The Wrong Side of a Sentinel Event Review (Niki empathizes)

Chapter 40

I woke up in Raquel’s and Grant’s guest room when a bright shaft of morning light slipped between the honeycombed shades and into my eyes. This never happens at home where I’ve installed black out shades in my bedroom, because I work night shift. My hand, tingly-numb from sleeping on it, reaches for and locates my phone on the nightstand. I check it for texts.

There’s one from the PICU manager asking if I’m interested in picking up an overtime shift. She doesn’t realize I’m out of town.

Next, Maddie’s sent a selfie of her and Wade eating hot dogs in Amber’s backyard after our phone conversation yesterday.

I’m disappointed there isn’t one from Corey. It hurts a bit, but I remind myself this is a tough time for him. Then I dismiss the matter from further thought.

After a serving a quick Raquel drops her kids off at school, we go to a cross fit workout at her gym. She’s is an animal, performing amazing feats with weights, pull-ups, and standing squats. I admire her “guns,” the well-defined muscles of her upper arms, noticeable in her tank top.

“Niki, you should work on your core. You’d gain a lot of strength with a little work,” observes Raquel.

“Maybe, but I rarely go to gyms. Don’t judge me. I like the outdoors, running or riding a bicycle. Maybe because hospitals are such closed environments. You are a lot stronger than me though.”

Afterwards, we stop for smoothies before going home. Then I shower, and borrow a pair of slacks and a blazer from Raquel, hoping I don’t look out of place at the deposition this afternoon.

Grant greets me in the conference room at his office building, fifteen minutes before the deposition is scheduled. We choose our places at the conference table, facing the door before the other nurse and her legal representative arrive.

“Thanks for coming Niki. I realize you hadn’t expected to sit in, but I think it will be useful to us. I don’t want you to say anything, just listen. Have you sat at deposition before? No, of course you haven’t, because I would have been there for you. Sometimes it’s good to have a lawyer in the family, right?”

“Absolutely Grant, I just hope I never need you. The long-term goal of my career is to never sit on the wrong side of a sentinel review committee.”

“Well, unfortunately, it happens to very good nurses sometimes. I’ve seen my share,” admits Grant.

“I guess I’m kind of feeling bad for this nurse I’ll meet today, Grant. I mean, good or bad aside, I don’t know anyone in health care who starts a shift thinking, ‘today I’m going to hurt a patient.’ People go into nursing to help others, not to cause accidental harm.”

“I understand, Niki. What you have to realize, is that this case isn’t really about placing blame on the nurse. What we want to establish is that an employee of the hospital, in this case a nurse, made a mistake contributing to a wrongful death, making it the hospital’s responsibility. Nobody is interested in suing the nurse. We’re defending Dr. Straid from being sued. He stands to lose a considerable amount of his financial assets. He has a couple kids in college, a house, and a business to protect.

Maybe the nurse won’t get sued, but she’s going to have to find a way to sleep at night for the rest of her life if she’s blamed for contributing to the death of a child, I think to myself. I keep forgetting which team I’m on.

“But Dr. Straid’s not guilty, is he Grant?”

“Of course not, the nurse didn’t inform him of how sick the boy was. The hospital is the deep pocket here Niki, not the nurse. A patient should be safe in a hospital, right?”

“Yeah, you’re right, Grant. Patients should be safe in any hospital.”

“That a girl. Now, here comes the nurse, and the hospital lawyer. Remember, don’t talk just listen.”

It Happens (Niki sees in contrast)

Chapter 39

“Good work, Niki. Knowing the lab results and rash indicated a severe infection, yet this information was not reported to our client, Dr. Staid until after the boy’s death points the responsibility away from him, towards the nurse, and therefore at the hospital. That’s exactly the thing we’re looking for in the chart.

There’s an old saying among lawyers though, ‘Never ask a question in court that you don’t already know the answer to.’

So Niki, my question is: What difference would it have made in the patient’s outcome if Dr. Staid had been informed of the critical lab value and the rash sooner? Would the boy have received different care? Would he have survived?”

“I can’t answer that definitively, Grant. I mean, had the severity of the boy’s infection been diagnosed sooner, the shock that killed him would have been anticipated. Once the antibiotic came in contact with the bacteria in the boy’s bloodstream, the the bacterial cell walls burst, releasing their toxins and setting up a cascading circulatory reaction. That’s why the rash worsened from pinpoints to the huge purple blotches the nurse describes in her late entry note after the failed code. If this reaction had been anticipated, perhaps the boy would have been transferred to a pediatric intensive care unit where the technological support he needed was available, instead of admitted to a hospital unfamiliar with pediatric emergencies. Maybe he would have survived if that had happen. Maybe not. This kind of infection spreads like wild fire through the body of its host. Saving the boy’s life would have been challenging even for a PICU team. However, by the time they realized how sick he really was, it was too late. A small community hospital without a PICU couldn’t keep up. I feel bad for the family and for the staff.

As a nurse, Grant I have to admit I wonder why Dr. Straid didn’t come in to assess the child when it was decided to admit him? I know that happens a lot though. They leave it in the hands of the ER doc or a resident, and then see the patient in the morning. We have hospitalists where I work. A pediatrician is available both day and night.”

Mentally, I think of all of the times we’ve summoned Dr. Polk from the call room because a patient needed him.

“That question has been addressed,” replied Grant. “It’s our theme that, had he been informed of how sick the child was, he most certainly would have been at the bedside long before the code, when more treatment options could have been considered. The nurse did not inform our client of how sick his patient was in a timely manner, limiting our client’s ability to help the child.”

“Well, then you’ve got what you need, I guess.” Why does my stomach churn every time Grant and I reach this conclusion?

“Yes, and thank you Niki. We’re deposing the nurse tomorrow. Are you willing to sit in? I don’t want you to say anything, but maybe by hearing her deposition you’ll pick up on something else to strenghten our defense.”

The idea of being face to face with a nurse whose testimony I’m hired to shred makes me uncomfortable, but since I don’t have to ask her any questions, just listen, I figure it will be alright. I’m sort of interested in this whole legal process anyway.

“Sure. I’ll do that,” I tell Grant.

“Excellent,” he replies. “We meet in this conference room in the afternoon.

Seeking Justice (Niki reviews a nurse’s notes)

Chapter 37

In the conference room, Grant gives a brief explanation of the case I’m to review:

“According to the ER record, the parents reported their three-year old wasn’t interested in eating for a couple of days and when he stopped drinking fluids too they became concerned, bringing him to the hospital’s ER. A temperature of 102.5 was recorded, but otherwise his vital signs were normal, with a slightly elevated pulse. Concern for dehydration led the ER staff to draw blood tests, and start an IV. They decided to admit the boy to the pediatric unit for IV fluids, antibiotics, and observation overnight.

He arrived on the pediatric unit at 10:30 pm. According to the nurse’s admission note, he was lethargic. He received a dose of IV antibiotic within an hour of his arrival. After that, the order of events is vague. His mother noticed a rash on the boy’s chest and arms during the antibiotic infusion. The nurse called the attending pediatrician, who was at home, and reported the rash. The boy received a dose of IV diphenhydramine, and steroid to treat the rash assumed to be an allergic reaction to the antibiotic. The boy fell asleep.

The next entry in the nurse’s note records that an hour later she was called to the room by the boy’s parents. The rash had spread over his entire body. They were unable to rouse him.

The nurse documented a blood pressure of 67/45, a pulse of 50, and respirations of 10. She called a code, and the boy was intubated in the room. Resuscitation attempts followed. The attending pediatrician was summoned from home. He arrived half an hour later. Unfortunately, the resuscitation attempts were unsuccessful, and the child died.

Later, the results of the blood tests drawn in the ER revealed a severe bacterial infection, which was the cause of the rash, not an allergy to the antibiotic. The parents are suing the hospital and the attending pediatrician for wrongful death. Our client, the attending pediatrician, maintains that he is not at fault because the nurse failed to report the results of the blood tests, and how sick the child actually was. Therefore, the responsibility for the boy’s death rests on the nurse, and as her employer, the hospital.

What I need you to do, Niki, is review the chart, and find indications that the pediatric nurse neglected or did not follow standard practice in her care of this child; anything pointing to our client’s innocence.”

“Wow. Okay Grant. I’ll read through the record, and see what I can find.”

“Thanks Niki. If you need anything, let Claudine know. I’ll see in you in a couple hours. Raquel and I are looking forward to having you stay with us the next couple of days.”

“Me too. Thanks for inviting me, Grant.”

After Grant leaves the room, I settle into the leather chair at the large, polished table of the conference room, a hard copy of the medical record lying on it. Leafing through its pages, I feel queasy at the realization that whatever I find wrong will be used to blame another nurse. I dismiss the thought, however.

“I am a patient advocate,” I remind myself. “By reviewing the medical record, I’m helping a family receive justice.”