Access Nurse Consultants

Lessons Learned from My Mom's Illness- #1 - It's All About Relationships

2010-12-06T09:40:00.000-06:00

Lessons Learned from My Mom's Illness- #1 - It's All About Relationships

First, let me give you some background information. My mom turned 79 in June of this year. At that time, she was an on the go woman who never slowed down. She was up every morning at 5 a.m. and got ready for the day. She was active in her community, church, and family. She took one medication, Protonix, for her stomach. She had complained of a cough for months and her general practitioner told her it was due to her pulmonary hypertension and age. She then started complaining of shortness of breath and fatigue. Again, her general practitioner told her it was due to her age. He did not do a chest X-ray or refer her to a cardiologist.

In July, she went to her doctor complaining of cough, fever, fatigue and shortness of breath. He diagnosed her with mycoplasma pneumonia. No chest X-ray and no blood cultures were taken. He ordered a broad spectrum antibiotic. A week later and she was still feeling ill. My mom called the doctor and all he did was change her antibiotic. She continued to spiral downhill.

During this time, I was working in Washington, D.C. on a travel nurse assignment. It was a very challenging assignment mentally and physically. I called my mom every day for moral support. I called her one day in July at 1 p.m. in the afternoon and she was still in the bed. My mom started to cry and told me just how bad she felt. My mom was always up at 5 a.m. and was dressed and ready for the day. Also, my mom rarely cried. She could barely talk due to all the coughing. She was still running fever. Both her sisters died with lung cancer. My mom never smoked but my dad smoked most of their married life. She was scared that she had lung cancer. I was over 700 miles from home. I had a decision to make. This was when I learned the first lesson from this ordeal: It's all about the relationships.

I was making good money is D.C. I had several weeks left on my contract. Should I stay or go home. My other four siblings were there close to my mom. But I was the nurse of the family. I was the one who knew the health care system. Besides all that, she was my mom and my friend and she wanted and needed me to come home. The decision was easy. I was going home to take care of my mom. The next few months would be spent taking care of mom. The whole family rallied together to fight to get my mom properly diagnosed and treated. We spent time laughing and crying together. We spent time building our relationships even stronger that before this happened. I learned that life without strong, deep relationships is empty and hollow. My mom has told me numerous times how thankful she is that I came home but she will never know how thankful I am. I continue to learn a lot from my mother and value her advice. My relationship with her and my whole family has been enriched all because I came home.

Check back next Monday for Lesson #2 - The importance of listening.

2009-12-15T10:30:00.000-06:00

Legal Nurse Consultants and Product Liability Cases
• The LNC can examine the standard of care (in pharmaceutical and medical device cases) practiced by the professional who prescribed the drug or medical device.
• The LNC can quickly review medical records and determine what crucial medical records are missing and need to be ordered.
• The LNC can thoroughly review all medical records specifically looking for co-existing illnesses and preexisting problems and/or conditions.
• The LNC can in pharmaceutical cases delineate the plaintiff’s pharmaceutical history specifically looking for drug-drug interactions, contraindication for use, prior use of the alleged drug or a drug in the same family without injury, or “physician-hopping”.
• The LNC can identify any possible third- party counterclaims.
• The LNC can make the link between the injury and the drug or device therapy.
• The LNC can perform medical literature searches related to the product including indications for the product, expected patient outcomes, package inserts and any warning associated with the product.
• The LNC can be utilized to identify and obtain the appropriate experts for the case.
• The LNC can transform that stack (or boxes) of medical records into a format useful to the attorney.
• The LNC can educate the attorney regarding pathophysiology that makes the causation issues clear.
• The LNC can assist with creating or obtaining demonstrative evidence for trial.

Screening a Case for Merit

2009-12-14T08:14:00.002-06:00

One of the most common services a legal nurse consultant (LNC) is asked to perform is screening a medical malpractice case for merit. A LNC looks at the case to make sure all four elements of a medical malpractice case are met.

1) Duty - This is usually the easiest element to satisfy. All professional health care providers who have a relationship with a patient have a duty to that patient. The patient/health provider relationship is often established when the doctor, nurse, etc. begins treating the patient.

2)A Breach of Duty - This occurs when a health care provider does not act according to the standards of care for his/her profession. A LNC looks at this element carefully knowing that the standard of care must be proved through expert testimony or that it must be an obvious error (such as removing the wrong limb during surgery or administering the wrong medication).

3)The Breach caused an injury - The LNC knows that the breach must be the proximate cause of the injury. The LNC will look at other potential causes of the injury such as underlying disease states, noncompliance issues, and usual complications of surgery/treatment. The LNC knows that bad outcome does not always mean that bad practice occurred. The LNC knows that causation must be proven and looks at this element understanding that if causation is not proven to a "reasonable degree of medical certainty" then there is no case.

4) Damages - Without damages,there is no basis for a claim, regardless of whether the medical provider was negligent. Likewise, damages can occur without negligence, for example, when someone dies from a fatal disease. This is a key element. The degree of damage must be looked at as well. What were the short-term and long-term damages ?

A LNC is able to review a medical malpractice case for merit in five hours or less. Nursing home cases may take longer because of the large volume of records. A LNC will be able to tell the attorney the good, the bad, and the ugly about the case at hand. A LNC can give the attorney an idea of expert witness that may be needed, the potential arguments of the defense, and the extent of damages. Knowing the cost of a medical malpractice case, a LNC is a valuable tool that saves the attorney both time and money. If an attorney uses a doctor to review cases for merit, the doctor usually charges double to triple that of a nurse. Also, a nurse has a better understanding of the health care team as a whole and can speak to breaches made by doctors, nurses, lab techs, etc. Lastly,the LNC is able to examine, recognize, and interpret all relevant medical related information in a case that a non-medical professional might miss. That is why a LNC is a valuable addition to the litigation team.

Tips to prevent medical errors

2009-11-11T08:34:00.001-06:00

Tips to Help Prevent Medical Errors

This blog is written in response to the blog, 98,000 Reasons to Care about Patient Safety, by Jane Ayre at InjuryBoard.com. This is the number of Americans who die from medical errors each year. As a nurse, I know that patient safety is a concept that is foremost in the minds of healthcare providers, administration, and regulatory agencies. How can you, the consumer, help prevent medical errors ? In this blog, I will outline tips to help the consumer prevent other medical errors.
1. Be an active part of your healthcare team. Ask questions not just in the hospital but anywhere you receive healthcare. If you don’t understand something, ask for clarification.
2. If you have a choice, choose a hospital at which many patients have had the procedure and surgery you need and have had good results.
3. When choosing a specialist, ask your own physician for a personal recommendation. I have been known to ask my primary doctor: “If this were your wife, who would you send her to for this condition?”
4. Ask all healthcare workers who have direct contact with you whether they have washed their hands. Adequate hand washing is a primary way to prevent infection.
5. Before you leave the doctor’s office or hospital, make sure you understand the treatment plan. This includes understanding about your medications, follow-up care, and when to contact the doctor.
6. Before you leave the hospital, make sure you understand when you can resume regular activities. Make sure your doctor understands your regular activity level. You should know when you can shower, take a tub bath, lift 5 lbs, return to work, etc.
7. If you are having surgery, make sure that you, your doctor, and your surgeon all agree on what exactly will be done. For example, if you are having surgery on your right arm, make sure all involved knows it is the right arm. Make sure the site is marked before surgery.
8. Make sure someone is in charge of your care. This could be your personal physician. You need a point person to direct your care.
9. Make sure that all health care professionals involve in your care has your important health information. I love patients who come in with a written history. It is important that healthcare professional know your allergies, past surgeries, past and current medical conditions, etc.
10. Have a family member or friend designated as your advocate. Ask that person today. Make sure they know your medical history and your preferences in regards to medical care.
11. Before a test or treatment, ask why it is needed and how it can help you. Be informed before you consent.
12. If you have a test, follow-up and get the results.
13. Learn about your condition and treatments. If you use the Internet, use reliable sources. Treatment recommendations based on the latest scientific evidence are available from the National Guidelines Clearinghouse at http://www.guideline.gov. One of my favorites is www.mayoclinic.com.

You can visit my previous blogs on detail ways to prevent medication errors. I have outlined below the top 6 tips:

1. Make sure all healthcare professionals involved in your care know everything you are taking. This includes over-the counter medications, vitamins, herbs, and dietary supplements. Review these with your doctors once a year.
2. Make sure all healthcare professionals involved in your care know about any allergies and adverse reactions you have had to any medications.
3. When you get a new prescription from your doctor, make sure you can read it.
4. Understand your medications. What is it for? How is it to be taken and for how long? What are the side effects? Can I take it with other medications? What should I avoid while taking this medication?
5. Ask the pharmacist if you have any questions about the directions on your medication labels.
6. Ask for written information about the side effects.

Be involved in your care. Ask questions until you understand. Never consent to a test, surgery, or procedure until you are informed. Do not feel like a nuisance, you are standing up for your right to safe medicine that is appropriate for you and your condition. Your diligence could save your life. Share this with your family and friends.

Adapted from Agency for Healthcare Research and Quality

Medication Administration Abbreviations

2009-10-22T09:48:00.002-05:00

Sometimes reading a medical record can be a real headache. It is full of medical abbreviations. Below is a list of common medication administration abbreviations , use prn.

Doses
cc = cubic centimeter
gm = gram
gr = grain
gtt = drop
mcg = microgram
mEq = milliequivalent
mg = milligram
ml = milliliter
oz = ounce
tsp = teaspoonful
Tbsp = tablespoonful
U = units

Times
ac = before meals
BID = twice a day
pc = after meals
PRN = as needed (commonly written with a time frame and reason the medication is being given. For example q 2-4 h prn for pain meaning every 2-4 hours as needed for pain)
Q = every
QD = every day
QID = four times a day
QOD = every other day
q h = every hour (so q2h would be every two hours)
qhs = every bedtime (sometimes written as just hs)
TID = three times a day
Stat = immediately

Routes of Administration

AD = right ear
AS = left ear
AU = both ears
buc = inside the cheek
IM = intramuscular injection
IV – intravenous
IVPB – intravenous piggyback
OD = right eye
OS = left eye
OU = both eyes
opth. = pertaining to the eye
otic = pertaining to the ear
PO = by mouth (NPO means nothing by mouth)
PER G.T.= through gastrostomy tube
PR = per rectum
SL = sublingual
SQ or sub-Q = subcutaneous (also written as SC)
Supp – suppository
Susp = suspension
TPN – total paternal nutrition
Tab = tablet

Other

c- with
s – without
MAR – medication administration record
OTC – over the counte
Sig- label
EC – enteric coated
DC – discontinue
Per – through by

Legal Nurse Consultants and Personal Injury Cases

2009-10-19T14:31:00.000-05:00

The legal nurse consultant can be utilized in personal injury cases in the following ways:
· The LNC can quickly review medical records and determine what crucial medical records are missing and need to be ordered.
· The LNC can by a thorough review of the medical records identify issues in the case, including strengths and weaknesses and important evidence.
· The LNC can identify facts or statements that may suggest liability for the other party.
· The LNC can identify the consistencies and inconsistencies of the plaintiff’s complaint.
· The LNC can speak to the consistency between the mechanism of injury and the claimed and documented injuries.
· The LNC can educate the attorney regarding pathophysiology that makes the causation issues clear.
· The LNC can assist with the calculation of damages. The LNC can identify and request all billing records for medical care related to the incident. The LNC can speak to special and general damages.
· The LNC can perform searches of the medical literature regarding the issues of causation and damages.
· The LNC can be utilized to identify and obtain the appropriate experts for the case.
· The LNC can transform that stack (or boxes) of medical records into a format useful to the attorney.
· The LNC can attend independent medical examinations (IME’s).
· The LNC can testify as an expert fact witness.
· The LNC can assist with creating or obtaining demonstrative evidence for trial.

How does the Wound Ostomy & Continent Nurses Society Position Paper on Avoidable vs Unavoidable Pressure Ulcers impact malpractice cases ?

2009-08-23T19:53:00.002-05:00

A recent position paper by the Wound Ostomy and Continence Nurses Society discussed avoidable versus unavoidable pressure ulcers. The paper concluded that there are clinical circumstances in which a pressure ulcer is unavoidable. The rationale behind this statement was that pressure ulcer formation is a complex process that may not be halted, even with excellent multidisciplinary care. Further, the skin is the largest organ in the body and its integrity is dependent upon the function of all other organs systems for nutrition, circulation, and immune function. Often the disease process can overwhelm the skin and interrupt nutrition, circulation, and immune functions to the skin. The statement of position states that it is the responsibility of the healthcare facility to adopt best practices aimed at pressure ulcer prevention. The rationale for this is that there are increasing reports of success in reducing the prevalence and incidence of pressure ulcers by implementing evidence-based clinical practice guidelines.
The following are the definition of avoidable and unavoidable pressure ulcers from the Centers of Medicare and Medicaid:
· Avoidable Pressure Ulcer: Avoidable means that the resident developed a pressure ulcer and that the facility did not do one or the more of the following: evaluate the resident’s clinical condition and pressure ulcer risk factors; define and implement interventions that are consistent with residents needs, resident goals, and recognized standards of practice; monitor and evaluate the impact of the intervention; or revise the intervention as appropriate. (483.25c/TagF314).
· Unavoidable Pressure Ulcer : Unavoidable means that the resident developed a pressure ulcer even though the facility had evaluated the resident’s clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; monitor and evaluated the impact of the interventions; and revised the approaches as appropriate. (483.25c/TageF314)
So how does this position paper impact pressure ulcer malpractice cases?
· One of the recommendations of the position statement is accurate documentation of preventive measures targeted at the reduction of risk. Also, the clinical reasons why prevention interventions are not appropriate or feasible should be documented. If the pressure ulcer is determined to be unavoidable, the rationale must be evident.
· So in screening your pressure ulcer cases pay close attention to the documentation. A risk assessment tool should be done upon admission. Many hospitals have in their policies that skin assessment along with a risk assessment should be done daily. Most nursing homes do weekly skin audits. The skin should be consistently assess and the results of this assessment should be well documented.
· If the patient’s score on the skin risk assessment puts them at risk for pressure ulcer, a pressure ulcer prevent protocol should be started. This should be documented on the chart.
· In screening your case, see if these protocols were followed. Was the patient turned every 2 hours? Were pressure relieving devices used? Was nutrition consulted? Was preventive skin care initiated?
· If a pressure ulcer did develop, was it adequately treated and monitored? Pressure ulcers should be re-assessed weekly to assess if treatment is working effectively. If not, was a new skin care regimen ordered?
· Was the pressure ulcer assessed weekly as to size, characteristics, odor, etc.?
· Were lab values related to nutrition and infection being monitored? If these lab values were outside of normal limits, were the appropriate medical professionals notified? Was the problem adequately addressed?
· If the pressure ulcer was malodorous or had an exudate, was the wound cultured?
· If the pressure ulcer developed past a Stage I, was a wound care nurse consulted?
In the end, these cases come down to assessment and documentation. The position paper cannot be used as an excuse for pressure ulcers to develop. Most pressure ulcers can be prevented with good, effective, and early interventions.

Protecting Yourself from Medical Errors - Part III

2009-08-23T19:52:00.000-05:00

This is the final installment in Protecting Yourself from Medication Errors. In Part III, I will discuss protecting you from medication errors in the hospital.
Part III – The Hospital
1. Take your complete list of medications with you to the hospital. Many patients keep a typed list in their wallets. Give this list to you nurse. Ask and make sure the doctor completes the Medication Reconciliation Form. This form ensured that the doctor is aware of your home medications.
2. Do not take your home medications while you are in a hospital. The doctor will prescribe the medications you need at the dosage you need while you are in the hospital. If you take your home medications, you may over medicate yourself or cause a drug interaction.
3. Know the name of each medication you are taking and why. If you are told any different, you should ask about the difference.
4. Know your rights and speak up. If you are unsure of a medication, ask about it. Ask to see the MD’s order. Ask why you are taking it. You have a right to know and YOU may prevent a medication error.
5. Look at all your medications before you take them. Medications may look different in the hospital than at home. The hospital may use a generic brand or you may be on a different strength. Ask about any differences you see. Again, YOU may prevent a medication error.
6. Do not take any medication until your hospital identification is checked.
7. Make sure the hospital is aware of any and all allergies. Make sure you are given an allergy bracelet and that it is noted on your chart and medication administration record (MAR).
8. At discharge, have the nurse go over all your medications. Ask questions about new prescription and dosage changes. Don’t forget to update your list.
9. Remember your rights: Right time and frequency, Right person, Right drug, Right route of administration, and Right dose.

Protecting Yoursel from Medication Errors- Part II

2009-06-03T07:33:00.001-05:00

In Part I, I discussed protecting you from medication error in the doctor’s office. In Part II, I will discuss protecting you at the pharmacy. I have reviewed two cases recently that dealt with patients receiving either the wrong drug or wrong dosage. Both errors occurred at the pharmacy. Both errors were potentially fatal.

Part II – Pharmacy
1. If at all possible, get your prescriptions filled at the same pharmacy. Personally, I have gotten my prescriptions filled at the same pharmacy for 20 years. Recently, my pharmacist caught a drug interaction that the doctor missed. Your pharmacist is not someone who simply fills your prescriptions but is a valuable part of your healthcare team.

2. When you have your prescriptions filled, ask this simple question: Is this the medication that my doctor prescribed? A study by the Massachusetts college of Pharmacy and Allied Health Sciences found that 88% of medication errors involved the wrong drug or the wrong dose.

3. Ask the pharmacist if you have any questions about the directions on the medication label. For example, ask if three times a day means around the clock or during waking hours only.

4. Ask how the medication should be taken. Some medications require that you take medications with food. Also, ask what to do if you miss a dose.

5. Ask about any special instructions that come with the medications. We all know not to mix pain medications with alcoholic beverages but did you know milk can block the effectiveness of tetracycline.

6. Ask your pharmacist about the best device to measure your liquid medications. Many people use a household teaspoon, which do not hold a true teaspoon. Ask how to accurately use the device the pharmacist recommends.

7. Ask for written information about the drugs side effects. Many pharmacies have printed information that comes with medications. Review these with your pharmacist. This way will know the expected and unexpected side effects. Ask what to do if side effects do occur. If you do experience side effects from a medication, report this to your doctor and pharmacist.

Again, become an active part of your health are team. Ask questions, research, and be pro-active. In Part III, I will talk about protecting yourself from medication errors in the hospital.

2009-05-20T20:31:00.000-05:00

Medication errors are the most common medical errors. Medication errors affect at least 1.5 million people every year. There have been some recent public medication errors such as the Heparin mix -up with the Quaid babies. So how can you protect yourself and your loved ones?

Part I - Doctor's office

1. Make sure all of your doctors know everything you are taking. This includes prescriptions, over-the counter medications, and vitamins and herbs. Your heart doctor needs to know what your stomach doctor is prescribing. Drugs can interact into a deadly combination. A sleeping pill mixed with a pain pill is an example of deadly prescription drug combinations. Many over-the-counter decongestants cancel out the effects of blood pressure medications.

2. Keep a complete list of all of your "pills.” A complete list includes the name, dosage, how often you take it, and when you take it. This should be reviewed by your primary physician at least once a year.

3. Make sure your doctors know about any allergies or adverse reactions you have to medicines. Add this to your complete list. List the drug name and your reaction to the medication.

4. When a doctor writes you a prescription, make sure you can read it. If you can't read it, then the pharmacist may not be able to read it.

5. Ask about the medicine. Make sure the doctor explains it to you in terms you can understand. Write it down. Ask the following questions:
What is it for?
What dosage is the medicine?
How many times of day will you take it and for how long?
What are the side effects? What should you do if side effects occur?
Is it safe to take with your current medications, vitamins, and over-the-counter medications?
What do you do if you miss a dose?
What food, drink, or activities should you avoid while taking this medicine?

6. Research the drug. Two good websites are: www.drugs.com and www.rxlist.com .

Become an active part of your health care team. Ask questions, research, and be pro-active. In part II, I will talk about protecting yourself from medication errors in the pharmacy.