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Anil Chopra, MD Shirley Strachan-Jackman, NP
Emergency Medicine, UHN
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I am not a lawyer (they make more money!) ICRC of CPSO Medicolegal consultant with BLG, CMPA Hospital quality reviews
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I am not a doctor…Chopra makes more money! medicolegal consultant for CNO, as well as law
firms in Toronto and Southwestern Ont. (Aviva, Rogers Partners, Lerners LLP)
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Discuss: Risky business!
To offer some advice to try to keep you out of trouble with the College, your employer and lawyers!
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Two large downtown academic EDs 110,000 patients 100 nurses 70 ED docs 4 NPs 1 PA Millions of trainees!!
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Communication/Professionalism
Care
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CP x 4 hours, resolving Px: VSS, tender left ant chest Dx: MSK CP Rx: Tyl #3 F/U prn
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Nursing notes: chest pressure with sweating Worried about heart attack as father died of MI
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“I didn’t have time to write everything down!” “Do you want me to look after sick patients or
write essays!” “I’m sure I did that even if I didn’t write it
down.” “It looks like 60/40 in my notes, but I meant to
write 160/40.” “I scribbled it out because I wrote on the
wrong chart”
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Standard of Care* You are expected to find time to write concise,
legible, timely notes documenting what you found out, what you did and what you think.
Legal Interpretation If you wrote it down, that’s the facts. *PHA, RHPA, CPSO, CNO, Accreditation, hospital
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Sharing information Continuity of care Measure of quality of care Legal protection
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Case 2
26 year old female sent in by her GP Presented with signs of slight confusion/
difficulty ambulating Bloodwork- Na 112 mmol/L Admitted to GIM- hyponatremia Order- correct sodium slowly @ 125 cc/ hr
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The patient remains in the ED d/t no beds The infusion was started- the nurse went
back to check on the patient and realized that 1 litre had been infused in one hour
The family claimed that this rapid infusion of sodium led to permanent brain damage known as central pontine myelinolysis
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Medication Errors
“The Canadian Adverse Events Study: The Incidents of Adverse Events in Hospital Patients in Canada” ▪ 1 in 19 adults will be given the wrong medication or
wrong medication dose ▪ 24% of preventable adverse events were related to
medication errors
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Statistics Canada
Medication errors increase when nurses work longer hours and excessive amounts of overtime
Among nurses who work OT- 22% reported medication errors compared to 14% of those who did not work OT
Almost ¼ of medical errors are caused by medication mistakes
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UHN Medication Incidents
In 2013- 885 medication incidents were reported
Total 46 came from the Eds
< 10% result in measurable harm
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Top Reasons Why Nurses Get Sued
Medication errors Communication errors Failure to monitor and assess Failure to properly advocate for the patient Working while impaired whether by
inadequate sleep or controlled substances Negligent or inappropriate delegation and
supervision
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In 2013, CNO received 285 public complaints and 993 reports
Total Membership: -112,582 RNs - 41,996 RPNs - 2,242 NPs In 2013- 1,072 nurses were being monitored
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Normal interpretation of films and patient discharged home
Talus # Dx 3 weeks later: ORIF, chronic pain/arthritis/disability
CXR: rapid growth of lung malignancy diagnosed 4 months later: patient died
CT head: patient decompensated next day All successful legal action
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Clear written discharge instructions to patient and family/caregiver not given
Discrepant findings on imaging: - ?MRP - timely notification: PACS, phonecall, fax - redundancy: ordering MD, FD, ED
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Knowledge deficit: eg. missed dissection Failure to take adequate Hx: eg. AMI Failure to perform adequate Px: eg. ischemic leg Failure to consider DDx: eg. PE Failure to order/interpret tests: eg. ECG, CT **Failure to diagnose: eg. torsion *Failure to treat: eg. sepsis Failure to consult: eg. glaucoma Failure to admit: eg. chest pain Failure to communicate: eg. discharge instructions
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Duty of care Breach of duty Harm or injury Causation
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New matters: 3497 ICRC: 1256: - 59% NFA - 21% Advice - 10% Written Caution* - 4% Verbal Caution* - 2% Discipline - 3% SCERP - 1% Undertaking *Homework
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So, how to save yourself…. and the patient
Be pleasant with your patients: why piss them off? (leave your ego at home)
Talk to patients and the annoying people who show up with them!... Are there any red flags?
A physical exam involves touching the patient …no telemedicine in the ED
Write it down!! : +’ves & -’ves Call a friend when you need help Discharge = last chance to save yourself & the
patient
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Case 3
18 month old presented to ED with a 2 day history of fever
Temp 39.5 degrees C at home; vomited x 1; cough and runny nose for one week; drinking fluids on and off
Tylenol given at home
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Temp on arrival to the ED was recorded at 40.1 rectally, HR 180, RR 34, 02 sat 98%
Received Tylenol; repeat temp 39.0 rectally Received ibuprophen one hour later- CXR 3 hours later child was discharged home- no
repeat set of v/s were done The only documentation by the nurse was
“saline lock discontinued”
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Next day child returns via ambulance seizuring
Diagnosis: bacterial meningitis
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Abnormal Vital Signs
“What looks like bronchitis could be a pneumonia”
“A high fever in a 2 year old could be a treatable flu, or it could be meningitis”
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Discharge Documentation
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Red Flags to Lawyers
Crowding or squeezing entries above a signature or between lines
Erasures Change in slant of hand writing Using different pens Notes on different days in same colour ink from
same pen Typed entry followed by handwriting Missing original records that have been replaced by
photocopies
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Case 4
32 year old male NFA- found sleeping in the hallway- had ingested 40 mg oxycontin
Known drug abuser and had previous ED visits for illicit drug use
No SI/ HI Alert and co-operative- patient wanted to see
“crisis” “wanted a warm place to sleep” v/s were documented normal except he had a
temp of 39.8
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Pt was put on a stretcher, not undressed and crisis was called
Patient seen by crisis- brief assessment by physician- released
Pt returns next morning complaining of pain in his right arm
Dx: necrotizing fasciitis- underwent an amputation of his right arm below the shoulder
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EMS Report
Documented abscesses on both arms- multiple sites
??? Reported to the triage/ primary nurse
Patient claims had he been undressed and assessed- seen degree of infection
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Summary
Avoid a lawsuit is to be aware of the standard of nursing practice
Nurses are at high risk for compassion fatigue Maintain competence in your speciality area
of practice Know your legal principles and incorporate
into everyday practice Practice within your boundaries
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