NURSES WILL DO IT ALL
Illustration: St. Luke's
A recent Louisiana case demonstrates the problems with both system processes, and individual nursing or medical actions. [Mapes v. State, 336 So3d 494 La App 2022] Donald Mapes was a correctional center inmate transferred to a hospital for kidney stones. Hospital physicians ordered a complete blood count which indicated that his platelet count was 25. The hospital’s protocol for critical lab values was for the lab to call the nurse, and then the nurse to verbally inform the doctor. Let’s start here.
Why does the lab need to call a nurse for the nurse to advise the doctor about the results? Why doesn’t the lab call the physician directly? Shouldn’t the person who ordered the diagnostic be the one the results are reported to? Does the hospital think nurses have more free time than the lab or the doctors that they can just act as middlemen in this process? And doesn’t adding another communication layer make the process more error-prone?
In this case, the lab notified the nurse of the platelet count at about 5:20 pm. Mapes was transferred back to the correctional facility about 12 hours later. His condition deteriorated and he was sent to another hospital where he was diagnosed with a fatal intracerebral hemorrhage. Subsequent CBCs there demonstrated a further platelet drop to levels of 8 and 9. He died the following day. There was no documentation that the nurse had notified the physician of the dangerous platelet count.
The family filed a complaint before the Medical Review Panel (MRP) alleging malpractice in transferring him, and in failing to properly assess, diagnose, and monitor him. The case was brought against the initial hospital, its physician staff, and the correctional facility. The MRP found that, although the nurse breached the standard of care in failing to notify the doctor, it was unlikely that such a verbal report would have changed the outcome. As for the physician, the MRP found that he was not aware of the low platelet count at the time he discharged Mapes. This was a breach on the doctor’s part, in not checking lab results before returning him to the correctional facility, and in not repeating the CBC. As with the nurse’s breach, however, the MRP did not think his having done so would have changed the outcome.
All the defendants moved to have the case dismissed, arguing that the plaintiffs would not be able to prove that the departures were the proximate cause of his death. The court granted this for the hospital (& therefore the nurse) but not for the physician or the correctional facility. The plaintiffs appealed the dismissal as to the hospital. The appellate court believed the verbal report might indeed have changed the outcome, as could have repeating the CBC. It reversed the dismissal and sent the case back for trial.
The lessons learned? Documentation of communications with other providers is critical in demonstrating that nurses are following protocols and providing acceptable care. More importantly, in my opinion, the critical level reporting protocol should be streamlined. Nurses should not be put in the middle of this process, any more than they should be entering orders into a computer for a physician. The provider who orders diagnostics should be the one responsible for obtaining the results and acting on them.
Nurses have enough of their own work to do and are stretched to the breaking point as is. The ubiquitous availability problem must be addressed. If housekeeping is not available, nurses will clean the spill. If unit clerks are not available, nurses will answer the phones. If nursing attendants are not available, nurses will perform their tasks, as well as their own. If critical lab results are found, the nurse will act as an intermediary and take responsibility for the physician being notified. This must stop. Nurses should not be expected to do anything other than NURSING.
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