The emergency department (ED) of a large hospital can often be a busy, chaotic place. The very nature of medical emergencies means that treatment often has to be instantaneous and that the health status of a patient can change quickly.
Clinicians who work in the ED have to be able to multitask, parse information from several sources at once, juggle numerous patients, and make split-second decisions. It is a difficult job, and, as one clinician found out, a job in which inattention — just for a short time — can mean the difference between life and death.
Mr. O was a nurse practitioner employed in the ED of an urban medical center. Located in a busy metropolitan area, the hospital’s ED had a steady flow of patients. Mr. O had been working in the ED for the past five years, and the stress was beginning to wear on him.
Everything shifted for Mr. O when he got married. His priorities changed. Mr. O and his wife now had a child at home, and long shifts in the ED were draining. In addition, he no longer wanted to pull double shifts that kept him from spending time with his family. Mr. O was on the verge of leaving the hospital to work in a physician’s office.
During Mr. O’s shift one night, two paramedics wheeled in an obviously intoxicated man.
“A woman walking her dog found him lying on the street—semiconscious and incoherent—and called us,” said the lead paramedic. “He was physically and verbally combative when we tried to help him, and he is having difficulty speaking and walking.”
The patient looked familiar to Mr. O, but that was not terribly surprising. Local drunks were often brought to the ED.
Mr. O started a file, noting that the patient, Mr. J, arrived in the ED at 10:45 pm. Mr. O then tried to question Mr. J, but the patient was too intoxicated to answer coherently. Because Mr. J had trouble focusing and was belligerent, the questions had to be asked repeatedly to elicit an answer.
Mr. O was able to ascertain that the patient was aged 26 years and that he had ingested alcohol. Mr. J denied drug use. Mr. O noted that the patient was responsive to pain and able to move his extremities.
Several ambulances then arrived with the victims of an automobile accident, and Mr. O was needed elsewhere. He placed Mr. J on his side — on a stretcher — and put him in a holding area between the waiting room and the exam room. Mr. O then attended to the incoming patients.
When Mr. O later returned to check on Mr. J’s status, the patient was unresponsive, not breathing, cyanotic, and had fixed and dilated pupils. Mr. J was rushed into the exam room and quickly treated by the head ED physician, Dr. F. The clinicians worked furiously for 30 minutes but were unable to save the patient. Respiratory failure was deemed the cause of death.
Several months after the incident, Mr. O was served with papers informing him that Mr. J’s father was suing him, Dr. F, and the hospital for the wrongful death of his son.
“I’ve looked at the patient’s file,” said the attorney, “and I don’t see anywhere in the chart that you noted taking Mr. J’s vital signs before leaving him on the stretcher.”
Mr. O felt a surge of panic. “I’m not sure if I did,” he said. “Ordinarily I would, but he was hard to examine because of his extreme intoxication, and then a trauma case came in. I may have neglected to check his vitals. Or maybe I did, but I didn’t write it in the chart. I’m just not sure.”
“The patient’s records indicate that he arrived in the ED at 10:45 pm and was found unresponsive at 11:30 pm,” stated the attorney. “Did you check on him at any time between 10:45 and 11:30?”
“I don’t remember,” answered Mr. O. “There was a lot going on that night.”
“What is the hospital policy on how often you should be checking vitals on a patient in the ED?” the attorney asked.
“We are supposed to check every 15 minutes,” explained Mr. O. “But sometimes it gets very busy and 20 minutes or so might go by before we get a chance.”
“In the physician’s report, prepared after the patient died, Dr. F wrote that he was told that the patient had been checked on by a nurse at around 11:05 pm. Do you remember telling the physician that?”
“Honestly, no,” said Mr. O. “I wish I did.”
After several more discussions, and after depositions had begun, Mr. O’s attorney advised him that settling the case would be the best option. The case was later settled for an undisclosed amount.
Memory can be faulty, which is why hard evidence—such as a written medical record—is given more credibility than individual testimony. The defense attorney in this case consulted Mr. O to settle because there was no record of the clinician checking on the patient before 11:30 pm or taking the patient’s vital signs.
The document prepared by Dr. F was created after the incident and contained secondhand information indicating that Mr. O had checked on the patient. But the patient’s medical file showed no record of this, nor did Mr. O recall monitoring the patient.
The evidence at trial would have shown that the hospital has a policy mandating that a patient’s vital statistics be checked every 15 minutes, which the patient record indicates did not occur.
In light of these facts, and the fact that Mr. O should have known that alcohol consumption depresses the respiratory system, Mr. O would likely have been found negligent in his care of the patient had the case gone to trial. Settling out of court avoided the time, money, and emotional strain involved with a trial.
It is vital to comply with hospital policy. Protocol in this case clearly mandated that a clinician check an ED patient’s vital signs every 15 minutes. Had there been only a five-minute deviation, this lag in response time probably would have been overlooked.
Yet, there was no record of Mr. O taking Mr. J’s vitals at initial intake, and no documentation supporting a follow-up within 45 minutes. In court, these factors attest to the fact that Mr. O (and, by extension, the hospital) did not meet the appropriate standard of care.
Record-keeping is crucial as well. Notes in Mr. J’s chart as to when the initial exam took place, what the results were, and timed/dated entries regarding follow-up could have helped Mr. O — a busy practitioner — remember this particular case. Had he rendered treatment, this documentation could have avoided a lawsuit altogether.
Ann W. Latner, JD, a former criminal defense attorney, is a freelance medical writer in Port Washington, N.Y.