All posts by The Trauma Pro

General

Nursing Malpractice: The Basics – Part 2

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What are common sources of malpractice complaints against nurses? The most common event is medication error. Most people worry about common errors like wrong dose, wrong drug, and wrong route of administration. But one less commonly considered drug-related responsibility is assessment for side effects and toxicity of medications administered.

Other common reasons include failure to adequately monitor and assess the patient, and failure to supervise a patient that results in harm. Significant changes in patient condition must be reported to the responsible physician. However, doing so does not necessarily get the nurse off the hook. If the physician’s response leads the nurse to believe that they have misdiagnosed the problem or are prescribing an incorrect drug or course of action, the nurse is obligated to follow the chain of command to notify a nursing supervisor or other physician of the event.

And finally, one of the most common issues complicating malpractice cases of any kind is documentation. Lawsuits must typically be filed within two years of the event that caused harm. Once that occurs though, several more years may pass before significant action occurs. Collection and review of documentation, identification of experts, and collection of depositions takes time. And unfortunately, our memories are imperfect after many years go by. Good documentation is paramount! “Work not documented is work not done,” I always say. And poor documentation allows attorneys to make your good work look as bad as they want and need it to.

Reference: Examining Nursing Malpractice: A Defense Attorney’s Perspective. Critical Care Nursing 23(2):104-107, 2003.

General

Nursing Malpractice: The Basics – Part 1

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Back in the old, old days, there was really no such thing as nursing malpractice. Nurses had little true responsibility, and liability largely fell to the treating physicians. But as nursing responsibilities have grown, they have become an integral part of the assessment, planning, and management of their patients.

As all trauma professionals know, our work is very complex. And unfortunately, our understanding of how the human body works and responds to injury is still incomplete. So, unfortunately, undesirable things happen from time to time.

But does every little adverse event or complication mean that someone is at fault? Or that they can/should be sued? Fortunately, the answer is no.

The law is complex, at least to professionals outside the legal field. Following are the basics of malpractice as it relates to nurses.

There are four elements that must be present for a malpractice case to be brought forward:

  1. The nurse must have established a nurse-patient relationship. Documentation provided by the nurse or other providers in the medical record must demonstrate that they were in some way involved in care of the patient.
  2. A scope of duty must be established within the relationship. For example, an ICU nurse will have duties relating to examining the patient, recording vital signs, reporting significant events to physicians, etc. The exact duties may vary somewhat geographically and even between individual hospitals. Written policies help to clarify some of these duties, but often, experts are required to testify to what the usual standards of care are when not covered by policy.
  3. There must be a departure from what is called “good and accepted practice.” The definition of this leaves a lot of wiggle room. It is defined as the care that an ordinarily prudent nurse would have provided in the given situation. It does not need to be the optimum or best care. And if there is more than one approved choice, a nurse is not negligent if they choose either of them, even if it later turns out to be a poorer choice.
  4. Finally, there must be a cause-effect relationship between the nurse’s action and the patient’s alleged injury. This linkage must be more than a possibility, it must be highly probable. For example, wound infections occur after a given percentage of operations, and it varies based on the wound classification. It’s a tough sell to bring suit for improper dressing care in a grossly contaminated wound that is likely to become infected anyway. Typically, expert witnesses must attest to the fact that the patient was, more likely than not, harmed by the nurse’s action or inaction.

Tune in to my next post for Part 2 of Nursing Malpractice!

Pet Peeve

Pet Peeve: “High Index of Suspicion”

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How often have you heard this phrase in a talk or seen it in a journal article:

“Maintain a high index of suspicion”

What does this mean??? It’s been popping up in papers and textbooks for at least 30 years. And to me, it’s meaningless. You try to figure out that sentence!

An index is a number, usually mathematically derived in some way. Yet whenever I see or hear this phrase, it doesn’t apply to anything quantifiable. What the author is really referring to is “a high level of suspicion,” not an index.

This term has become a catch-all to caution the reader or listener to think about a (usually) less common diagnostic possibility. As trauma professionals, we are advised to do this about so many things, it really has become sad and meaningless. And don’t we all do this anyway?

Bottom line: Don’t use this phrase in your presentations or writing. It’s silly and doesn’t make any sense. And feel free to chide any of your colleagues who do. Please give us some concrete data so we don’t have to be so suspicious!

Reference: High index of suspicion. Ann Thoracic Surg 64:291-292, 1997.

Pet Peeve

Pet Peeve: Conflicts Of Interest

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For the longest time, one of my pet peeves has been potential conflicts of interest (COI) involving authors on research papers. There is no simple definition of the term “conflict of interest.” However, a simple way to think of it is a situation where one’s personal interests may influence their professional responsibilities.

Upton Sinclair said it more simply in a book he was writing in the 1930s:

“It is difficult to get a man to understand something when his salary depends upon his not understanding it!”

The corollary of this is more useful when applying to research:

“One can be led to believe anything when their salary depends on it.”

Psychological research has demonstrated time and time again that human behavior is easily influenced. Even receiving a tiny gift leads the receiver to perceive the giver favorably and to be more willing to reciprocate, even without being asked. Ever wonder why your hospital won’t let pharma representatives sponsor lunches anymore? Or even give you a pen? Believe it or not, these little things can change your attitude regarding their product. And even if you firmly believe you can’t be swayed, you can’t change the basic operating system in your brain. Your behavior will change.

We know that behavioral changes after receiving a small gift can be significant. What if the gift is not so small? What about a research grant? A position on an advisory board? Free drugs or devices for your research? Corporate stock? These can significantly improve one’s academic rank, job security, financial status, and more. Think about this with respect to my corollary quote above.

An interesting paper published by the Canadian Medical Association twenty years ago looked at industry-sponsored randomized controlled trials and how often they produced statistically significant positive results. The authors reviewed papers in eight leading surgical and five leading medical journals over three years. They applied a rigorous evaluation method looking for a positive correlation between industry support and study results, controlling for quality and study size.

The authors found that overall, positive results were nearly twice as likely in industry-funded studies. These numbers were even more pronounced when looking at surgical procedures and drugs. Drug studies were 5x more likely to be positive, and new surgical procedure studies were 8x more likely when receiving industry support.

Does this surprise you? It shouldn’t. There are numerous ways to design (manipulate) studies by playing with the characteristics of the study groups, statistical analysis, and even the wording of the manuscript. And at worst, the study could just be trashed, never to see the light of day at the author’s whim (or sponsor’s). Ever wonder why you (almost) never see a negative or even a neutral result in a study where the authors have received some benefit from industry? They are very frequently positive (or “non-inferior”).

Like other high-quality journals, the Journal of Trauma and Acute Care Surgery has recognized the potential dangers of COI and its impact on the integrity of the papers they publish. A publication in process from the journal editors outlines the new stance and policy regarding conflicts. They believe it is such a potential problem that they have revised their COI policy.

The Journal will now require detailed COI forms to be filed at the time of manuscript submission. The manuscript will only progress in the review process once received. Reviewers cannot see them but are encouraged to independently review data in physician payment databases. I’m not confident all reviewers will be this meticulous. If the editors believe a significant conflict exists, they may require revision or retraction. Egregious violations could even result in banning from publication.

Bottom line: It’s about time! More and more journals are cracking down on conflicts of interest. This doesn’t mean that they won’t accept manuscripts with such conflicts. It merely means that the authors must provide a detailed list of all their conflicts. It will then be up to you to gauge if these conflicts could have impacted the study and how large a grain of salt to keep on your desk as you read it and decide if it is believable.

References:

  1. Association between industry funding and statistically significant pro-industry findings in medical and surgical randomized trials. Can Med Assn J, 170(4):477-480, 2004.
  2. The Journal of Trauma and Acute Care Surgery Position on the Issue of Disclosure of Conflict of Interests by Authors of Scientific Manuscripts. Journal of Trauma and Acute Care Surgery, Publish Ahead of Print DOI: 10.1097/TA.0000000000004024, 2023.
Thorax

Delayed Presentation Of Right Diaphragm Injury

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Diaphragm injury from blunt trauma is uncommon, occurring in only a few percent of patients after high-energy mechanisms. They usually occur on the left side and are more frequently seen after t-bone type car crashes and in pedestrians struck by a car.

Blunt diaphragm injury on the right side is very unusual. Even so, it is more easily detected due to obvious displacement of the liver that can be seen on chest x-ray. Blunt injuries on the right side usually result in a large rent in the central tendon or detachment of the diaphragm from the chest wall. This allows the liver to herniate into the chest, and the chest x-ray finding is not subtle.

This image shows an acute herniation of the liver through the diaphragm. Due to the size of the liver, only part of it can typically fit through the rent. Radiologists call this the “cottage loaf” sign. Why? Here’s the bakery item it is named after. Get it now?

Thankfully, most of these injuries are identified in the acute setting. They must be addressed surgically because, if left untreated, more and more of the liver will slowly move into the chest resulting in respiratory problems in the long run.

Acute management usually consists of laparotomy to address both the diaphragm tear and any other associated intra-abdominal injuries. The liver should be reduced by sliding a hand next to it laterally into the chest cavity and pushing the dome downwards. The right triangular ligaments should be taken down (if they are not already destroyed) to mobilize the organ better so the diaphragm laceration can be closed. This is typically accomplished with some type of large (size 0) permanent suture. A chest tube will be needed to evacuate the iatrogenic pneumothorax created by opening the abdomen.

Chronic right diaphragm injuries are a different animal entirely. There is no longer any need to evaluate for intra-abdominal injury, so the procedure is usually performed through the chest. For smaller injuries, thoracoscopic procedures have been described that push the liver downwards and then either suture the diaphragm primarily or (more likely) incorporate a piece of mesh.

Larger injury requires conversion to an open procedure so more muscle power can be used to push the liver downwards to facilitate the repair. However, do not underestimate the adhesions that will be present between diaphragm and liver (and possibly the lung) in long-standing injuries. It may take some time to dissect them away. Rarely, a laparotomy (or laparoscopy) may be needed to assist for very large and complex injuries.

References:

  • Management of Delayed Presentation of a Right-Side Traumatic
    Diaphragmatic Rupture. World J Surg 36:260-265, 2012.
  • Delayed Discovery of Diaphragmatic Injury After Blunt Trauma:
    Report of Three Cases. Surg Today 35:407-410, 2005.