not enough to make a difference!
      These nurses sound like they were inexperienced. And where was the orthopedic surgeon in all this? Should he or she have asked the nurses what the patient’s blood count was? This was surely the cause of the patient’s “bottoming out” not the reaction to the pain medication.
      It is so easy to point fingers and accuse one group of workers when it is the whole system that is failing.

  • Dawn

    As an ICU nurse, I find myself routinely horrified by the way we withhold pain medication and sedation when we question a patient’s neurological status. Can you even imagine how terrifying and uncomfortable it must be to be intubated and on a ventilator? How achey your body must be after days in a hospital bed? Yet we are routinely asked to withhold sedation and narcotics to see if these patients will ‘wake up a little bit.’ It’s torture.
    It’s not that I don’t feel empowered to advocate for my patients; We are just not being heard. And families, unfortunately, seem much happier to see their loved one show signs of life, even if they are wild, frightened eyes looking around or grimaces and pained expressions than the peaceful rest that they call a ‘coma.’
    So lady, I know what you mean. What about a little Percocet for mom if morphine is dropping her pressure? What about an EEG to to assess neuro status in that guy on the vent instead of withholding the drugs that will make him comfortable? What we do to people.. it’s unconscionable. And how we justify it to ourselves is a mystery.

  • rezmed09

    Unfortunately there reasons why there are lawyers and why we use them. Sometime that is the only way to get people’s attention. On the other hand, many attorneys would not accept a case unless it was “economically worthwhile”.

  • http://www.shammeddoc.blogspot.com Shammed Doc

    This so unfortunate. There had to be a way that you and/or the nurses communicate with a physician. The constructive way that you have described is exactly what I have been preaching all along. Despite this incident, I strongly believe that a non-punitive environment is, all in all, the healthiest to achieve best results. However, such a cultural change appears to be not shared by all, which leads to what you have described. The problem with the medical profession policing themselves is that you put a bunch of ruthless competitors in a room and ask them to police each other. Ganging-up is quite possible, and ends up eliminating who might very well be the better doctors. Sorry that the situation is that bad. I hope your mom recovered after all, and thanks for allowing her and your experience be the subject of a constructive conversation on the blog.

  • http://anapolschwartz.com Anita L. Pitock

    Mary Lynn,
    I am both a nurse and attorney (medical malpractice) and what is frightening to me personally and professionally, is that I see this all the time. So many patients and their families come to me saying no one will tell them what happened or explain things to them. Way too often do I see no communication between doctors and nurses. I have seen cases where a patient’s blood pressure drops for hours to a critically low number (48/22) and no one is reacting. I worked in a critical care/care unit, and say “how can this happen?” -but it does. Old people and children are especially vulnerable and need our protection.

    I went into medical malpractice because, as a nurse, I care about the patients. In my role, in addition to filing suits for patients who are injured, a great deal of time is spent helping patients to understand what happened (and not filing suits). Patients get frustrated when they are stone walled, many just don’t want things to be repeated, but instead, are aggravated by the lack of response.

  • http://anapolschwartz.com Karen Swim

    Mary Lynn, your post resonated with me as well. My mom was a nurse and I grew up in hospitals and nursing homes. I worked in healthcare (clinical laboratory, managed care, marketing) for more than 20 years and during my husband’s long cancer battle saw the system intimately from a patient’s perspective. I grew up sharing my mother’s tenderness for patients and a love for healthcare, but when viewing the system as patient with an insider’s perspective I clearly saw the flaws and the frustration of those who were not insiders attempting to navigate the system on their own. I am not for abuse of the system but applaud those that advocate for patients whether that means filing a lawsuit or not.

  • Baldedoc

    Two points: firstly to the ICU nurse. There are now 10s of well done studies that show that iintermitent sedation and narcotic cessation decrease ICU length of stay, ventilator days and mortality so if you have to “justify your behavior” just tell yourself you’re saving the patient’s life because you probably are.

    Secondly, lawyers never improve communication. The first thing the doctor’s lawyer would tell him/her is to not talk to the plaintiff and the deposition is not a useful medium for communication.

    • Dawn

      You are describing the ‘sedation vacation’ that is protocol in the majority of intensive care units. Good practice, yes. But not what I’m referring to.

  • Greg

    Lemme get this straight – elderly patient has pain, takes opiate, has severe low BP, has to go to telemetry for monitoring, cheats death. Hospitalist stops opiates. Patient’s daughter wants opiates restarted due to pain. Perhaps the hospitalist is concerned that patient may have another episode of “severe low BP, has to go to telemetry for monitoring, cheats death”? I mean, if it happened the first time, why wouldn’t it happen again?

    Suppose, for malpractice sakes, that the hospitalist gave a second opiate, and “severe low BP, has to go to telemetry for monitoring, cheats death” happened a second time. Wouldn’t we all be posting about how stupid the hospitalist was to have given opiates in a elderly patient who had just had a bad reaction to the same medications? What if mom didn’t cheat death the second time, and the case ended up in malpractice court. How on earth would the hospitalist defend the action to give the opiates the second time? It would pretty much be an open-and-shut case in favor of Mary Lynn Summer, and we on Kevin MD would be again laughing at the stupidity of the hospitalist.

    Yes, pain is bad. Yes, we want to treat pain and doing so improves outcomes for pretty much everything. But remember that the definition of insanity is doing the same thing over again, expecting different results.

    • Mary Lynn Summer

      Greg,

      You started by saying “Lemme get this straight” and then proceeded to NOT get it straight. The point you missed is that my mother most likely did not have a reaction to the pain medicine. She had just had major surgery and her hemoglobin was around 6 and her hematocrit was in the mid-twenties. She needed blood.

      Once she got the blood (after I, the family member, asked for stat labs due to a very low BP that was not being treated), she was fine.

      I now work in a hospital where I doubt this would happen because they have written and active systems in place to ensure the floor nurses are empowered and heard. Their risk management and nurse-support is aggressive and impressive. And guess what? It does not cause animosity between the doctors and nurses, nor between the ER and ICU (the people who respond to do a “group assessment” of the patient) and the floor. It’s a pretty good system.

      The other flaw in your comment is assuming the hospitalist responded to my request by communicating his reason for not ordering pain medicine. He did not ever communicate with me,despite repeated requests, until I planted my body in the middle of the nurses station and politely refused to leave until I could speak with the doctor. I only did this after 1-1/2 days. I am not an aggressive, impatient family member.

      • Matt

        Very interesting conversation in between Greg and Ms.Sumner. As a doc myself, I gotta say that they are BOTH right. Ms.Sumner is completely justified in being unhappy with an attending physician and risk management representative being unresponsive and not following through with timely patient/family communication. Greg is right in that we, as physicians, practice medicine defensively, which is often not to the benefit of our patients. Ms.Sumner may not understand that it may be simply defensive medicine, and not a misunderstanding of the patho-physiology of the situation, that prevented the attending physician from re-starting pain medications after reaction of severe hypotension. Lastly, as has been mentioned, once attorneys are involved, ALL communication completely STOPS as we are told as physicians NOT to speak with anyone. Ms. Sumner would NOT be “meeting with the doctor to review the sequence of events”. That is, other than in a deposition, where the situation is so adversial that all efforts turn to “winning” the lawsuit, and not trying to figure out how to improve care in the future.

  • Susan H

    You have illustrated the intellectual steps of rationalization which lead patients to view their pursuit of money as a righteous moral imperative.
    Have you considered other actions which might accomplish your stated goals of improving future patient care for all:
    * writing a nursing research paper about specific case law, rather than evidence basis, which drive pain med prescription decisions?
    *suggestions for specific types of additional informed consents in which heirs and legatees of patients may waive rights to wrongful death damages for adverse events occurring after administration of pain meds?
    * becoming politically active to encourage legislation similar to EMTALA which requires professional legal specialists in malpractice to take cases pro bono in order to serve the mission of bettering the healthcare system?

  • Joe Says

    Dear Mary, Will you please come back to the blog later and tell us how your career faired after the incident you describe here. My guess is you will be out of a job after 180 to 365 days.

  • http://www.shammeddoc.blogspot.com Shammed Doc

    I have to see anywhere an evidence that threatening with litigation or involving lawyers would improve the communication process. We have here only one side of the story. But, taking it for face value, the problem is essentially that of communication, which could be a system error, not helped by the current environment of delivering health services. A more transparent and non-litigious (or minimally litigious) environments would probably improve satisfaction, which is the center issue in the initial posting.

  • Mary Lynn Summer

    I’m listening to you all. I’m not an angry or litigious nurse. I have no intention of hiring an attorney. I’m happy in my job and have several long-term friendships with the physicians with whom I work. I ache with them when they get sued, and I’m very aware of the unwarranted torture a competent doctor is put through because of those who are quick to sue. I don’t sue because I am on the doctor’s side and believe, even in the instance I described, the doctor was doing what he thought was best. He is not a malicious, incompetent, or indifferent person.

    If I came across as an angry and embittered nurse, resentful of doctors, then I apologize. I had an issue with ONE doctor on ONE admission. Since that time another family member was admitted to the same hospital and he did not survive. When the doctor treating him went “above and beyond” in assisting with the end-of-life complexities, I returned to the risk manager to tell her what a wonderful job he did. If I complain about a negative, then it’s my responsibility to also recognize the positive.

    So to those whom I angered, I get it.

    My point was that conversation between Mr. Nash and KevinMD was thought provoking and made me wonder how one does best accomplish the goal of improving patient safety. I’ve enjoyed the different points of view and am grateful for KevinMD for giving us a place to have an open discussion. I hope, in the end, this kind of interchange benefits both practitioners and the patients we treat.

  • Joe

    Interesting
    I have just written my third response to the wife of a gentleman with a bad outcome….not malpractice. I will continue to answer her concerns (actually accusations), because it is the right thing to do. That stated, in my experience many of these statements that ” the doctors aren’t answering my questions” as often as not are in reality patients and families who don’t want to here the hard honest truth.

  • SarahW

    Difficulty. Physcians clam up because they think that’s what a lawyer would tell them to do.

    In the first place, that is not what a competent attorney would ALWAYS tell you to do, there are times when guided communication is the better path. Moreover a competent attorney is frequently wishing his hospital/doctor clients had handled interaction with their patients in a more constructive fashion, indeed, been more open, especially when they are dealing with patients or family who DO have the capacity to understand decisions or share valuable information.

    That the patient or family’s priorities might be different is allowed, but ignoring is danger, danger for litigation, and creates anger, confusion and bad feeling.

    For patients, litigation will have the advantage of confrontation, and full access to records. Remember that when you try to avoid a patient or family member, and ignore information that interferes with your plan.

    • http://anapolschwartz.com Anita

      I agree Sara W. Talking with patients, listening to patients and addressing their concerns is always the best way to avoid litigation. Ignoring them send the message that you don’t care, makes then angry and frustated. It is when they can’t get answers they reach out to lawyers.

  • http://nomidazolam.blogspot.com J-M

    I clearly see the problem. Dr’s are on the defensive IMMEDIATELY! Without an attorney present. Having been through an episode myself, these people are NOT explaining anything. Their idea is, “We are in charge, shut up and deal with it.” If this attitude persists, we will never get good care.

    In my own case, nobody listened to me, nobody described what they were doing and did whatever they wanted, even when I said NO! Then they want to get all self righteous because there are attorneys out there who can hold their feet to the fire and at least TRY to get the law followed?

    I can only speak for myself, but what *I* wanted was for the medical people to follow the law and take my complaints seriously. Not just brush me off and then bill me for things I said NOT to do! Believe me there is no amount of money that could ever “make me whole.”

  • http://www.possiblesociety.org;www.bettmartinez.com bett l.martinez, M.Ed.

    I recently had an experience while visiting an 80 year old friend hospitalized after hernia surgery. They had followed some protocol and removed his catheter. He’s a gentle man but was experiencing severe pain, and was very distressed, wanting the catheter re-inserted. Nurses said they couldn’t, and when pressed said they couldn’t without a doctor’s permission. After pressing them to call three times with no luck, I offered in a very calm voice to find one myself – “I know you guys have a lot to so, so if you can’t get a doctor to answer in the next 10 mins. I will help you out by going down to Emergency and calling out “Dr. Dr.!”

    In five minutes they had the surgeon on the phone, and they let me speak with him. Though he was a bit reluctant at first he ordered a scan saying the cath would be reinserted if they found 300cc of urine. They found 400 cc. Reinsertion was no picnic, of course, but my friend was soon relieved, and was allowed to go home with the catheter for a few more days, return, and under careful monitoring by a urologist, the catheter was removed and he took water till it was established he could urinate on his own.

    I don’t know how possible it is to change things by complaining after the damage is done. In other instances as well, I’ve found that calm and firm actions with hospital staff can have positive results on behalf of our loved ones. Don’t go to the hospital without one!

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