Correctional Nurse Legal Briefs: Understanding Professional Liability

Medical Lawsuit

This post is part of a continuing series on legal issues important to correctional nurses. Find other topics in the series here.

From my case files:

A nurse hears a man down code called overhead while returning from providing sick call in one of the housing units. When she arrives at the scene she sees that the inmate is sprawled out on the cell floor and appears unconscious. The housing officer tells her the inmate is breathing so she runs back to the medical unit to get oxygen and emergency supplies. When she reaches the medical unit she tells another nurse to activate emergency medical services as the patient will definitely be heading to the hospital. The sick call nurse returns to the housing unit with the emergency supplies, provides standard emergency treatment, and, some minutes later, assists the emergency personnel to prepare the patient for transport. Three months later she is named in a malpractice lawsuit.

As professional health care providers, nurses are held to standards of practice related to our licensure. Malpractice is claimed when a professional acts or fails to act to the level of their professional education and skill. This is also referred to as professional negligence as negligence, itself, is a general term for carelessness or a deviation from actions that would be taken by a reasonable person in the same situation.

Components of a Malpractice Claim

Six elements must be present in a malpractice claim to prevail. All factors must be convincingly presented for the nurse to be deemed liable in a malpractice case.

Duty owed the patient: Nurses owe a duty of care based on licensure and role at the time of the claim. A nurse-patient relationship is established by a nurse accepting an assignment involving the patient and continues until closure of that assignment. That closure can come when the patient is handed over to another qualified individual, as in the case of infirmary care, or when the patient is released to personal self-care as at the conclusion of a sick call episode or release from the facility. That a duty is owed in a particular circumstance is fairly easy to establish. If a nurse is in the midst of a shift and working under a job description when presented with a patient such as in our case above, the nurse owes a duty to the patient to respond as any prudent nurse would in a similar situation.

The nature of the duty is established by the circumstances of the incident. This can be less clear and, in a court case, often requires the testimony of expert witnesses of similar background. These expert witnesses base their testimony on practical experience in a similar setting but also on published standards. Standards for correctional nursing practice are published by the American Nurses Association and are structured around the nursing process. Expert witnesses may also rely on accreditation standards. In correctional settings, that would be the National Commission on Correctional Health Care Standards and the American Correctional Association Standards. Although voluntary, these standards lay out indicators of quality health care processes that may be in question in a legal claim. There are also some states that have specific state statutes and regulations that address minimum standards of care expected in the correctional setting.

Breach of the duty owed: Once duty is established, a breach of that duty then needs to be clearly presented. The groundwork has already been laid by the expert witness(es). A breach of duty relates to action or inaction that does not meet the expected standard of care for the situation. Duty owed can be established through various, often written, sources such as:

  • Standing policy, procedures, protocols
  • Emergency procedures
  • National guidelines and standards

Foreseeability: A successful malpractice case must also establish that the nurse should have reasonably been able to foresee that harm would come. No one has a crystal ball to see into the future and some random harm can come from nurse actions. Foreseeability establishes that the injury could have been considered and steps taken to keep the patient from harm. In our case example, a nurse was called to an emergency man-down in a housing unit and was the only health care staff on the scene. Patient abandonment was alleged as the nurse did not assess the patient or provide immediate care before leaving the scene. A prudent nurse, it was claimed, would have stayed with the patient, rendering care while an unlicensed staff member brought the equipment. The plaintiff’s lawyer argued that the nurse should have foreseen that the patient would be harmed by her departure without any other healthcare provider left there to deliver care.

Causation: The case now moves to cause. Did the nurse’s breach of established duty directly cause the injury? Causation of an injury can be multi-faceted so narrowing down cause to the nurse’s action or inaction in breach of duty may be challenging. In this case, the patient suffered a hypoxic stroke, but would the outcome have been different if the nurse had repositioned the patient and provided rescue breathing? That would be for the plaintiff’s legal counsel to support through the use of medical experts with experience in a similar setting.

Injury: Physical injury must then be established. This, again, must be directly linked to the nurse’s breach of duty. There are some rare exceptions here, but injury must be quantifiably physical rather than merely psychological in nature. In the case above, the nurse’s abandonment must be established as the proximate cause of a physical injury to the patient. This patient was permanently disabled due to brain injury.

Damages: The final element of a malpractice allegation is damages incurred. This infers the level of the injury to the plaintiff caused by the nurse but damages can also be ascribed in a broader manner. There are three main categories of damages sought:

  • Special damages (out-of-pocket): These are the primary damages of a malpractice case and are determined by actual economic loss such as lost wages, medical expenses, medications, or therapy. These damages can only be claimed with proof such as receipts and bills.
  • General damages (noneconomic): These are less quantifiable damages such as pain and suffering or emotional distress. Although receipts or bills would not be available to establish this type of damage, the plaintiff much have some evidence to support the request.
  • Punitive damages: Punitive damages are intended to add a punishment to the defendant. If a clinician lapse is particularly egregious or misconduct or tampering are discovered in the case, punitive damages may be high.

Although not part of the legal case, malpractice determinations are reportable and considered by State Licensing Boards for disciplinary action such as suspension or revocation of licensure.

In this particular case, settlement was reached before trial, as so often is the case. The plaintiff was awarded a large but undisclosed settlement. Was the nurse guilty of malpractice? What do you think?

Photo Credit:© Matthew Benoit – Fotolia.com

Caring Within The Culture of Incarceration (podcast)

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cnt-podcast_cover_art-1400x1400Dr. Stacy Christensen, a nursing professor at the Central Connecticut State University in New Britain, CT, talks about her work with incarcerated women in the Connecticut State Prison System and her article about the application of Leininger’s theory of Culture Care in the correctional setting. Enhancing Nurses’ Ability to Care Within the Culture of Incarceration” was published in the June 2014 issue of the Journal of Transcultural Nursing.

In this episode she explains the key elements of Leininger’s theory of Culture Care and how incarceration can be thought of as a culture. The incarcerated patient population has a common language, customs, and rituals. Leininger defined culture as the learned, shared, and transmitted values, beliefs, norms, and lifeways of a group. Correctional nurses need to be culturally aware to effectively deliver care in this setting.

News Items

Coffee Consumption and Mortality

Findings from a meta-analysis of more than 20 published studies indicate that coffee consumption is inversely associated with all causes of mortality. Best mortality figures were for those drinking 4 cups per day. They also found no association between coffee consumption and cancer mortality. Although past studies indicated a concern for caffeine related to increased blood pressure, insulin resistance, and elevated lipids, habitual coffee consumption results in a tolerance for the acute effects of caffeine. Researchers aren’t sure what components of coffee are beneficial but indicate that coffee is a major source of antioxidants, which could be part of the positive effect. In addition to reduced mortality, coffee consumption was linked to reduced risk of suicide, Parkinson’s disease, and gallstones.

Increases in Heroin Overdose Deaths — 28 States, 2010 to 2012

The CDC has published data on Increases in heroin overdose deaths between 2010 and 2012 in the latest issue of the MMWR – Morbidity and Mortality Weekly Report. There has been an alarming rise of heroin overdose deaths in the last two years – more than double. Deaths have increased across gender, age, ethinic groups, and geographic region – although the increase is more significant in the northeast and south regions. In a related news story, the study’s co-author Dr. Len Paulozzi, a medical epidemiologist at CDC’s National Center for Injury Prevention and Control, said that the over-prescribing of narcotic painkillers (such as Oxycontin and Vicodin), which has been going on for 20 years, is responsible for the increase in heroin use and overdoses. He continues by commenting that solving the problem of deaths from heroin overdose begins with stopping the addiction to narcotic painkillers. Dr. Andrew Kolodny, president of Physicians for Responsible Opioid Prescribing, is also quoted in the news item as saying that there is very little difference between heroin and Oxycontin or Vicodin and that the medical community has to prescribe more cautiously.

Do you think a theory of cultural care would work in correctional nursing? What do you think about the positive effects of coffee? Have you seen an increase in heroin addiction in your patient population? Share your thoughts and insights in the comments section of this post.

Eight Ways to Improve Clinical Judgment

医者の表情Although every nursing specialty has its challenges, correctional nursing involves complex situations that can appear simple, but aren’t. There are many unknown factors in sizing up a situation. Correctional nurses are most-often the first healthcare provider to see the patient situation. As a gatekeeper, the nurse must make a fairly autonomous judgment on what needs to be done and who needs to be involved. Therefore, clinical judgment skills are absolutely essential for nurses working behind bars. Recent posts have discussed the vital role of clinical judgment, reasons correctional nurses need clinical judgment, and clinical judgment booby traps to avoid. In this final post of the series, we are turning to ways to improve clinical judgment. Incorporate these methods from traditional clinical settings and educational programs to improve your clinical judgment and that of nurses you work with.

Clinical Practices

 Case Review

Case review is one of the best ways to develop clinical judgment, especially with nurses new to the specialty. Although you can use cases developed purposefully it may be even better to include review of actual cases as a regular part of the process of unit management. For example, reviewing actions, reactions, and interactions of a recent complex or emergent patient situation can allow nursing staff an opportunity to learn from the experience and from each other. Much can be gained by providing an opportunity for staff to dialog about clinical judgment and reflect on their practice and the practice of others. Of course, this dialog must be carefully facilitated so that team members develop abilities to critically review a case without being critical of each other. You want this to be an empowering experience rather than a disempowering one. Careful guidance is needed until staff develop the skills necessary to be encouraging, purposeful, and thoughtful in their dialog.

Peer Review

Guided peer review is another way in which staff can develop clinical judgment skills. Similar to traditional physician peer-review, nursing peer review is a analysis of written documentation of past patient care on an individual practice basis. This process, by the way, is also helpful to encourage more thorough documentation. Learn more about nursing peer review in corrections from this series.

Reflection

Reflective practice is another clinical activity encouraging development of clinical judgment. Reflection on an actual significant clinical experience such as an unexpected death or near-miss experience can yield a wealth of wisdom for the nurses involved. By guiding the discussion toward analysis and synthesis of information, the experience can expand both individual and group learning. New staff members can be asked to keep a journal of their patient experiences that is reviewed periodically with the nurse manager or a senior staff member. The journal activity helps with reflection and the documentation can guide discussion into deeper meanings of assessments or a better understanding of facility processes.

Simulation

Another clinical activity that builds clinical judgment is simulation. Simulation allows a safe practice experience while developing procedural skill and team kills in collaboration and coordination of care. Use the disaster drill and man-down simulations to encourage clinical judgment development. Debrief the simulations as you would an actual experience and guide staff to truly think about why various decisions were made.

Educational Practices

Clinical judgment development can also be infused into standard educational programming. Many in-services involve a lot of information with little application. Instead, a better way is to provide foundational information and then engage staff in a dialog about how to apply this information in practical and realistic situations. An example of how not to do this is an inservice I taught on dealing with chest pain in correctional settings. It had a ton of information about assessment, interventions, and facility policy. We even talked about how to deal with the on-call physician. Participants left with a head full of what and how but not much application or critical thinking about dealing with chest pain. Here are some ways this program could have been improved to help develop clinical judgment.

Dialogue

Adding interaction and dialog to a learning experience engages the learners in thinking and applying the information. Providing real life examples and cases is an excellent way to encourage discussion.

Probing Questions

Probing questions combine with interactive dialogue to fully engage participants. A probing questions looks beyond yes or no and moves the thinker from reaction to reflection. Questions such as “What do you think would happen if……” or “Why do you think that might happen?” encourage learners to analyze a situation and work through possible solutions.

Mind Mapping

Mind mapping, also called concept mapping, is a creative method of displaying information and how it connects together. This process is gaining popularity in undergraduate nursing programs to help students think about the various elements of a clinical situation. Why not use it with practicing nurses? A mind map is a visual organization around a core concept. Here is an example of a mind map developed during a presentation on chest trauma.

mindmap

Algorhythms

An algorhythm is a decision tree that guides through a particular situation. While a mind map is based on relationship of information, an algorhythm is a decision tree and is expressed in a linear fashion, often answering questions of yes or no and then moving on. This example is from an ACLS course on responding to bradycardia. For the chest pain inservice I described earlier, I might have asked participants to develop algorhythms for respond to chest pain.

algorhythm

The key to clinical judgment development in an educational setting is to engage the learner with the thinking processes and to reflect on their own practice and how they might incorporate this new knowledge into their practice.

Do you have ideas for how to apply these eight processes in clinical and educational practices in your setting?

Photo Credit: © ぶぶたん – Fotolia.com

Three Clinical Judgment Booby Traps to Avoid

Risk concept. Sign question on bear trap.Over time, as we develop our practice, we store up clinical reasoning helps that can speed our decision-making for commonly reoccurring scenarios. We begin, for example, to develop rules of thumb and analogies resulting from common pattern recognition that originate from past successes. The formal term for this is heuristics. In fact, clinicians rarely use formal computations to make patient care decisions in day-to-day practice. Rather, we develop an intuitive understanding of probabilities combined with a concoction of rules of thumb, educated guesses, or mental shortcuts.

Without care, other factors can cloud our thinking. In particular, we must be mindful of our biases, cultural background, and assumptions when making clinical judgments.

Biases

Biases are rooted in our human nature and hard to avoid. We can, however, mindfully consider them as we reflect to improve practice. A few biases of importance to avoid when making clinical judgment are described here.

Premature closure is one of the most common errors. In this bias clinicians make a quick diagnosis (often based on pattern recognition), fail to consider other possible diagnoses, and stop collecting data (jump to conclusions). In fact, even the suspected diagnosis is not always confirmed by appropriate testing. A premature closure issue common in correctional nursing might be “I know this patient-he is faking this condition to get attention”.

Confirmation bias occurs when clinicians selectively accept clinical data that support a desired hypothesis and ignore data that do not. Clinicians who rely heavily on pattern recognition and become overconfident in diagnostic abilities can fall prey to premature closure and confirmation biases. If a patient is acting erratically and an officer shares a high breathalyzer reading, a nurse may settle on an alcohol intoxication diagnosis when there are also signs of a head injury.

Availability bias results in overweighing evidence that comes easily to mind. This could be recent evidence or what we perceive as meaningful events. For example, if you have ever had a legal claim against you for a particular diagnoses or clinical action, you have had heightened awareness of that diagnoses for some time afterward.

Assumptions

Assumptions about what is and isn’t present can also affect our thinking and judgment. A simple example can underscore how assumptions can get us tripped up. Consider this puzzle that you must solve. A donkey is tied to a 6 foot rope. A bale of hay is 8 feet away from the donkey. Without biting through the rope, how can the donkey get to the bale of hay? Answer: He just walks over to it. There is not mention that the rope is anchored to the ground. Most people hearing this story, though, assume that the donkey is tethered. Sometimes we need to see what isn’t there as well as what is there when evaluating a patient, too.

Culture

Our culture can lead to unconscious ‘habits of the mind’ that affect clinical judgment. Repeated personal experiences and cultural socialization are absorbed into our ways of thinking about the world around us. For example, over time, correctional clinicians may absorb a jaded view of inmate intentionality or the surrounding security culture of the facility. Attitudes about patient motivation can cloud our judgment and alter subjective interpretation of symptoms.

Sometimes getting over our biases, assumptions, and culture in clinical judgment is as easy as changing the questions we ask ourselves. Imagine seeing a drawing of 2 triangles a square and a circle. If you ask yourself the question “What is this?” You may answer – 2 triangles, 1 square, and 1 circle. How might that change if you ask yourself “What could this be?” Maybe the answer now is – a jack-o-lantern or a clown face. Sometimes self-questioning can break us out of our biases, assumptions, and cultural norms.

How have you seen biases, assumptions, and culture affect clinical judgment? Share your experiences in the comments section of this post.

Photo Credit: © valentinT – Fotolia.com

October 2014 News Round Up (podcast)

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cnt-podcast_cover_art-1400x1400Correctional nurse experts Mari Knight, Johnnie Lambert, Denise Rahaman, and Sue Smith join Lorry to discuss the hot topics in correctional healthcare news in this monthly round-up.

Ohio prisons credit $10M savings to Medicaid changes

Our first story comes from the Ohio prison system where they are reporting saving $10 million dollars in medical expenses this fiscal year through maximum use of the Medicaid system and Affordable Care Act. Frankly, the various ways prison and jail systems cover inmate medical expenses can be confusing. Of note is the enrollment of inmates in Medicaid for better continuity of care and access to medications.

How Gangs Took Over Prisons

Our next news item is an extensive article in the Atlantic about how gangs took over prisons. The information is fascinating. The article mainly focused on gang activity in the California Prisons System – Pelican Bay State Prison, in particular – and relied heavily on a book by David Skarbek called “The Social Order of the Underworld”. It can be helpful for nurses to understand their patient’s culture. Information from this article and the book may be of particular interest for nurses working in facilities with major gang activity.

NLN Recognizes the Role of the LPN/LVN

This next item is a document published by the National League for Nursing on the recognition of the role of Licensed Practical/Vocational Nurses in advancing the nation’s health. This is of particular importance in our practice setting as we have a high percentage of nursing care delivered by LPNs/LVNs. Based on surveying the changing employment characteristics of LPNs, the NLN is recommending curriculum revisions to meet healthcare system needs – such as adding geriatric and culturally relevant care. The paper reports movement of LPN practice into long term care and community settings where they are dealing with predictable chronic conditions. Of note is a section on Scope of Practice variability and what they call “the growing disconnect between scope of practice standards and the reality of practice”.

Nursing Student’s Program Helps Save Lives in State Prison

Our final story discusses a nursing graduate student who is positively affecting patient care in the California Prison System. The student is Kelly Ranson, chief nurse executive, at Kern Valley State Prison, a high security prison in the state system. She gained approval to implement her Health Promotion and Disease Prevention course project in the facility. This involved diabetic self-management among the male inmate population. The article noted collaboration with security administration and a team approach with mental health staff, dieticians, medical staff and peer support. This report provides a model for implementing health care innovations in a correctional setting.

Five Reasons Correctional Nurses Need Clinical Judgment Skill

Green plant mazeIn corrections, nurses are usually the first health care professional to assess a health concern or complaint. Patients present with virtually every type of health problem, and many have co-occurring conditions that can complicate the diagnosis and plan of care. Therefore, correctional nursing practice requires knowledge and experience with a broad array of conditions and presenting problems to make clinical judgments about the nature of the problem, actions to be taken, and urgency of response.

Correctional nurses also coordinate and negotiate for the delivery of care within the restrictions and expectations of the organization, which requires decision-making conviction. Clinical judgment guides direct care delivered by the nurse as well as communication with others to coordinate care and ensure patient safety. Accuracy in judgment improves patient outcomes and quality of care by eliminating unnecessary actions and reducing delay in definitive care and treatment.

Although every nursing specialty has its challenges, correctional nursing involves complex situations that can appear simple, but aren’t. There are many unknown factors in sizing up a situation. Correctional nurses are most-often the first healthcare provider to see the patient situation. As a gatekeeper, the nurse must make a fairly autonomous judgment on what needs to be done and who needs to be involved.

Here are five reasons clinical judgment is especially important for correctional nurses:

  1. Detainees or inmates are entitled to a clinical judgment under the 8th or 14th amendment whenever attention to a health concern is requested. See this post for more information on the right to a clinical judgment.
  2. Nurses most often are the first health care provider to see a detainee or inmate for any health concern. The nurse’s clinical judgment will determine if the person sees any of the other health care providers and if so, how soon.
  3. Ineffective clinical judgment affects the patient adversely now and perhaps in the future, it affects other nursing staff and providers. It can also affect our relationship with custody staff.
  4. Correctional nurses must make judgments in a wide array of situations from minor discomforts to life-threatening emergencies.
  5. And, they must do it while navigating the correctional environment with safety, location, and resource challenges.

What other reasons are there for correctional nurses to be skillful in clinical judgment? Share your ideas in the comments section of this post.

Photo Credit: © leungchopan – Fotolia.com

Clinical Judgment: A Vital Correctional Nurse Competency

decisionsRhonda has been called to the booking area to medically screen a 44 year old man brought by the police on charges of driving a stolen vehicle and drinking while driving. On the way to jail he hit his head on the window of the squad car. Approaching the area she sees an obese white male, hands cuffed behind his back, leaning facedown on the booking counter, propped up by two police. The man is yelling that he is going to faint and can’t breathe.  A chair is brought so he can sit and Rhonda notes that he is diaphoretic and flushed in the face. He reports that he has prescriptions for two inhalers but otherwise has no medical problems. His voice tone is belligerent and he is dressed in shorts, a t-shirt and sandals;  inappropriate for the winter weather. Rhonda can see that his legs and feet are mottled and swollen. He also has a swollen area over his eyebrow on the right side and the eye on that side is swollen shut. There are four policemen waiting for the nurse to screen the arrestee and another six custody officers waiting to proceed with booking. 

Christine Tanner, a nurse researcher, has studied expert nurses to determine components of clinical judgment and when it is most specifically needed. She found that clinical judgment skills were particularly important when

  • The clinical problem or concern is undetermined;
  • The presenting data is ambiguous; and
  • When the situation presents conflicts among individuals with competing interests

Our case above has all three elements. Rhonda has a problem to solve and she needs to do it quickly amidst competing interests – the patient’s, the police, and the correctional officers. The patient condition is undetermined at the moment. Rhonda cannot merely review the patient’s medical record for a list of diagnoses. His presenting data is ambiguous and non-specific. The clock is ticking and the pressure is on.

Tanner reviewed 200 studies on clinical judgment in nursing practice. From this review she concluded that a nursing clinical judgment involved the following components:

  • Gaining a grasp of the situation holistically
  • Seeking an understanding of the situation which is beyond just the objective findings on assessment
  • Considering factors contributing to the presentation
  • Attending to the patient’s response to the nurse
  • Deciding an appropriate course of action
  • Reviewing outcomes and making changes as needed

What clinical judgment do you think Rhonda made in this situation? Even though there was pressure to book the man, she was concerned about a concussion and his respiratory condition. She did not approve him medically for booking and he was sent on to the hospital emergency room. There it was discovered that, although he was intoxicated, he did have a mild concussion, and, more importantly, was discovered to have moderate congestive heart failure. He was in the hospital for over a week.

Have you had a challenging patient presentation that seemed ambiguous at the time or had competing interests to consider? Share your story in the comments section of this post.

Photo Credit: © mstanley13 – Fotolia.com

Win a Copy of My New Book! Enter by November 1

3DBookI am excited to announce that my newest publication – The Correctional Health Care Patient Safety Handbook – is now available for purchase on Amazon (affiliate link). It is a steal at $29.50 for print and $9.99 for the Kindle version. But, even better is to get a free copy, right! So, I’m holding a raffle for 3  correctionalnurse.net readers to get an autographed copy sent directly to you. How cool is that?

Just click on this link and enter your first name and email address. If you are a winner I will contact you for a mailing address for the book. You can enter once per day until November 1 – so you have plenty of opportunity to win!

Why do you need this book?

Most of us entered health care to help those who are ill, injured, or suffering. Yet our patient care systems can get in the way, leading to patient harm instead of the quality care we intended. The Correctional Health Care Patient Safety Handbook provides practical evidence-based help to improve your clinical program and, thereby, reduce clinical error, managing risk and improving clinical quality. By reading this book, you will discover:

  • How a patient safety framework can reduce legal liability while enhancing continuous quality improvement efforts
  • The best methods to assess and improve an organizational culture to support patient safety
  • The key ways therapeutic systems support patient safety
  • Why communication and teamwork are so important for reducing clinical error
  • How to involve your patients to reduce errors and liability
  • The practitioner issues that can sink your clinical program and what to do about them

So, click on the link and enter to win your own copy!

Correctional Nursing Peer Review (podcast)

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cnt-podcast_cover_art-1400x1400Peer Review for Nurses? Many correctional health care settings are gearing up for correctional nursing peer review as NCCHC implements new accreditation standards this month. In this episode correctional nurse experts Catherine Knox, Kathy Page, Becky Pinney, and Pat Voermans join Lorry to discuss correctional nursing peer review and changes in the NCCHC accreditation standards for standard C-02 – Performance Enhancement.

The performance enhancement standard has been around for many years and focused on peer review for medical providers. This latest revision now includes all licensed staff; thus adding RN and LPN team members to the peer review process.

Panelists discuss the importance of this change for correctional nurses and nurse leaders. They also dispel some common misconceptions about nursing peer review; differentiating peer review from annual performance review and competency evaluation. Practical ways to perform nursing peer review are also described.

A series of blog posts about correctional nursing peer review can be found on the Essentials of Correctional Nursing blog.

In The Nursing News

How is Ebola Transmitted?

Lots in the news about the Ebola virus hitting US soil. Since much is still unknown about the virus and no vaccine or medication treatment is yet available, it is important to be careful around anyone who may be infected. Nurses, in particular, spend time in close contact with patients so we need to know about transmission and protection. On October 15 the CDC increased their caregiver protection barriers to more closely match World Health Organization recommendations. Standard precautions for droplet and body fluid contamination were enhanced with double gloving and full body coverage, including head and neck. Important points:

  1. Ebola has been detected in blood and many body fluids. Body fluids include saliva, mucus, vomit, feces, sweat, tears, breast milk, urine, and semen.
  2. The virus is spread by direct contact; meaning that body fluids (blood, saliva, mucus, vomit, urine, or feces) from an infected person (alive or dead) have touched someone’s eyes, nose, or mouth or an open cut, wound, or abrasion.
  3. Ebola is killed with hospital-grade disinfectants (such as household bleach). Ebola on dried on surfaces such as doorknobs and countertops can survive for several hours; however, virus in body fluids (such as blood) can survive up to several days at room temperature.
  4. Although coughing and sneezing are not common symptoms of Ebola, if a symptomatic patient with Ebola coughs or sneezes on someone, and saliva or mucus come into contact with that person’s eyes, nose or mouth, these fluids may transmit the disease.

Would your health care unit have the equipment necessary to protect you should you need to isolate a patient for evaluation for Ebola infection? Think about this now and have the conversation. Be prepared.

Men with Osteoporosis are Neglected

The International Osteoporosis Foundation has published a report on osteoporosis in men. Although we tend to think about osteoporosis as an elderly female condition, a third of all hip fractures occur in men. Men are prone to brittle bones as they age; particularly after the age of 70 when testosterone reduces significantly. Other factors contributing to osteoporosis in men include smoking, drinking more than 2 drinks per day, low vitamin D levels, a family history and taking certain medication such as cortisone, antiepileptic drugs and SSRI antidepressives. If you care for elderly male inmates, consider osteoporosis and concern for falls.

USPSTF: Screen Everyone 45 and Older for Abnormal Glucose

The US Preventive Services Task Force drafted new diabetes screening guidelines recommending that everyone 45 years and older should be screened for abnormal blood glucose and type 2 diabetes. They hope to identify those with abnormal glucose levels to initiate lifestyle interventions before the condition progresses to diabetes. The guidelines are open for comment until early November, 2014.

Patients Listen More to Female Doctors

An interesting French study suggests that patients heed guidance more regularly from female providers than from male. The study design hypothesized that patients would listen more to a physician of the same gender but it turns out that both male and female patients were more disposed to listen to a female physician. Based on this and prior research the authors suggest that female doctors may be more collaborative with patients and male doctors more dominant. Also, earlier studies have shown that women doctors report feeling more comfortable discussing personal and sensitive issues. It would be interesting to see a similar study regarding nurse-patient relationships.

Making Ends Meet: The Blunt End and Sharp End of Clinical Error

A 33 year old male inmate from a maximum security state prison was admitted to a community hospital with flank pain and hematuria. His Arrow Chamber Funnel ChartINR was discovered to be 8.2 (therapeutic range 2-3). His medical history included deep vein thrombus resulting from Protein S deficiency. A medication error investigation revealed that the patient had been receiving three times the amount of the current order of warfarin (Coumadin) and no INR diagnostic tests had been completed for the last 2 weeks.

Investigating What Went Wrong

Hundreds of doses of medication are administered every day in most correctional facilities so it is not surprising that medication errors are some of the most common to emerge in practice. Investigating errors can lead to information necessary to make improvements to reduce future risk. An error can result from poor decisions and actions along the entire medication use system: ordering, transcribing, dispensing, administering and monitoring. Often poor practices are found in several areas that result in an incident.

Blunt End/Sharp End Evaluation of Clinical Errors

A helpful model of error causation looks at the various components of a clinical error as an inverted triangle with the point of care being at the sharp end and the various complexities of organizational structure, system, and process being at the blunt end; removed from the actual error episode. Blunt end components, then, contribute to an environment that either encourages or does not prevent the error under consideration.

Case Analysis by Blunt End/Sharp End

Figure 1.2The Blunt End/Sharp End model provides a framework for evaluating a clinical error like the one described above.

Sharp End: Investigating the sharp end of the error focuses on the actions of the clinicians in direct contact with the patient. Here are some sharp end investigation questions for this case:

  • Did the nurse follow standard medication administration safety steps when administering the recent doses of warfarin?
  • Were there multiple strengths of the medication in the medication cart and did the nurse administer an incorrect dose?
  • Did the prescribing provider order the strength of the doses administered?
  • Did the prescribing provider order INR lab tests?
  • Were the tests completed but not reviewed or documented in the medical record?

Blunt End: Investigating the blunt end of the error focuses on the policies, procedures, systems, resources, and constraints surrounding the incident. Here are some blunt end investigation questions for this case:

  • What are the policies regarding INR evaluation while on warfarin?
  • What tracking systems are in place for patients on anticoagulation medication?
  • Is there an adequate process for discontinuing previous medication dosing when new dosing is ordered?
  • Are nurses working in this area appropriately oriented to the medication administration process?
  • What percentage of the nursing staff are new, float, or agency staff?
  • How much overtime or double shifts are nurses in this unit working?
  • What communication system is in place for nurses to question medication orders?

Always Look Upstream

When investigating significant errors such as the one above, it is easy to fall into several mental biases.

Attribution error bias: It is easy to pin an error on a character flaw or defect of the clinician at the sharp end of the error. Rather than look for all issues, evaluators stop at the shortcomings of staff members involved in the incident.

Confirmation bias: Making a quick judgment of the cause of an error can lead to accepting evidence that supports that judgment while neglecting evidence that would favor other causes. If an organization is prone to evaluating only the sharp end of a clinical event, evidence supporting this view would encourage investigators to stop looking elsewhere.

Hindsight bias: Actions and outcomes viewed after the fact show an ‘obvious’ path of cause and effect. At the time of the actual event, however, multiple possibilities vie for attention, making the future less apparent. Investigators must consider the event from a perspective of an unsure outcome.

By intentionally looking upstream to the blunt end of a clinical situation, the full picture is able to be evaluated and meaningful process and system corrections can be made; leading to reduced risk of future error.

In the case presented above, faulty medication discontinuation practices, poor interdisciplinary communication (both written and verbal), along with inconsistent medication validation at the point of administration contributed to the poor patient outcome.

How do you evaluate clinical error in your setting? Share your process in the comments section of this post.

Information from this post comes from Chapter 1 of my new book: Correctional Health Care Patient Safety Handbook: Reduce Clinical Error, Manage Risk, and Improve Quality (affiliate link). Click on the link to purchase a print or ebook version. Or, enter my raffle for your own free copy – 3 winners. Hurry, raffle ends November 1: Raffle for a Free Copy of the Patient Safety Handbook

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