System Failures and Medical Malpractice – Imagine:

• A critical care manager accepting a supposedly experienced nurse’s description of her experience and knowledge base gained out an out of state hospital.
• A critical care manager that supports nurses thinking that they do not need close observation while being precepted.
• A hospital that has, on staff, surgeons that are only present for the surgeries they perform and morning rounds; and these surgeons are not easily accessible, even by telephone, at other times when emergencies arise.
• A hospital where patients can come out of the OR without dressing over lines inserted into major vessels.
• A hospital that hires someone into a managerial position in a CVICU (Cardiovascular ICU) that has absolutely no heart or open heart surgery experience.

Now Imagine How the Following Patient Care Scenario Could Occur in the Above Setting:

• A critically ill patient comes to your unit for coronary artery bypass surgery after having this procedure refused to be performed by three other surgeons.
• This patient gets “tuned up” in the CVICU prior to surgery and goes to the OR with an IABP (intra-aortic balloon pump) in place.
• Upon arrival to the CVICU after surgery the admitting nurse, when pulling back the covers to assess the patient, finds the IABP site without a dressing and covered in bloody drainage. The admitting nurse at that time actually mentions that the chance of this patient dying of sepsis within a 2 week period are inordinately high.
• This patient shows signs of sepsis in less than 24 hours.
• A nurse cares for this patient a couple of nights later that is being precepted. She resents any input from her preceptor.  The preceptor, who was also in charge, has to leave the unit to help someone transport a patient to CT scan.  While coming back to the unit her phone rings and she is told her preceptee’s patient is coding.
• This nurse runs into the unit to find CPR being performed on this relatively fresh post-op open heart patient that has a temporary pacemaker attached to wires inserted to the surface of the heart.   
• This nurse tells the nurse she is Precepting to turn the temporary pacemaker on and to hold compressions. Unfortunately this nurse that supposedly had experience caring for open heart patients did not only not realize that the first thing she should have done was turn the pacemaker on, but she did not know how to unlock the pacemaker in order to access the device.
• The preceptor goes to the pacemaker, unlocks it, turns it on, and the patients’ heart rate and blood pressure immediately come back up to an acceptable range.
• A couple of days later the patient is continuing to deteriorate and is in renal failure and significantly fluid overloaded. It is during the day and the patients’ nurse pages the attending.  Unfortunately they were never able to get a return call from the attending because they were busy operating at another facility.  The heart failure team, who was not involved in this patient’s care at all, did step up and attempt to assist the nurse with her deteriorating patient.  Unfortunately his condition was becoming much more critical and he now had liver involvement and his coagulation studies were elevated and they were unable to insert a vascath to allow for dialysis to be performed.
• This patient expired on the 10^th day of his hospitalization, and approximately one week after surgery.  

Would this patient have survived even with none of these situations occurring?  He was a very high risk candidate for this surgery. 

Is this a case that could have been litigated?  How does one review a medical record and find the type of things that occurred here and (I believe) significantly lowered his chance of survival?

This is a real patient care scenario.  I loved working as a bedside nurse.  I imagined when I retired that I would go back and work a prn position.  I worked 9 straight 12 hour shifts to either care for or direct the care of this patient.  My 10^th shift was cancelled.  What occurred with this patient had a profound effect on me and was a big part of why I made arrangements to retire a week later.