Objectives Screen cases for merit Identify key areas of OR - PDF document

11/12/2012 Deciphering Operating Room Nursing Liability Retained Sponges and LNC Case Review 1 1 Objectives • Screen cases for merit • Identify key areas of OR documentation for timely case review • Increase credibility with attorneys • Discuss perioperative issues that may result in allegations against nurses in lawsuits • Discuss the risk factors associated with RSI’s 2 Four Ds Duty Damages Dereliction Due to 3 1

11/12/2012 Theories of Liability  Res ipsa loquitur – “the thing speaks for itself” 4 Theories of Liability  Failure to follow standards of care  Failure to use equipment in a responsible manner 5 Theories of Liability  Failure to communicate  Failure to document 6 2

11/12/2012 Theories of Liability • Failure to assess and monitor 7 Theories of Liability  Failure to act as a patient advocate 8 Retained Sponges And OR Nursing Malpractice 3

11/12/2012 Screening Cases for Merit 10 Chart Review 11 Sources of SOC 12 4

11/12/2012 The Perioperative Patient Experience Preoperative Phase Preoperative Nurse Responsible for: Patient intake, review of medical and past surgical history. Initiating surgical preop checklists as per institution. First meeting with anesthesia provider(s) 13 Intraoperative Phase First “meet and greet” with OR nurse assigned Review of chart, labs, etc. Hand off report from preop nurse Transfer to OR suite 14 IntraOperative Role of the RN Circulator Assists the scrub technician, opening sterile supplies for the assigned surgical procedure. Performs a visual, audible, concurrent count with the scrub technician upon completion of setup, throughout and upon completion and according to OR policy. 15 5

11/12/2012 Anesthesia Provider M.D. or CRNA 16 PACU Nurse 17 Risk Factors • Communication issues • Distractions • Human error • Change up in surgical procedure • Obesity • Emergency procedures 18 6

11/12/2012 Retained Surgical Items Most common: Sponges Can be left in a minor incision or as deep as the retroperitoneal cavity 19 Retained Surgical Items • Laparotomy pads • 4x8 inch sponges • Dissecting sponges • Cotton strips, sponges • Surgical or “Huck” Towels 20 Kittner/Dissecting sponge or “Peanuts” 21 7

11/12/2012 Cottonoids or “Strips” and “Patties” 22 23 24 8

11/12/2012 “Raytex” or 4x4 Sponge 25 Laparotomy Pad or “Lap Pad”/”Lap Sponge” 26 Huck Towels 27 9

11/12/2012 Role of the Scrub technician Prepares necessary sterile items for assigned surgeries Upon completion of sterile setup, performs an initial surgical count with the RN circulator of all items to be used in a surgical procedure according to O.R. policy. 28 Role of the Scrub technician Assists the surgical team as needed throughout the surgical procedure. Maintains a visual awareness of the surgical field and and can account for laparotomy sponges left in the body cavity and relays this count to the circulating nurse. Conducts “closing counts” WITH the RN circulator 29 Role of the RN Circulator Remains aware of number and types sponges using an Approved counting tool, such as a count sheet, count board, etc. (can be different from OR to OR) Initiates “closing counts” as the surgical team begins closure. 30 10

11/12/2012 Symptoms of Gossypiboma Can occur as early as 11 days post surgery. Patient will present with:  Pain, Fever  Infection OR  Asymptomatic 31 Parties Named in a Lawsuit • Hospital/ASC • Surgeon(s)/Fellow(s) • Residents/Physician Assistants/RNFA’s • Anesthesiologists/Nurse Anesthetists • Registered Nurses, LP/LV Nurses, Surgical Technologists 32 LNC Documentation Review Where to look: Perioperative Record Dictated OR Record. Look for notation of counts Note your team members Were they relieved?- Note the timelines 33 11

11/12/2012 Best Case Scenario • Legible documentation! • E-docs are great but not the end all! Still need to document either by computer or handwritten addendums • Good flow of information and timelines • Surgical counts performed and reflected in perioperative record. 34 Worst Case Scenario • Illegible document • Gaps in documentation • Empty spaces – • Poor or missing timelines • No nursing documentation to reflect an incident in the room or corrective action taken 35 National Association of Insurance Commissioners’ (NAIC’s) severity of injury scale and type of injuries: Death (09) — resulted in death of • claimant. • Permanent injury • - grave (08) — quadriplegia, severe brain damage, • lifelong care or fatal prognosis. • - major (07) — paraplegia, blindness, loss of two • limbs, brain damage. • - significant (06) — deafness, loss of limb, loss of eye, loss of one kidney or lung. • - minor (05) — loss of fingers, loss or damage to organs. Includes non-disabling injuries. 36 12

11/12/2012 National Association of Insurance Commissioners’ (NAIC’s) severity of injury scale and type of injuries: Temporary injury • • Major (04) — burns, surgical material left, drug side effects, brain damage. Recovery delayed. • Minor (03) — infections, mis-set fractures, fall in hospital. Recovery delayed. • Insignificant/slight (02) — lacerations, contusions, minor scars, and rash. No delay in recovery. • Emotional injury only (01) — fright, no physical damage. 37 NAIC’s Statistics • Major and Grave Injuries are the serious injuries that result in med mal claims • Median Payout for those injuries: is $278,000 to $350,000 ( Fl and Mo ) and almost $1,000,000 in Illinois. • Wrongful death claims do not result in huge compensations as there is no long term medical care involved in these claims 38 Surgical Claims Data – • Retained Objects • Average award is$125,000. • Million dollar verdicts are rendered in approximately 10% of plaintiff verdict. • NEJM reports that there are approximately 1,500 cases of retained objects per year. • NEJM study revealed 88% of surgical cases involving incorrect counts were documented as correct. 39 13

11/12/2012 Case Study Mrs. G, 45 year-old female, was brought to the OR for an elective open cholecystectomy. 40 Risk Factors Hurried Schedule Loud Music Scrub is in training with a preceptor Inattentive to surgical field 41 Other Risk Factors Lunch Relief 42 14

11/12/2012 Minimal or No Hand off report during relief 43 Incorrect Closing Counts 44 Xray in the OR 45 15

11/12/2012 Retained Sponge and Return to Surgery 46 • Points to Consider on Malpractice Review: • How was the baseline count performed and recorded? • What factors were involved that could have affected the counting process? • What processes were missed or neglected regarding placing a sponge in the surgical wound? • What part did the surgeon play in the closing count process? 47 • 48 16

11/12/2012 Association of periOperative Registered Nurses (AORN) The Recommended Practices for Sponge, Sharp, and Instrument Counts provide clear direction in the system for performing counts to decrease the risk of a retained foreign body. Recommendations are reviewed and updated annually Recommendations serve as guide for individual operating rooms to formulate policy and procedure. 49 Have an OR Case? Avoid a Bad Hair Day Call Med League 50 17