Medical-Legal Topics

What’s a medical error? Part 1 by Pat Iyer

July 27th, 2010

I was talking to my son and his girlfriend about medical errors and he asked me to define them. Here are some cases we have handled.

* the hospitalized patient who was alert, oriented, and ambulatory until the nurse administered an inappropriate dose of Morphine, resulting in a serious overdose;
* the emergency department patient who developed quadriplegia after the nurse removed the cervical collar without an order and without the spine being cleared;
* the unsupervised nursing home resident on a pureed diet who choked on deli meat he grabbed off another resident’s tray;
* the newborn infant delivered by vacuum extraction who experienced signs of respiratory distress that went unnoticed by the nursery staff until the infant experienced a respiratory arrest and expired due to complications from a brain hemorrhage;
* the critical care sitter who sexually assaulted a patient;
* the intubated patient who pulled out his endotracheal tube because the nurse did not restrain his hands and he could not be re-intubated:
* the paraplegic receiving supplemental nutrition via a nasogastric feeding tube who experienced an aspiration event and died because the RN programmed the feeding pump incorrectly, resulting in the infusion of an excessive amount of feeding over a short period of time;
* the unsupervised emergency department psychiatric patient who jumped off the roof of the hospital while waiting to be admitted to a psychiatric unit
* the medical surgical patient who rolled off the bed while the sheets were being changed because the nurse did not put the side rail up;
* the surgical patient who developed compartment syndrome and nerve damage because the surgery shredded the popliteal artery in his knee and the nurses did not perform neurovascular checks

What are these?

Tags: medical errors, Medical malpractice, nursing error, Nursing malpractice, nursing negligence
Posted in Legal nurse consulting, Medical malpractice, Nursing malpractice, medical errors | No Comments »

What’s a medical error? Part 2 by Pat Iyer

July 26th, 2010

I was talking to my son and his girlfriend about medical errors and he asked me to define them. Here are some more cases we have handled.

* the oncology patient who suffered from a large extravasation of a chemotherapeutic drug;
* the patient who fell off the operating room table because the nurse did not apply safety straps;
* the patient whose swollen leg was not reported to the physician on the day of discharge, and who died of a pulmonary embolism shortly after discharge
* the man who jumped through a window because the nurse did not recognize the need to start one to one supervision
* the surgical patient diagnosed with a retained sponge despite the “correct” sponge count;
* the nursing home patient scalded in a bathtub;
* the psychiatric patient who had a history of suicidal ideation and attempts, who was unmonitored, left the hospital, and hung himself in the nearby woods;
* the pediatric patient who went into respiratory distress and whose home care nurse asked his father to come home instead of following directions to call 911;
* the nursing home patient who fractured two hips after being dropped out of a hydraulic lift by a nursing assistant, who did not report the incident;
* the postoperative woman who experienced intra-abdominal hemorrhage and subsequent shock that went undetected by the Post Anesthesia Care Unit nurse.
* untold numbers of pressure sore cases

What are these?

Tags: medical errors, Medical malpractice, nursing errors, Nursing malpractice
Posted in Legal nurse consulting, Medication errors, Nursing malpractice, medical errors | No Comments »

Why don’t healthcare providers follow the rules? Part 2 by Pat Iyer

July 19th, 2010

Wrong site surgery is the most common medical error

Wrong site surgery is the most common sentinel event

Normalization of deviance occurs when a provider, such as a nurse, nurse knowingly disregards a safety practice, such as using two patient identifiers to verify patient identity. Repeated deviation from the safe practices tends to “normalize” the risky behavior in the nurse’s mind. In another example, The Joint Commission Medication Management Standard requires labeling of all medications. Yet a survey by the American Nurses Association indicated that only 37 percent of nurses surveyed reported they always label syringes and 28 percent never label syringes when administering medications.

Despite awareness and education, some providers choose to willfully disregard safety practices. Patient safety experts define a “no blame” culture as one that argues that most errors are committed by hardworking people; the traditional focus on identifying who is at fault is a distraction. A “just culture” differentiates between blameworthy and blameless acts. Two physicians, Wachter and Pronovost, acknowledge that there are areas of performance that pose a clear risk to patients, such as failure to practice hand hygiene, use a checklist to reduce blood stream infections, mark the surgical site to prevent wrong-site surgery, or perform a preoperative time out.

Nurses are implicated in some of these issues. They work for the organization, which typically has relatively clear lines of authority and procedures for dealing with failure to follow accepted practices. On the other hand, physicians have traditionally been independent entrepreneurs, not employees. They are subject to weak peer enforcement. Peers often recoil from disciplining each other and hospitals have been reluctant to punish physicians for fear of alienating them and losing the business they bring in. The tradition of lax enforcement of safety rules has led too many physicians to ignore them. Wachter and Pronovost argued for a clear definition of unacceptable behaviors, with the initial warnings and counseling. Continued failure to adhere to safety practices after the initial penalty would lead to suspension or loss of clinical privileges (for physicians and others subject to credentialing, such as advanced practice nurses) or firing.

Isn’t it about time we stopped dangerous practices?

More reading:
Beaulieu, L. and Freeman, M, “Nursing shortcuts can shortcut safety”, Nursing 2009, December 2009, 16-20
Wachter, R. and Pronovost, P., “Balancing ‘no blame’ with accountability in patient safety”, New England Journal of Medicine, October 1, 2009, 1401-1406.
Cohen, M. “Risky imposter”, Nursing 2008, May 2008, 20.

What are these?

Tags: hand hygiene, hospital-acquired infection, medical errors, normalization of deviance, wrong site surgery
Posted in Healthcare Risk Management, Medical malpractice, Nursing malpractice, Patient safety, medical errors | No Comments »

Why don’t healthcare providers follow the rules? Part 1 by Pat Iyer

July 14th, 2010

Wrong site surgery is the most common medical error

I’ve been updating a chapter on the roots of patient injury for the fourth edition of Nursing Malpractice. I’ve been thinking about the reasons people don’t follow policies and procedures. Back in the 1980s when I ran a nursing hospital’s staff development department, I learned that if people did not have the knowledge, this was an educational problem and we were to educate. If they knew how to perform their jobs but chose not to, this was a management problem and their managers were to counsel and discipline. Now we think about this issue in expanded terms.

1. Safety standards are not monitored or enforced
People may not do their jobs correctly because there are no consequences if they don’t. Managers must be clear about the need to follow policies and procedures and the consequences of not doing so. Continual monitoring and education about the importance of patient safety sends an obvious message about the value of patient safety policies.

2. Lack of knowledge
Staff may be unaware of how to perform aspects of their job. They need training and competency checks. They may lack knowledge about how medical errors occur. Integration of patient safety information into the curriculum of schools of nursing helps to increase knowledge and skills.

3. Dysfunctional systems
Convoluted systems are sometimes created by providers or administrators who lack essential training in human factors and systems engineering, which may make it too hard to adhere to the practice. This invites workarounds because it becomes too difficult to follow the procedures.

What are these?

Tags: hand hygiene, medical errors, normalization of deviance, Patient safety, wrong site surgery
Posted in Healthcare Risk Management, Medical malpractice, Nursing malpractice, Patient safety, medical errors | No Comments »

Pat Iyer’s 9 tips on detecting altered medical records Part 5

July 12th, 2010

• Examine logs or communication books kept at the nursing station of some nursing homes. I found a note in a nursing home communication book that stated, “When you recopy the nurses’ notes, leave enough room for the night shift to describe the fall.” The case settled soon thereafter.
• Obtain billing records to determine if care was charged for but not documented. A record of an office visit may have been removed from the file, but the billing record verifies that the patient was seen.
• Sometimes there will be a dispute over when or how frequently a patient was treated and what diagnosis was made by the physician at that time. These disputes can often be resolved by requesting a copy of the medical insurance company’s records and comparing the billing records and diagnosis codes with the doctor’s records.
• Evaluate the hospital or nursing home’s staffing records to determine if the people who have documented in the medical record actually worked that day.
• Look for any documentation in the file indicating when the chart was copied and to whom it was supplied. Request copies of the chart from these entries and compare the two sets.
• Request a copy of the facility’s policy on documentation.
• Request the policy on incident reports.
• Request copies of physician office scheduling books to determine when the plaintiff was supposed to have been seen in the office.
• Request records of companies employed to act as answering services for physicians.

Modified from Roy Konray and Pat Iyer, “Tampering with medical Records, in Pat Iyer and Barbara Levin (Editors) Medical Legal Aspects of Medical Records, released in March 2010, for more tips.

What are these?

Tags: altered medical records, altered records, spoliation of evidence, spoliation of medical records, tampering with medical records
Posted in Healthcare Risk Management, Legal nurse consulting, Medical malpractice, Medical records, Nursing malpractice, Tampering with evidence, Trial lawyer skills, medical errors | No Comments »

Pat Iyer’s 7 tips on detecting altered medical records part 4

July 7th, 2010

• Look for the “too good to be true” pattern of documentation. For example, the patient was steadily losing weight but supposedly consuming 100 percent of his 2000 calories per day diet.
• Note entries that are self-serving and needlessly explanatory of the events that occurred. 50
• The medical record examiner needs to look not only at the content of the records but also at the extraneous details of the whole record. Psychologists have long observed that people normally focus on the overall message without seeing the details. The astute record examiner needs to step back from looking at the overall content and, as a separate step in the review of the records, focus on extraneous details.
• Look at the bottom of a questionable form to see if the facility has a date of printing on the form. Compare the date of the form with the date of the entries.
• Determine the meaning of codes at the bottom of a form. For example, a progress note was supplied to an attorney in discovery by a physician being sued for medical malpractice. The preprinted form on which the doctor kept his notes contained a code (0595) and the manufacturer’s telephone number. A quick call to the stationery company that created the form revealed the code was actually the date the form was created. The physician was caught in a flagrant lie with no way to explain how an “original” progress note from 1994 could end up on paper manufactured in May of 1995.
• Always ask to examine the original records. Often, codes appear on the back side of a page. The examiner needs to review the original in order to determine what codes are applicable to both sides of the page. Also, if there is no written entry on the back side of the form, it is not normally copied or supplied in discovery even though it may contain preprinted codes. The person doing the copying normally views a page without handwritten or typed entries as a blank page and will not copy it.

Modified from Roy Konray and Pat Iyer, “Tampering with medical Records, in Pat Iyer and Barbara Levin (Editors) Medical Legal Aspects of Medical Records, released in March 2010, for more tips.

What are these?

Tags: altered medical records, altered records, spoliation of medical records, tampering with medical records
Posted in Healthcare Risk Management, Legal nurse consulting, Medical malpractice, Medical records, Nursing malpractice, Tampering with evidence, Trial lawyer skills, medical errors | No Comments »

Pat Iyer’s Dirty Dozen Tips for Detecting Altered Medical Records Part 3

July 5th, 2010

• Examine handwriting to see if there are obvious changes in the appearance of the writing within an entry. Another thing to look for is a change in style. If notes are sloppily written and suddenly a page of neatly written notes appears from the same author, this may be a sign that the page has been rewritten at a later date.
• Look for red flag notes. Sometimes the individual will leave a note behind that states that a record has been changed. For example, a medical record included a page that contained a handwritten note that stated, “Phyllis, substitute this page for the evaluation completed 5/6/04.” The page was copied with the handwritten note on top of the clinical record.
• Be aware of a typed entry that follows handwritten entries, or vice versa.
• Look for discrepancies from the type of charting that is required by regulations and facility policy.
• Look for an excessive number of late entries, especially involving circumstances surrounding the act or injury in question. Examine the timing of the late entry. Sometimes the healthcare professional adds a late entry after learning of a problem. Review the chart to see if there were other intervening opportunities for the healthcare professional to add the late entry before the time of discovery of a problem.
• Look for words that are squeezed into an entry.
• A half sheet instead of a full page of a medical record may be found. Careless photocopying could have occurred, but it is also possible that the page was cut or folded over to hide information.
• When reviewing the original medical record, look for a photocopy of a page that has replaced an original.
• Look for obliteration of entries. Was correction fluid or heavy marker used to cross off entries?
• Review the original record to detect different color ink used within the same entry. This will not show up on a photocopy unless a heavy felt tip pen is used as one of the writing instruments. Even a slight change in the color of the ink suggests that two different pens were used to create the record (the implication being that one part of the record was added at a later date).
Compare the family’s photographs of the patient with the medical records. Are there pressure ulcers in the photographs that are not described in the medical records? Are the patient’s tongue and teeth green with mold, but the medical records document daily mouth care?
• If photographs of a pressure ulcer are available ask a clinician to compare the stage of pressure ulcer in the photographs with what is documented in the medical records.

Modified from Roy Konray and Pat Iyer, “Tampering with medical Records, in Pat Iyer and Barbara Levin (Editors) Medical Legal Aspects of Medical Records, released in March 2010, for more tips.

What are these?

Tags: altered medical records, spoliation of medical records, tampering with medical records
Posted in Healthcare Risk Management, Legal nurse consulting, Medical malpractice, Medical records, Nursing malpractice, Tampering with evidence, Trial lawyer skills, medical errors | No Comments »

Generations and Medical Malpractice Part Two

June 30th, 2010

There are four generations of people employed in health care. Consider how each reacts to situations that put patients at risk for medical errors and medical malpractice. These guidelines are generalities and may not apply to a particular person.

3. Gen X
Gen Xers were born between 1965 and 1978. The Watergate debacle, which revealed the extent of dirty politics, was an influence on this generation. Women’s liberation affected traditional household roles and saw the rise of strong feminists. The gas crisis in 1973 resulted in a sudden feeling of vulnerability. The Gen Xers were the first generation of children affected by both parents working. They were exposed to massive corporate layoff, leading them to value self reliance. Quality of life and balancing work and home life affects this generation. They may be less likely to accept working long hours and schedule changes as they are driven by a need for life and work balances. They saw an increase in divorce rates. This is the impatient generation. They are in a hurry, and want quick promotions and for work to be fun and informal. The Gen Xer tends to be more productive, producing more work in less time. They often prefer to work alone and may distrust and challenge authorities. This may influence their ability to work as part of a team and affect the need to communicate with others.

4. Gen Y or Millennials
The Gen Y population was born between 1981 and 2000. This is the generation that is drawn towards the family for safety and security. They are a global generation who accept multiculturalism and multitasking as a way of life. The Gen Ys are savvy about technology and instant communication. They are highly creative and well educated, confident, hopeful and goal-oriented. They enjoy teamwork. They are a digital generation that is globally concerned. They expect 24-hour a day information. They have difficulty dealing with complex problems and are inexperienced within the medical world. They benefit from mentoring and structure. This is a group who has a high need for feedback and structure. Data shows that 30 percent of Gen Y nurses turnover in the first year of practice and 57 percent by the second year. They have been taught to question each situation to find meaning in every task.

The Veterans may be reluctant to challenge authority, which may be necessary when the healthcare provider needs to be a patient advocate. The Baby Boomers, Gen Xers and Gen Yers have been taught to speak up. Gen X and Gen Y healthcare providers get frustrated with older people who resist technology. All generations want to be respected, valued, and rewarded for their efforts. Healthcare workers do best when they recognize there may be generational differences, and welcome the diversity.

What are these?

Tags: Gen X, Gen Y, generations of workers, Medical malpractice, Millennials
Posted in Communication skills, Medical malpractice, Nursing malpractice, medical errors | No Comments »

Generations and Medical Malpractice Part One

June 28th, 2010

1. Veterans or Traditionalists
This generation has born between 1927 and 1946. They have specific values such as “remember the lessons of history”. They have loyalty to the organization. The Veterans worked to get their retirement. They have a nose to the grindstone work ethic. They are the keepers of the institutional memory. They tend to be patriotic, polite, and fiscally conservative. They have a high work ethic and are the senior employees and physicians, eyeing retirement and considering slowing down trial practice. Many of them are influenced by a military model as they grew up in World War II. They understand and follow a chain of command.

2. Baby boomers
Born between 1946 and 1964, Baby Boomers are the largest group. They were influenced by several events in the tumultuous world of the 60s including the civil rights movement. The Baby Boomers have a strong work ethic. They are workaholics and loyal to the organization. They will stay until the work is done. They are highly competitive, question authority, and invented the type A personality. They have an overwhelming need to succeed. The Baby Boomer believes in team work and consensus building. They are optimistic. Baby Boomers are often found in management positions. The Baby Boomer is uncomfortable with conflict and reluctant to go against peers. It is hard for them to ask for help; they have difficulty admitting something is wrong. This may influence their behavior when caught up in a situation that could lead to patient injury.

What are these?

Tags: baby boomers, generations of workers, Medical malpractice, traditionalists, Veterans
Posted in Communication skills, Medical malpractice, Nursing malpractice, medical errors | No Comments »

Pat Iyer’s Dirty Dozen Tips for Detecting Altered Medical Records Part 2

June 23rd, 2010

• Compare the nursery records generated at birth with those sent to the hospital to which the baby is transferred.
• Review the copies of hospital records found within a physician’s office records with those supplied by the hospital.
• In most hospitals, the mother’s labor and delivery record is normally copied and placed into the newborn’s chart. The copy from the mother’s chart must be closely compared with the copy from the newborn’s chart in order to see if there are any added additions to a set of records.
• Often, copies of a record are supplied to others in the ordinary course of treatment long before a problem or an attorney appears on the scene. The record examiner should not assume that the records supplied in discovery are identical to the ones supplied to others before a problem manifested itself. It is not unusual for a doctor referring a patient to a specialist to send a copy of the patient’s chart to the consulting doctor. Likewise, when a patient changes providers, a copy of the first doctor’s chart is sometimes sent to the subsequent treating doctor. These records need to be closely compared to see if there are any additions.
• Compare the letters and reports written by physicians when they are found in more than one set of records. Are the letters identical or does one set of records contain fewer or different reports?
• Compare the set of records obtained by the plaintiff prior to litigation with the set provided after the plaintiff’s attorney requested the records.
• Compare the set of records obtained early in litigation with those obtained shortly before resolution of a claim.
• Compare a set of records supplied to the plaintiff with those supplied to a regulatory agency.
• Observe for new entries added to later copies of the record, or pages that are missing from the first set of records. Look for additional pages that were not supplied with the first request for records.
• Look for a stamp or mark (usually on a face sheet) that indicates that the chart was kept under the control of the Risk Management Department or the Health Information Management Director’s office. This indicates that restricted access to the chart was in place. This has likely occurred because of an unexpected outcome or a suspicion of wrong doing.
• Note descriptions of the patient that may reveal antagonism between the patient and staff. A bad clinical outcome may lead to the temptation to alter records.
• Note finger pointing or blaming of other staff members or professionals after an incident occurred.

Modified from Roy Konray and Pat Iyer, “Tampering with medical Records, in Pat Iyer and Barbara Levin (Editors) Medical Legal Aspects of Medical Records, released in March 2010, for more tips at www.medleague.com.

What are these?

Tags: altered medical records, spoliation of evidence, tampering with medical records
Posted in Healthcare Risk Management, Legal nurse consulting, Medical records, Medication errors, Nursing malpractice, Tampering with evidence, Trial lawyer skills, medical errors | No Comments »

Medical-Legal Topics

What’s a medical error? Part 1 by Pat Iyer

What’s a medical error? Part 2 by Pat Iyer

Why don’t healthcare providers follow the rules? Part 2 by Pat Iyer

Why don’t healthcare providers follow the rules? Part 1 by Pat Iyer

Pat Iyer’s 9 tips on detecting altered medical records Part 5

Pat Iyer’s 7 tips on detecting altered medical records part 4

Pat Iyer’s Dirty Dozen Tips for Detecting Altered Medical Records Part 3

Generations and Medical Malpractice Part Two

Generations and Medical Malpractice Part One

Pat Iyer’s Dirty Dozen Tips for Detecting Altered Medical Records Part 2

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