Shock did not begin to describe Ms. R’s feelings when she was served with papers informing her that a patient was suing her. Ms. R, 53, had been a nurse practitioner for a quarter of a century, and had never before been party to a lawsuit. She was proud of her spotless record, and the fact that she was always careful in everything she did, unlike, she felt, many of her younger contemporaries. She always strove to be professional and businesslike, and her attitude had been noted and praised by the cardiologists with whom she worked.
The practice Ms. R worked for included five cardiologists and five NPs, as well as two office managers and a revolving set of interns and junior staff members. Ms. R had been with the practice for the bulk of her career and was highly regarded by the owners. Ms. R was practical and highly skilled, and her willingness to work tirelessly allowed her to rise to the level of top NP in the practice.
One of the cardiologists in the clinic had been conducting an outpatient myocardial perfusion study, and requested that Ms. R be assigned to the project. Ms. R’s job was to administer adenosine intravenously to patients. Mrs. U, at 73, an older patient in the study, was hard to forget, as she incessantly asked questions in a demanding and querulous manner. After years of experience dealing with these types of patients, Ms. R didn’t let the older woman’s tone bother her, and she simply answered Mrs. U’s questions in a businesslike manner. Mrs. R inserted a butterfly needle into the vein of Mrs. U’s right arm just above the elbow to administer the radioactive tracer.
“Ouch!” yelled the patient. “Nurse, that hurts! Can’t you be more careful?”
“We’ll be done in a moment,” replied Ms. R.
Everything seemed routine and Ms. R knew that some patients complained more than others, so she ignored Mrs. U’s grumblings. Still, Mrs. U adamantly protested that she had substantial arm pain after the needle insertion. When Mrs. U’s test was finished, Ms. R thought that was the end of it. She was wrong.
Six months later, Ms. R was served with papers notifying her that she was being sued for negligence. According to the papers, Mrs. U alleged that Ms. R negligently inserted the IV, causing median nerve injury, which had caused constant pain in her arm, shoulder and fingers since.
Ms. R could not understand how this had happened. She went over the entire process in her mind. Her technique was book perfect, and she’d inserted butterfly needles thousands of times during the course of her career with no ill result. The physicians in her practice were sympathetic and advised Ms. R to meet with the defense attorney provided by the practice’s insurance.
The defense counsel obtained copies of the patient’s records, and retained an expert physician who met with both Ms. R and himself. The expert asked Ms. R to demonstrate the procedure she used to insert the IV, and he concluded that she had done so flawlessly.
“I would suggest that you have Ms. R explain and demonstrate to the jury the process she uses to insert the needle,” said the expert. “I can see no way that a median nerve injury could have occurred based on her technique, or from anything in the patient’s chart.”
“It may not even come to that,” said the attorney. “I’m going to make a motion to dismiss this case. I don’t think there is enough evidence to support a malpractice lawsuit.”
The defense attorney did make a motion to dismiss, and the court held a hearing to establish whether there was enough evidence to proceed to a trial. At the hearing, Mrs. U testified about the lingering pain in her shoulder, arm and hand, and how Ms. R had not heeded her protests. The plaintiff’s attorney introduced two experts, a nurse, and a neurologist, who both opined that Ms. R must have done something wrong, since the patient reported pain afterwards.
“There is no reason that a patient would have pain unless the needle was inserted incorrectly,” stated one of the plaintiff’s experts.
Despite the stress of having to testify in court, Ms. R calmly and professionally explained the process she used to insert the small, short needle into a superficial vein. She testified that she had done the procedure thousands of times and that none of her patients had ever suffered any problems. Ms. R then showed the judge the butterfly needle and demonstrated how it was used.
After her testimony, the defense expert testified that there was no way the median nerve could have been injured by Ms. R’s actions. The court agreed and dismissed the patient’s lawsuit.
The court ruled that the testimony of the plaintiff’s experts (the nurse and neurologist) was conclusory and thus insufficient to support a malpractice suit. Essentially, the judge stated, the expert witnesses jumped to the conclusion that Ms. R must have done something wrong simply because the patient reported pain afterwards. In the absence of an explanation showing how an injury might have occurred, a negative outcome reported by a patient does not prove negligence.
While the judge was impressed by Ms. R’s careful documentation of the IV process, he did note that she had, perhaps, been lacking in other ways.
“Ms. R allegedly failed to explain to the patient what she was doing, and failed to follow up when the patient complained of pain,” said the judge. “However, even if this amounted to less-than-optimal nursing practice, this court does not see how it could have caused injury to the patient.”
As Ms. R surmised, some patients are naturally more sensitive and anxious. While Ms. R was not found liable in this case, she might have been able to avoid the lawsuit completely by simply taking the time and effort to walk the patient through the procedure step-by-step and then address the patient’s claims of pain when they occurred.
Explaining to a patient what you are going to do, and how you are going to do it — before beginning — is an effective deterrent. Patients who know what to expect are less likely to have issues with their care. And if a patient does complain of pain, even in a situation where you are aware that this particular patient has a tendency to overreact, the best practice is to immediately address the situation. Taking the time to show compassion can often prevent a lawsuit.
Ann W. Latner, JD, a former criminal defense attorney, is a freelance medical writer in Port Washington, N.Y.