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When should nursing staff call a rapid response team? by Pat Iyer

Wednesday, August 4th, 2010

A sudden deterioration in a patient’s condition should stimulate activation of emergency efforts. The goal of a rapid response team (RRT) is to avert a cardiac arrest – to take action before the patient stops breathing. here are some generally accepted reasons to call a team of professionals to the bedside:

Staff worried about patient
Acute change in heart rate
Acute change in systolic blood pressure
Acute change in respiratory rate

a rapid response team could save your life

Acute drop in O2 saturation
Acute change in mental status
Drop in urine output
New, repeated, or prolonged seizures
Fractional inspired oxygen of 50% or greater
Failure to respond to treatment for an acute problem/symptoms

The composition of RRTs varies from hospital to hospital. A team typically consists of 2-3 people who are assigned to flexible responsibilities within the facility. The team may consist of respiratory therapists, physician assistants, nurse practitioners, critical care nurses, intensivist (critical care doctors), hospitalists (physicians employed within a facility to provide inpatient care) or residents. The team’s role is to assess and stabilize the patient, assist with communication with the attending physician, educate and support the nursing staff and family, and assist with transfer to another level of care, if needed.

The rapid response team serves a vital role, but not all hospitals have them. Does yours? Consider this important patient safety feature when you pick a hospital.

What are these?

Tags: cardiac arrest, intensivist, rapid response team, RRT
Posted in Healthcare Risk Management, Legal nurse consulting, Medical malpractice, Nursing malpractice, Patient safety, medical errors | No Comments »

Failure to rescue by Pat Iyer

Monday, August 2nd, 2010

Failure to rescue is a big source of patient injury

Imagine this scene: You are visiting your elderly father in the hospital when you notice his speech is becoming slurred and he is less awake than usual. Concerned, you call his nurse into the room. She assesses your father, then picks up the phone and requests an emergency response team. A team of professionals enter the room, assess and stabilize your father, and arrange for him to be transported to the ICU with a tentative diagnosis of rule out stroke. Your father’s attending physician is called as the team is completing its assessment. The critical care nurse on the team pulls the floor nurse aside to congratulate her on her astute assessment. The process from start to finish has taken 20 minutes.

Failure to rescue is a term that describes the outcome when a patient’s condition deteriorates before the changes are recognized and acted upon. Failure to rescue is a nursing-sensitive performance measure on the list of 15 identified by the National Quality Forum in 2004 to be collected by CMS (Centers for Medicare and Medicaid Services). A 2009 study performed by HealthGrades showed that patient safety incidents with the highest incidence rates were failure to rescue. There were 92.7 incidents (per 1,000 population). Starting June 1, 2010, CMS began collecting data about a facility’s failure to rescue rates.

The use of rapid response teams (RRTs) to provide timely rescue efforts in hospitals has gained momentum and popularity, although not all hospitals have them. The concept originated with a critical care nurse from New Zealand who recognized the need to bring resources to the bedside of a patient whose condition deteriorated before more serious events occurred. Without rapid response teams, nurses who recognize ominous changes in the status of their patients are forced to contact the attending physician and wait for a return call. Should an attending physician refuse to deal with or minimize the concerns of the nurse, the nurse has to use the chain of command within a facility – in effect, to go over the head of the attending physician with the assistance of nursing administration, to find a physician who will respond. This is a slow and difficult process.

RRTs have the capability of bypassing the attending physician to turn what can be a 2-3 hour long process into a 5-10 minute arrival to the patient’s bedside. The use of a team within a facility empowers the staff nurse, and provides a safety net for both the nurses and the patients. Implementation of RRTs has reduced cardiac arrests, deaths, the number of unexpected emergency admissions to ICU, and the length of a hospital admission for cardiac arrest survivors. RRTs build teamwork and spread knowledge and skills throughout the hospital. The goals of the team are to provide immediate detection and diagnosis, to treat patients early, and to mitigate harm by turning adverse events into “near misses”. The system is designed to protect the patient from further harm and to allow for recovery from possible medical errors and system deficiencies.

Is the RRT system working? A survey of 56 staff nurses identified the three categories of reasons for why the RRT was activated:

• The patient exhibited signs and symptoms that were either unexpected or significantly different from baseline.
• Despite the absence of objective data, the nurse had a “gut feeling” that “something was wrong.”
• The nurse was convinced that the patient needed immediate evaluation and was unable to get the treating physician to respond as the nurse thought necessary. This is what one nurse said:

“It’s during shift change so everybody’s calling and running and doing this and that, and we called the doctor and he said, ‘Well, she’s got a pulmonologist on the case, call them.’ He gave us nothing. No orders. No meds. No, no nothing. . . At that point we decided we’re not going to wait for anybody else, we’ll just call rapid response and get them down here.”

Consider this comment in comparison to the often slow process of obtaining medical attention when a facility does not have a RRT. In addition to the direct patient safety benefits of such teams, RRTs empowered nurses and gave them a sense of control over the patient situation, identified other processes negatively affecting patient safety, and improved communication and respect between disciplines, thereby raising job satisfaction.

Sources: Shapiro, S, Donaldson, N, and Scott, M. “Rapid response teams: seen through the eyes of the nurse”, AJN, June 2010, 110 (6), 28-34
www.healthgrades.com/media/dms/pdf/patientsafetyinamericanhospitalsstudy2009.pdf

Extracted from Patricia Iyer, Roots of Patient Injury, in Patricia Iyer, Barbara Levin, Kathleen Ashton and Victoria Powell, Nursing Malpractice, Fourth Edition, in press.

What are these?

Tags: cardiac arrest, failure to rescue, rapid response teams, RRTs
Posted in Emergency Medicine, Healthcare Risk Management, Legal nurse consulting, Nursing malpractice, Patient safety, medical errors | No Comments »

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

Tuesday, 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

Monday, 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 »

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

Monday, 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

Wednesday, 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

Monday, 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 »

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

Wednesday, 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 »

Pat Iyer’s Dirty Dozen Tips for Detecting Altered Records Part 1

Monday, June 21st, 2010

• Determine if the entries are in correct sequences and the date is within the correct time frame. For example, a physician recopying an office note may inadvertently use the year that the change is being made, rather than the right year for the chart entry.
• Search for discrepancies in dates. Entries may be inconsistently dated. Information may be added to a form out of sequence. For example, one medical record included a page listing the nursing home resident’s medical diagnoses, followed by the dates of the care planning sessions. The sheet contained the diagnosis of fractured hip, which occurred in June 2009. Yet the care planning sessions were documented as having occurred in May 2009. The form did not indicate that the hip fracture diagnosis was entered after the May 2009 session.
• Examine the chart for discrepancies in times or entries that are not in the correct chronological order.
• Look at the dates when treatments or medications were ordered versus the dates they were documented as having been given. For example, in one chart, the wound care sheet included an entry on 1/22/09 that antibiotics were started for a foul smelling pressure ulcer. In reality, the order for antibiotics was not written until 1/25/09.
• Create a chronology of care with the dates of admission and discharge. Look to see if care was charted after the patient left the facility.
• Look at the medication records to determine if medications were charted as being administered after the patient left the facility. Note if the patient’s medication administration record shows that oral medications were being administered when the patient was supposedly comatose and unable to swallow.
• Compare the condition of the patient on days of transfer from one facility to another. Look for discrepancies in the description of the condition of the patient. For example, a pressure ulcer’s presence may be ignored in a hospital chart but documented in detail when the patient arrives at a nursing home.
• Compare the observations of the physicians with those of the nurses. Are they consistent?
• Observe for any handwritten entry made by someone who significantly erred in treatment, particularly if the entry is at odds with the rest of the chart.
• Examine the typical way in which the healthcare professional documents. Are notes usually brief but become extensive on the day of an incident?
• Compare a set of original medical records with that supplied to the attorney. Use self-sticking tabs or notes to indicate when documents need to be copied or examined further. Always make a list of records that have been requested to verify that everything has been received.
• Whenever two sets of records are located, compare them. For example, compare the prenatal chart kept by the obstetrician with the prenatal records sent to the hospital prior to the labor and delivery.

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 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 »

“How to Detect Lies From Impressions and Expressions When Negotiating” by Guest Author Greg Williams

Wednesday, May 26th, 2010

When negotiating, can you detect lies based on someone’s expressions, or the impression that he makes on you? You’ve no doubt heard the expression, “He lied to me with a straight face.” The body never lies. So, when someone is lying, the body will compensate for his untruthfulness by displaying cover actions. Cover actions can be almost imperceptible nuances that occur when people lie, or they can also be exaggerated expressions. Nothing succeeds like success. When a person becomes confident about his ability to lie in a negotiation, and he continuously gets away with it, he will continue to lie. In most cases, he will become emboldened to increase the intensity of his lies. You’ll have the opportunity to catch him in a lie.

The way to detect and deter a liar is to observe the verbiage he uses during the negotiation, and observe his body language when you suspect him of lying. When lying …

Body language gives away lies

• People will tend to use phrases that make them feel comfortable. Take note of the comfort phrases that a person uses and note the change that occurs when he alters such phrases. When change occurs, he could be in the process of entering into a lie, or fully engaged in it.
• People will lie to make themselves appear to be more impressive or demur. The lie will usually be accompanied with body language that exemplifies the stature of the liar. Such gestures may be observed as when the individual raises his head higher, or thrusts his chin or chest forward when seeking to be perceived as being more impressive. A demur individual will tend to bow his head and present a less impressive image.
• People will also lie to get out of tough situations. Such maneuverings will usually be accompanied with gestures that reveal their discomfort. Thus, they’ll tend to keep their arms close to their body. They’ll also tend to be more reflective, as they try to keep their story on track.

To enhance your efforts of catching a liar in his lie, switch subjects in the middle of his suspected lie. Change the subject to anything that’s unrelated to what he was discussing. After a few minutes, ask him to continue speaking about what he was discussing when you suspected he was lying. When he resumes the discussion, take note from where he continues, versus where he left off. Also, take note of the degree his demeanor has altered. In addition, you can ask questions that highlight slight differences in what he said. For example, if he said the insurance carrier would not provide an offer of over $100,000, restate what you heard as the carrier would not offer more than $150,000. By slightly altering what you said he said, he’ll have to go into recall mode, if he was lying. If he’s telling the truth, more than likely, he’ll say without hesitation, “Oh no, it was $100,000.”

In any situation, before you can discern if someone is lying, you have to establish her baseline. That means, you have to be aware of how she gestures and use verbiage in normal environments. Then, as you seek to detect lies, note the differences between what is normal to what becomes different from normal. Therein will lay the signal to delve deeper into what she is saying. Once you discover how to hone your skills to detecting liars, it will be increasingly difficult for someone to lie to you successfully … and everything will be right with the world.

The Negotiation Tips Are …
• When you suspect a liar is lying, don’t be too quick to stop him. Observe the verbiage he uses and his body language. The more comfortable he becomes with his lies, the more lies he’ll tell. In so doing, he’ll give you greater insight into how he lies and why he lies. Then, you’ll know what to look for when you suspect he’s lying.
• If you’re astute at reading body language during a negotiation, you can pick up on nonverbal signals and detect a liar’s lie before he gets too deeply into it. In so doing, you will decrease the probability of being deceived.
• People lie because they’re seeking something they need at the time of the lie. In a negotiation, if you understand the need, you’ll understand the source of the lie. From that perspective, you can address it.

To inquire about having The Master Negotiator as a coach or consultant, or to conduct ‘live’ instructional sessions, and/or keynote presentations at your company, group, or organization, please send an e-mail to GregWilliams@TheMasterNegotiator.com and start getting more out of life, when you negotiate. Please include the verbiage, ‘Negotiation Inquiry’ in the subject line.
by Greg Williams – The Master Negotiator. If you’d like more information on how you can become a savvier negotiator, click here to checkout Greg’s new book, “Negotiate: Afraid, ‘Know’ More.” Please visit The Master Negotiator‘s website at http://www.TheMasterNegotiator.com for additional information and negotiation resources for individuals and businesses.

What are these?

Tags: Negotiation, Negotiation skills, negotiation tips
Posted in Business skills, Communication skills, Legal nurse consulting, Trial lawyer skills | No Comments »

Medical-Legal Topics

Archive for the ‘Legal nurse consulting’ Category

When should nursing staff call a rapid response team? by Pat Iyer

Failure to rescue by Pat Iyer

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

What’s a medical error? Part 2 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

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

Pat Iyer’s Dirty Dozen Tips for Detecting Altered Records Part 1

“How to Detect Lies From Impressions and Expressions When Negotiating” by Guest Author Greg Williams

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