As a Professional Legal Nurse Consultant, you’re reviewing lots of medical records. The same issues seem to be popping up. Think in the back of your mind “I should be looking for these three negligence issues“:
Three Most Common Nursing Malpractice Issues:
1. Communication problems: Whether you see lack of communication, or the opposite — too much but no substance to it, often the key to pursuing or defending a case lies in this one issue alone: COMMUNICATION. Sad, but often true, you need to be looking for communication breakdown. Sometimes, in your Professional Legal Nurse Consultant review, you’ll see little, if any, communication. As they say, “the right hand doesn’t know what the left hand is doing”, is not an excuse. So, be vigilant in your legal nurse consulting review and look for areas where there was either good or not so good communication among the nurses as well as between the nurses and the other health care providers.
2. Lack of interventions: First, the nurse must assess the patient. So, check out the nursing assessment forms for completeness. If you can’t get a thorough understanding of the condition of the patient at the time of the nursing assessment, this is a red flag. Next, go to the interventions. In your Professional Legal Nurse Consultant opinion, are they appropriate, timely, performed as described, and documented? While just because it wasn’t documented doesn’t mean it wasn’t done, there is a strong presumption it wasn’t. What makes you, the reviewing nurse expert, believe or disbelieve the nursing charting? As nurses, we are blessed with nursing judgment. Now’s the time to use it.
3. Medication errors: We, as nurses, administer lots of medications. It’s no surprise that there’s room for error, but that’s not an excuse. Remember the expression “Measure twice, cut once” when sewing or building? This means nurses need to double check themselves before giving a medication to be sure it’s right. Just like they taught us in nursing school. Sure, it could have come up from the pharmacy wrong, maybe it was written by the prescriber wrong, but who had the last clear chance to make it right? Professional Legal Nurse Consultants need to thoroughly review the Medication Administration Record and corresponding Nurses Notes. These two sections of the medical records alone can be a gold mine of information!
Keep these three common nursing malpractice issues in mind when, as the Professional Legal Nurse Consultant, you’re reviewing any medical record.
Next blog post we’ll examine the nursing practice areas where there’s the greatest likelihood of nursing malpractice. Stay tuned.
