Nurses On Trial: Malpractice Issues in OB Nursing
State of the Art
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Aside from the field of Obstetrics, no other specialty in medicine or nursing must attend to two patients at once; one or more contained within the body of the other. Expecting a baby is a unique time for parents and families. During this time frame women experience their first extended contact with a physician, midwife, or nurse. Most view pregnancy as a normal, physiological process and overall expectations are that the pregnancy will proceed normally with the birth of a normal, healthy baby. When these expectations do not turn out as planned parents are, naturally, devastated and after the initial shock will eventually seek answers for why an adverse event occurred. If parents and family cannot get the answers they seek from their health care providers, they may naturally look for answers and/or compensation from plaintiffs' injury attorneys.1
Newborn Injuries
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Newborns who have suffered brain injuries or other devastating outcomes are some of the most heartbreaking of all injured clients that attorneys will take on. The costs for care of an injured infant are enormous and beyond the abilities of average families to cover. These are tragic situations and many families will turn to the legal system for help. The damages sustained by a mother and/or her baby can present insurmountable obstacles in regard to long-term care. Filing a legal action may be the last resort for many families.
Teamwork In OB Health Care
The team approach to obstetrical care is still a work in progress for many health care institutions. Ideally, patients and families should expect team care that incorporates respect, cooperation, and communication. Every family deserves concern, consideration and open communication from hospital entities. If they don't get it from the hospital and its providers, devastated families have every right to demand it from a judge or jury in State or Federal Court.
What is at stake for an OB health care team is whether the standard of care for each of their their specialties has been met in any given malpractice case. (see http://www.midwivesontrial.com). The standards of care for nursing derive from ACOG and the Association of Women's Health, Obstetrical, Gynecological, and Neonatal Nurses (AWHONN). Nursing standard of care is defined as those acts that a reasonable and prudent registered nurse, in the same or similar circumstances, and with the same education and training, would perform. Shared responsibilities between nursing and medicine are expected. 2
Levels of OB Care
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Categories of Obstetrical services play a significant role in the care and disposition of women and their infants. Level I care is appropriate for uncomplicated maternal/infant care. Level II facilities provide care for uncomplicated and "moderately complicated" obstetrical and neonatal care. Level III institutions are usually found in university settings and are responsible for providing care to mothers and infants with all types of medical situations and acuities.3
Obviously, with the existence of various designations and levels of care, potential legal issues may arise. Especially common, in medical malpractice claims, is the failure to accomplish appropriate transfers in obstetrical situations where mothers and/or infants have potential for or existing medical needs that necessitate transfer to higher levels of care. Failure to timely transfer mothers or babies to the appropriate level of care has formed the foundation for many lawsuits claiming medical negligence and resulting injuries.4
Case Study
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A 33 y/o woman was 28 weeks pregnant with twins when she presented to a general hospital's emergency department complaining of uterine contractions. The patient was triaged in the emergency department and seen by an ED physician and two ED nurses who were on duty. The patient's OB physician was not a memeber of the medical staff at this hospital. He was contacted by phone and he ordered the patient to be immediately transferred to a Level III hospital for care. The OB provider declined to come into the first hospital to examine the patient in person. In addition, the Level III hospital refused to accept the tranfer until the OB provider conducted a history and physical.
The OB physician testified in court that he did not come to the Level I hospital because he was not told by the nurses that the patient was in labor. Meanwhile, the first infant (Baby A), presented breech and delivered. The infant was placed in the only isolette that existed in the hospital. The second infant was born an hour later and manually ventilated until a Level III team arrived to transfer both of the babies. Baby B died after 5 days of a pulmonary hemorrhage. Baby A remained at the Level III facility for 7 months and eventually died at home.
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This case was tried in court for the negligence of the OB physician and settled out of court with the Level I hospital. The Plaintiffs' attorneys argued that the mother's OB doctor was negligent for not coming to the first hospital when he was initially contacted. They argued that a transfer could have happened before the babies delivered. The nurses in the ED were named in the lawsuit for negligence in not realizing the acuity of the pregnant patient's condition and reporting it to the physician. The Level I hospital had no policies or procedures in place in the emergency department for high risk obstetrical situations. Because the babies delivered at the first hospital, Plaintiffs argued that they were in worse condition than if they had been immediately transferred.5
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The Defense attorneys for the Level I hospital argued that the mother was too critical to be transferred to a higher level of care. They claimed that the babies had received the same level of care at Level I than they would have received at Level III. Official cause of death for both twins was prematurity. The case was tried on the medical negligence claim, and the jury returned a verdict awarding $200,000; each estate was awarded $100,000, and less than $1000. to bury both infants. The Plaintiffs settled out of court with the Level I hospital for an undisclosed amount.
Unfortunately, the twins were allowed to deliver at a facility that could not properly care for them. The OB physician testified that he was not notified that the patient was in labor. If this was credible, nursing negligence was implicated with deviation from the nursing standard of care. As follows:
1. Failure of general medical/nursing managment which involves planning and conduct of patient care, including use of medications and deviation of nursing standards.
2. Injuries caused by a specific treatment or lack thereof. Incorrect procedures, communications, and decisions to treat. The majority of these deviations involve physicians and nurse-midwives.
3. Injuries caused by problems in diagnosis are the third category of negligence in these cases. These involve misdiagnoses and failure to diagnose. 6
Estate of Anne Cox, deceased minor, Estate of Michelle Cox, deceased minor, and Nancy Cox v. Dr. James Smith, Northwest Community Hospital, Sue Christensen, R.N., Gerry Rowander, R.N., Dr. Nancy Qusba, and Medical Emergency Service Assocs(1995)
1. Iyer, Patricia W. Nursing Malpractice, Chpt. 5 (5.1 Introduction) p.115
2. Ibid. p. 116.
3. Ibid. 5.2A Categories of Obstetrical Services. p. 117
4. Ibid. p. 118
5. Ibid. p. 118-119.
6. Ibid. p. 118
Breaches of Nursing Standard of Care in OB Scenarios
1. Failure to utilize chain of command when initial OB contact is unresponsive. Failure to notify Nurse-Midwife and/or Physician of concerning changes in a patient's condition.
2. Failure to follow established patient care plans.
3. Medication errors; negligent administration.
4. Failure to document; inadequate documentation, falsification of records and alterations of recorrds.
5. Failure to recognize serious patient conditions; failure to notify
6. Failure to follow policy and procedure.
7. Administration of care for which nurse has not been educated or trained.
8. Delegation of duties to individual who has not been adequately trained.
9. Failure to properly monitor or supervise patients.
10. Failure to maintain safe environment for patients causing injuries such as fall and burns.
11. Failure to adequately communicate with other providers, families, or patients.
12. Failure to properly observe the patient.
13. Failure to follow prescribed orders.
14. Equipment injuries
15. Retained foreign objects.
16. Floating issues
17. Failure to perform proper evaluation and screening.
18. Failure to identify high risk patients.
19. Failure to perform proper triage.
20. Failure to provide proper or correct advice.
21. Failure to maintain and properly use medical equipment.
22. Failure to give proper discharge instructions.
23. Failure to perform proper instrument counts; c-section.
24. Failure to inform midwife or physician of significant signs/changes in a patient's condition.1
1. Iyer, Patricia W. Nursing Malpractice.Second Edition. Chapter 19 p. 118
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