When an adverse outcome and missed diagnosis occur, problems in the organization of care and issues with communication between caregivers are frequently the true cause rather than an isolated error made by one practitioner. In recent years, seeking to capitalize on frustration with the health care delivery, plaintiff’s lawyers have sought to identify disagreements among providers in patient management and/or errors within the patient care management system. Allegations that nonphysician personnel should have recognized a problem with the care plan and accessed the “chain of command” in an effort to alter the clinical course are included in these types of claims.
Unfortunately, problems of communication are far from simple and are often compounded by failure to engage in critical thinking and the absence of flexibility in considering alternative explanations once an original assessment is reached. As the cases in this column explore, an interactive team wherein communication is encouraged is far more effective than an approach that is egocentric. Ultimately , every care provider needs to be concerned about his/her obligation for patient advocacy. In select instances there may be a need to resort to the command chain. However, even if the chain of command is initiated experience indicates that most often it will not prove to be a panacea.
Case: Who’s on First?
Patient A, an obese 22 y/o G3 P0111 woman at 32 weeks’ gestation, presented to the hospital during the afternoon with complaints of lower abdominal pain. She attributed her distress to the recurrence of a urinary tract infection (UTI). Indeed, her medical record included treatments for multiple UTIs, and on one occasion she had experienced pyelonephritis during a prior pregnancy. Upon examination, the physician noted vague lower pelvic and questionable flank tenderness. The fundal height was dates consistent. Occasional but irregular uterine contractions were palpated.
After a telephone consultation with her OB, a nonstress test was performed and interpreted as acceptably reactive for gestational age. The presentation was unstable breech, the cx long and closed, and the presenting part high. A UTI was diagnosed based on past and recent history and a clean catch urine that was described as “dirty.” Intravenous (IV) hydration and an initial single parenteral dose of a cephalosporin were ordered to be administered prior to her discharge. Because of a change in the nursing shift, there was a delay and IV antibiotics were not started until approximately 30 minutes later. In the interim, however, the patient’s discomfort increased and she had additional complaints of pain. RN #2 called the OB’s office due to the change in the patient’s status. However, because the primary OB was now out of the office and involved with a laboring patient, a different OB took the call. He ordered an increased rate for the IV fluid and “continued observation.” The nurse implemented these orders but then was reassigned to other nursing duties. Consequently, RN #3 began caring for the patient. Shortly after assuming care, approximately 45 minutes after the implementation of the last order, RN #3 assessed the patient and was concerned about her status. She noted an increase in uterine activity with no patient improvement.
RN #3 called the covering OB again. After discussion with the nurse, he agreed to see the patient at the conclusion of office hours. At the nurse’s urging, a telephone order for hospital admission was made. The admitting diagnosis was “early pyelonephritis.” The physician also ordered the administration of 15 mg of morphine(Drug information on morphine) sulfate. Approximately 40 minutes later, a fetal tachycardia of 185 bpm was identified. The patient was observed to be pale and anxious but remained afebrile. Her heart rate was 105 bpm. Uterine activity was more regular and strong. The physician was again contacted by RN #3; he advised her that he would be at the hospital “within the hour.” Unfortunately, 15 minutes later, intermittent fetal bradycardia was observed. The attending physician was now called STAT. The mother was complaining of pain that was both severe and unremitting . No vaginal bleeding was observed however the uterus was tense to palpation. An U/S examination at bedside revealed a large retroplacental hematoma. An emergent cesarean followed, productive of a flaccid and unresponsive 2200 gram female fetus,with APGAR scores Of 2, 4, and 4 at 1, 5, and 10 minutes, respectively. After a stormy course the neonate succumbed 12 days later to complications of prematurity and asphyxia/sepsis.
Subsequently, a lawsuit was filed against OB #2 and his group practice as well as the hospital for its nursing staff. The on-call physician was alleged to have ignored clear evidence of patient deterioration, failed to identify a serious obstetric complication, and inappropriately ordered narcotic sedation prior to reexamination, thus masking important signs and symptoms. Claims against the hospital and its nursing staff included allegations of failures in nursing assessment as well as the failure to initiate the “chain of command” when the physician did not respond in an appropriate manner to telephone calls once the patient’s condition was noted to change.