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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