Failure To Adequately Assess And Monitor The Patient Post Operatively Resulting In Patient’s Death Case Studies Example

Failure to adequately assess and monitor the Patient post-operatively resulting in Patient’s Death

The plaintiff in this case of medical negligence is the decedent while the principal defendant is a Nurse. There are multiple co-defendants in this scenario, however, most of the negligent action case comments, and recommendations are limited to the main defendant that is the nurse.
The decedent who is a 67-year-old male underwent a surgical procedure that involved the total replacement of his right knee. This was a major surgery, and he was immediately taken to the Post Anaesthesia Care Unit where he underwent further treatment. Post-operative pain management was effected by the insertion of an epidural catheter. The patient later on had an episode of hypotension that was successfully treated by the administration of ephedrine. The patient was then discharged to an Inpatient Medical Surgical Unit with the epidural catheter still in place.
According to the account of the defendant, she had customarily worked at the Post Acute Critical Care Unit but was reassigned to the Medical Surgical Nursing Care Unit. She comprehended her assignment at the time of the patient’s admission to being that of oversight responsibility for the patient care on the entire floor for that shift. The patient was assessed and found to be stable at the time of admission. Direct care of the patient was assigned to one co-defendant who is a Licensed Practical Nurse (LPN).
In an estimate of three hours after being admitted to the unit, the patient was unable to tolerate ordered respiratory therapy due to nausea and vomited shortly after that. According to the account of the defendant, the Licensed Practical Nurse had found the patient to be cyanotic and unresponsive ten minutes after he vomited. She immediately called a code, and the defendant responded including the code team as well. The patient was incubated and immediately taken to the Intensive Care Unit.
This account of events is disputed by the LPN and two other staff members who understood that direct care of the patient was the responsibility of the defendant nurse. They alleged that the defendant nurse was the person who had found the patient to be unresponsive and called the code herself. Another issue in dispute is the elapsed time between the episode of vomiting and calling the Code.
The eventual diagnosis was anoxic encephalopathy due to the time that elapsed before cardiopulmonary resuscitation was initiated. The prognosis was poor, and life support was withdrawn. Patient breathed autonomously until he was transferred to the hospice care where he subsequently expired. It was noted that ordered vital signs and checks of the xyphoid processes had not been documented and the fact that the patient had not been closely observed even after experiencing hypotension and later on vomiting and nausea. This should have resulted in additional observation and immediate notice of the physician.

The Verdict was that the defendant had breached the standard of care below the appropriate standard of care.

Review of the Case
I tend to concur with the decision of the court on this case. There is a clear violation of the standard of care rules instituted for the care of post-surgery patients. An epidural catheter is used to manage long-term pain after a surgical operation and in this instance it was effectively used to manage pain. However, an epidural catheter is subject to the risk of infection in the epidural space of the spine hence as a result before insertion there has to be administration of intravenous antibiotics (Cousins, 2012). The patient is also supposed to be in not less than fifteen minutes observation upon insertion of the catheter. Epidural Catheter is a form of spinal anaesthesia and hypotension is mainly common in elderly patients after its administration. These factors were not seriously taken into account.
Ephedrine that was used to treat the hypotension in the patient is an effective drug. It should nevertheless be administered with consideration that the conventional crystalloid loading may not take a preferred regime in elderly patients since an exaggerated hemodynamic response is expected due to blunted sympathetic responses and compromised cardio-respiratory system (Modak, 2013). Hypotension is, therefore, a common complication encountered in spinal and epidural anaesthesia and this case it was not handled effectively. There was no minute to minute monitoring of the patient done in order to assess the hemodynamic changes and carry out early institution of corrective therapy.
The eventual diagnosis of the patient clearly shows that the patient’s brain cells had been deprived of oxygen for some time hence began getting damaged. The nurse had diagnosed cyanosis but had acted swiftly to initiate emergency measures such as compressing the patient’s chest to keep blood circulating. Fast response by the nurse in disseminating information to the physician on any simple changes on the patient would have saved the patient. The Nurses are clearly negligent in this case and have not offered appropriate medical care to the patient who even needed more attention since he was an elderly person.

Practice Related Standard of Care Issues that were breached

Continued monitoring of vital signs was not carried out. The nurses did not thoroughly document all the body temperature and pulse rate readings of the patient. This is a very fundamental practice in monitoring a patient (Godara, 2013). Such serious omissions do not exhibit professionalism among the medical personnel including the defendant nurse.
The defendant nurse had been reassigned to the Medical Surgical Nursing Care Unit and had oversight responsibilities. This meant that she had to analyze all the patients in the unit and make sure they received proper patient care. She was well aware of the condition of the patient, in this case. Despite, not being in direct care of the patient, she should have taken the reasonable measures to ensure that the patient timely attention and monitoring due to the nature of his condition. The duty of the defendant nurse was to do this yet she had failed.
Cardiopulmonary resuscitation was initiated after a long time yet it is common medical procedure for it to be performed in an emergency situation. The defendant nurse did not perform this procedure before the Code team arrived. This was a clear violation of medical practice procedure.

Risk Management Action Plan to Prevent Reoccurrence of this Type of Issue

The Epidural anaesthetic should not be used in conjunction with other stimulant products such as caffeine, cough or cold products and dietary supplements for the purpose of weight reduction or muscle formation. Patients should be advised from desisting from taking such things when they are inserted into an epidural catheter as this would easily lead to potential side effects of a stroke, heart attack and seizures.
Patients receiving epidural analgesia should be kept close to the nurse station in a ward to enable close supervision. The patient should be in direct view of the nurse station to enable 24 hour's monitoring of his stability (Vincent, 2010).
The Anaesthetic should be convinced that the ward is sufficiently staffed to ensure proper and timely management of the epidural catheter. This information should be verified before the patient is brought to the ward.
There should be a good system of communication to inform the anaesthetics of any vital changes in the patient. The communication system should be free from flaws and properly maintained. The nurses should have 24-hour access to medically trained staff competent in the management of epidurals and immediately available to attend to the patients.

References

Cousins, M. J. (2012). Cousins and Bridenbaugh's Neural Blockade in Clinical Anesthesia and Pain Medicine. Philadelphia: Lippincott Williams & Wilkins.
Godara, H. (2013). The Washington Manual of Medical Therapeutics. Philadelphia: Lippincott Williams & Wilkins.
Modak, R. K. (2013). Anesthesiology Keywords Review. Philadelphia: Lippincott Williams & Wilkins.
Vincent, C. (2010). Patient Safety. Hoboken, New Jersey: Wiley.