Communication Failure Between Pulmonologist, Nurses Leads to Malpractice Claim

Communication issues are the root cause of many medical malpractice cases. Properly relaying vital information is key to treating patients and to staying out of legal trouble. This includes communication between providers as well as communication with patients.

In this case we look at how the failure of a pulmonologist to communicate with nurses resulted in a bad outcome for the patient.

Case Facts

The patient, Ms W, was a 33-year-old woman who arrived at the emergency department (ED) with complaints of dysphagia, shortness of breath, and facial swelling. Clinicians in the ED ordered a computed tomography (CT) scan, the results of which revealed that the patient had superior vena cava syndrome.

Ms W was admitted to the hospital by Dr P, a pulmonologist who was employed by the hospital. She then underwent a percutaneous transluminal angioplasty, which was performed by an interventional radiologist. The procedure itself was successful; however, upon removal of the sheath, the patient’s blood pressure dropped drastically from 161/90 to 81/50. Ms W began suffering from seizures and then became unresponsive. A code was called, and the clinicians frantically rushed to resuscitate the patient, which they were able to do successfully.

After Ms W was resuscitated, Dr P ordered that she be transferred to the intensive care unit (ICU), where she remained hypotensive.

After having transferred Ms W to the ICU, Dr P assumed all was stable, and went home for the night. He did not personally evaluate the patient prior to leaving, and he did not give specific instructions to the nursing staff regarding the patient, or alert them to Ms W’s particular circumstances.

During the night, Ms W’s condition deteriorated. As the night progressed, no urine output was noted, and the patient seemed confused and drowsy. The nursing staff, not having been apprised of the significance of Ms W’s low blood pressure, failed to contact Dr P until the patient had blood pressure in the 60s, no verbal response, and pulseless electrical activity. By the time Dr P made it to the hospital, the patient had died. 

Months later, Dr P was notified that he and the nurses who were on duty that night were being sued by Ms W’s family.

Legal Background

Dr P contacted the defense attorney provided by his medical malpractice insurance. The attorney retained the services of medical experts to review the patient’s chart and other documentation, in order to determine whether Dr P had maintained the requisite standard of care.

After reviewing the records, the experts reported back to the defense attorney that they found the pulmonologist’s treatment lacking. In particular, the experts questioned why Dr P failed to communicate more clearly with the nurses about the patient’s status. (The experts also faulted the nurses for not responding faster to the patient’s deteriorating condition overnight, and for not contacting Dr P sooner.) The experts concluded that Dr P had failed to appreciate the significance of Ms W’s severely low blood pressure and seizures and had failed to properly communicate the unstable condition of the patient to the nursing staff.

Meanwhile, the legal discovery process was taking place in the case. Discovery is the means by which parties exchange information that may be helpful to prove claims or defenses in the case. Discovery allows the parties to get a preview of what will be presented at trial. Aside from just turning over documents or records, oral testimony in the form of depositions often takes place. These depositions are taken under oath, and the information can be used at trial. Depositions give both parties an advance look at the evidence to be presented, and deposition evidence can be used in cases where witnesses can’t appear at trial. Depositions are particularly important as a tool to discredit testimony at trial that differs from what was stated in a deposition.

While the discovery process was happening, settlement negotiations were also taking place, as is often the case. After Dr P’s attorney had the medical records and discovery materials reviewed by the medical experts, the attorney advised Dr P that settling the case was probably the best option. After several settlement conferences, the case was settled out of court for an undisclosed sum covered by Dr P’s insurance.

Settling out of court is extremely common. In fact, going to trial is actually the rarity. Despite how it appears on television, few medical malpractice cases go to trial; most are dismissed early in the process or settled. When cases do go to trial, evidence shows that physicians usually prevail. But the high costs of a trial, both in terms of mental stress and money, often makes settling an appealing and better option.

Protecting Yourself

Clear, open, and complete communication between providers is essential in providing optimal care. This is especially true in a case such as this one, where a provider (in this case, Dr P) has vital information about the patient that needs to be conveyed to other providers (in this case, the nurses), who subsequently become responsible for monitoring the patient.

Although we can’t know what was going on in Dr P’s mind, it appears that he dropped the ball when it came to evaluating the patient before he left the hospital and conveying her status (including that she had coded and suffered seizures) to the nurses who would be caring for her overnight. Because the nurses were not apprised of this information, they were not alert for signs that Ms W was crashing, and they waited too long to alert Dr P. Had he properly conveyed the patient’s status to the nurses, they would have known to alert him as soon as her blood pressure began dropping further.

The lesson here: do not forget the importance of communication when you are practicing. Furthermore, it’s essential to not just have a conversation with other providers, but to document that the conversation took place so that there will be no questions later on.

So, what should Dr P have done?

1. He should have personally evaluated the patient prior to sending her to the ICU so he would have the latest information about her condition and would best be able to convey that information to whoever would be caring for her overnight.
2. Before he left for the night, he should have conveyed the information that he knew about the patient, and any he gained via the evaluation, to the nurses who would be tending to the patient so they would be aware and alert for problems overnight.
3. He should have documented in writing in the patient’s chart the information that he conveyed to the nurses, so that anyone caring for the patient would have that information and so that there would never be any questions about whether the information was actually conveyed.