A middle-aged woman had an appendectomy in outpatient surgery. Her postoperative vomiting and pain were controlled before she left the same day surgery area. She called the same day surgery nurse later in the day complaining of increasing pain and vomiting. Although the patient also complained of weakness and significant fatigue, the nurse apparently made the assumption that these symptoms were related to her surgery earlier that day and discounted the significance of the complaints. She advised the patient to “wait and see”. The patient had, in fact, ruptured her appendiceal stump and was leaking fecal material into her peritoneum. The patient later died of peritonitis and other complications related to her surgery.

The nurse had a decision support tool that included the words “weakness” and “fatigue” as red flags, but she failed to utilize it appropriately. This case is an example of the nurse jumping to a conclusion about the cause of the patient’s complaints and failing to err on the side of caution. The patient was at high risk because she had surgery that day, and was getting sicker at home. Although pain and vomiting are frequent complaints following abdominal surgery, the telephone triage nurse must “look outside the box” in order to identify unanticipated complications.

Lessons for Attorneys: Institutional Liability
How does an employer contribute to this kind of outcome?
1. Failure to provide adequate staffing for handling phone calls. A poorly staffed same day surgery unit may overtax the critical thinking skills of a nurse, setting him or her up to fail.
2. Initial phone call handled by unqualified people. In many settings, clerical people answer the call, collect the initial information about the nature of the call and then send it to the appropriate person. This relies on the untrained person to identify high-risk patients.
3. Failure to provide specialized training. Nurses who take calls from patients should be educated to recognize the potential significance of patient complaints and to provide the appropriate referral. Same day surgery nurses must be aware of the potential postoperative complications and direct the caller appropriately.
4. Failure to provide policies and procedures. Decision support tools should be provided, reviewed, and approved by medical, nursing, and administrative personnel. Nurses should be taught how to use them, but also be free to use clinical judgment and critical thinking.

Case contributed by Carol Rutenberg MNSc, RNC and described in Rutenberg, C, Greenberg, M., Councell, T. and Evans, A., (2011). Telephone triage: A primer for lawyers and LNCs, in Nursing Malpractice, Fourth Edition, Tucson, AZ: Lawyers and Judges Publishing Company.

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