Hypothetical

Patient has a serious heart condition that requires surgery. It is a serious surgery, but one with a high survival rate. He researches local surgeons and hospitals. He is impressed by advertisements by Big University Hospital, touting its U.S. News and World Report ranking as the best hospital in the region, one of the best in the State of Florida, and nationally rated in cardiothoracic surgery. Patient chooses to have the surgery performed at Big University Hospital by cardiothoracic surgeon Dr. Cooper.

What Patient doesn't know is that the cardiac ICU at Big University Hospital is a troubled unit. The nurses and nurse practitioners have learned over time that they cannot bring any patient concerns to Dr. Cooper. He will tell them to fix the issue and then get back to him. As a result, they simply don't bring concerns to his attention at all. Big University Hospital leadership is aware of this issue, but they tolerate it because Dr. Cooper is a superstar who brings prestige to the hospital and lots of patients - which means lots of revenue.

Patient's surgery is performed by Dr. Cooper successfully. Patient goes to the cardiac ICU for post-operative recovery.

As it happens, it is a holiday weekend. Dr. Cooper has vacation plans. He makes an arrangement with another surgeon, who is new to the group, to cover his patients while he is gone. Assume this is a standard practice that comports with the standard of care, and was done appropriately.

While in the cardiac ICU, Patient's condition starts to deteriorate. The nurse responsible for his care notices this, and brings it to the attention of a nurse practitioner. The nurse practitioner does not see the patient, but relies on the nurse's report. The chart shows that the nurse practitioner enters treatment orders.

The orders briefly help the patient, but then the deterioration continues. This process repeats a few times. The nurse updates the nurse practitioner on the patient's condition, the nurse practitioner does not see the patient, and the chart shows that the nurse practitioner enters treatment orders. Each time, the nurse documents the chart the same way: "Nurse practitioner aware." Assume that these treatment orders do not represent the standard of care for treating the patient given his pattern of brief improvement and then return to deterioration.

The nurse does not access the hospital's chain of command. No charge nurse is advised of the situation. No physician is contacted - neither Dr. Cooper nor the covering surgeon. The nurse practitioner never sees the patient personally.

Eventually Patient goes into shock. He ultimately dies.

Patient's surviving spouse hires counsel, who investigates and concludes that Patient's death was preventable and was the result of medical malpractice. They send a Notice of Intent to Big University Hospital.

The hospital gets its counsel involved. Counsel investigates during the pre-suit investigation period. Counsel interviews the nurse and the nurse practitioner who were responsible for Patient's care.

The interview with the nurse reveals that:

• She disagreed with the nurse practitioner's treatment orders
• Her documentation of "nurse practitioner aware" was her way of communicating her disagreement
• She did not go to the surgeons because "that's just not how it works on this unit"

The interview with the nurse practitioner, on the other hand, reveals that:

• She felt the nurse did not adequately explain what was going on with the patient
• If she had known the patient's true condition, she would have intervened in a major way
• She did not order the orders attributed to her in the chart
• She thinks the nurse went "rogue," entering her own orders - and says that happens often in this unit

Answer the Following Questions:

1. You are the Director of Risk Management at Big University Hospital. Your counsel reports all of the above to you. What risks to the organization can you identify from the information you have received? What would your plan of action be for addressing those risks and fixing the situation?
2. You are the Director of Patient Safety at Big University Hospital. The Director of Risk Management brings you up to speed on all of the above. Please outline your plan for addressing the deficiencies in the care of Patient and the dysfunction in the cardiac ICU. Based on the concepts you have learned to date in this course, what would you focus on and how would you recommend fixing the situation?
3. Should an incident report be completed regarding this situation? Explain why, or why not.
4. If an incident report is completed, would Patient's attorney be entitled to receive a copy? Why, or why not?
5. Does this incident qualify as a Sentinel Event for Joint Commission purposes? Why, or why not?
6. Must this incident be reported to the Agency for Healthcare Administration of the State of Florida? Why, or why not?