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Risk Management PaperPresented to:Carole L. Mackavey, RN, MSN, FNP-CIn Partial Fulfillment of the Requirements for the CoursesGNRS 5350: Professional Role and Business PrinciplesJune 10, 2013By FNP 6Jaya George, RN, BSN; Beatrice Gyebi, RN, BSN; Amy Harper, RN, BSN;and Romeo Jun Penaflor, RN, BSN ________________________________________________________________________The University of Texas Medical Branch at GalvestonIntroductionIn the health care system, risk management deals with patient safety, quality assurance and patient’s rights. Effective risk management is vital because of patient safety and also because of the high occurrence of malpractice claims, which result in great costs in terms of money, time and personal and professional losses, including damage to reputation. This paper discusses how T.G’s death and the law suit that followed could have been avoided if the pediatrician, the NP and the cardiologist had done things properly.FNP’S options to change outcomesAny adverse event in a practitioner’s medical treatment, especially one with such a devastating outcome, should be analyzed as a risk management case. The purpose of this is not to “blame” anybody, but to assess how to avoid this kind of event from happening again. The goal is to learn from the different perspectives of each of the practitioners. One of the main concerns is that when this child was referred to a cardiac specialist he was given the diagnosis of vasovagal syncope based solely on a history and physical (H & P). There was no EKG or echocardiogram done despite the presence of a murmur. As defined by Dains, the causes of syncope can be difficult to establish because generally the patients, like T.G., are seen after the event has occurred. It is one of the most common causes of fainting which occurs when your body overreacts to certain triggers, such as emotional distress. It can trigger a sudden drop in your heart rate and blood pressure which leads to reduced blood flow to your brain, which results in a brief loss of consciousness. Syncope can be benign and caused by a vagal response or may it indicate a more serious condition. According to Dains et al evidence-based practice, syncope is a common symptom with a range of prognoses. It is recommended that a history, a physical examination and an electrocardiography are crucial to syncope workup (Dain et al, 2012). There were several options that the FNP could have done which could have changed the outcome in T. G.’s case. The office visits the NP had with T. G. were not well documented in terms of lack of differential diagnosis and a complete review of systems. The purpose of developing each differential diagnosis is to allow the NP to explore other potential problems. A follow up visit that was not preceded by a “fainting” event would have been prudent for the NP. Every physician and NP develops a contract that describes their collaboration agreement and the process for how they will see their patients. This agreement should be a dynamic agreement that allows for improvement, such as adding a process to review all “referred out” children together. This would serve as a check and balance for each practitioner and their patients. The goal would be to establish a “blame free” atmosphere to discuss all aspects of each patient that was referred out. This would have given both pediatric practitioners the opportunity to evaluate the cardiologist’s original diagnosis which was based on the H&P and compared it to the suspicious EKG done in their office on January 24, 1989. In addition, the lack of a comprehensive SOAP note did not only open the NP for scrutiny from a medical point of view but also from a legal point of view. Had this system been established, it could have allowed both practitioners to review their patient’s case and re-evaluated T.G’s diagnosis and care despite being seen by two different specialists. Nurse Practitioners can use the risk management process as do other professions to improve on an open “blame free” model so we can analyze and learn from adverse events (Scott-Cawiezell et al 2006). The goal is “prevention” of adverse events and every NP needs to learn how to “manage stress” and adhere to “current guidelines by leaving their personal life stresses at the door of their workplace” to ensure that complete focus remains on the patient, and quality of care is the standard (Masters p 251, 2009). Deficiencies of FNP SOAP notesNurse Practitioners, as primary care providers, are the patient advocate in health care system to provide cost effective care by coordination of available health care services. We work in collaboration with other health care professionals and utilize consultation and referral as appropriate. Quality clinical documentation is an important element contributing to high quality care. The patient care documentation should be clear, consistent, complete and accurate to facilitate communication and continuity of care among physicians and other health care professionals involved. On analysis of the TG’s case, the first SOAP note by the family nurse practitioner is unclear and incomplete for the following reasons;A detailed history of the incident should have been recorded from the persons who witnessed the seizure and also from the school authorities. This being the third incident of fainting, a special attention should have been given to the sequence of this case.Important details such as loss of consciousness and its duration was not short listed in the SOAP note.Objective assessments such as complete set of vital signs and in depth review of systems were incomplete in the soap note.Lack of attention noticed in the plan of care such as lab work, immediate follow up appointments, limitations on sports and safety information.Differential diagnosis list usually in the order of priority was not formulated in the SOAP note.Second SOAP note was more in detail, with in depth review of systems, but the fact that he always experienced the fainting spells during exercise and loses consciousness for about a minute before the seizure activity should have alarmed her to seek a second cardiac consults or immediate admission to a hospital for a holter monitor. The above facts, such as inadequate and incomplete documentation, led to legal problems. Documentation paints a picture of your clinical practice. “Poor documentation portrays a nurse who is inadequate, unprofessional, and incompetent” (Kilmer, 2007). Quality of communication by the FNPWell-developed communication skills are the important component of a high quality delivery of care. The National Organization of Nurse Practitioner Faculty (NONPF), in their (2011) Nurse Practitioner Core Competencies, lists "provides patient-centered care recognizing cultural diversity and the patient or designee as a full partner in decision-making" as one of the competencies listed under Independent Practice competencies. In T.G’s case the nurse practitioner for the most part has established good communication with the patient’s family as well as the pediatrician. Nurse practitioner has used a collaborative approach with the family and pediatrician with each visit. She has discussed the case with the pediatrician and follow-up phone call with parents in a week. Some of the data that could have been documented is family history of any genetic illness and parents’ view about illness. Formulating the main deferential diagnosis and process of ruling out of diagnosis was not depicted in her notes. The cardiologist was completely left out of the loop and he was not involved with the patient care after the third episode. Third strike with the same patient with similar complaint might have led into a possible admission and further evaluation. Close follow up appointments were not made with the patient. Ultimately, as primary care providers, NPs are responsible for all their undiagnosed signs and symptoms and continuity of care. Research has shown that lack of quality and efficient communication lead to errors, frustration and inefficiencies in the delivery of care (McLain, 1988).Importance of formulating relevant differential diagnosisThe pediatrician in TG’s case did the right thing the second time he saw TG by coming up with a list of differential diagnosis:Heart murmur (does not sound pathological),Arrhythmia,Long QT interval, and Idiopathic hypertrophic sub aortic stenosis (IHSS).He realized from the differential diagnosis that the symptoms presented by the patient were beyond his expertise so he decided to refer the patient to a cardiologist. What we do not know, however, is whether the pediatrician knew this cardiologist’s background in terms of skills, subjective experiences, clinical competency, interpersonal skills and professionalism before referring T.G to him. Also we do not know if the cardiologist is specialized in pediatrics.The cardiologist on the other hand did not act competently because he came up with one diagnosis, vasovagal syncope, and stuck to it instead of going through the process of differential diagnosis. This led to a missed diagnosis. Differential diagnosis is a way the clinician determines which one of several diseases may be causing the patient’s symptoms. A differential diagnosis list, therefore, is the list of possible diagnoses usually in order of priority. Before arriving at a final diagnosis it is important to consider all the various possibilities of medical problems that the patient is presenting. After this, the clinician rules in the possibilities and rules out other conditions based on the information at hand. To rule out a diagnosis, the clinician looks for the absence of findings that are frequently seen with a specific condition being present; the absence of a sensitive finding is evidence against the condition being present. To rule in a diagnosis, the clinician looks for the presence of a finding with high specificity; the presence of this finding is strong evidence that the condition is present (Dains, Baumann & Scheibel, 2012) The differential diagnoses become more important especially after the initial clinical investigation because it gives an idea of what tests to order in order to narrow the list or identify the specific disease responsible for the patient’s complaints. Follow up visits to monitor the patients response to treatment are essential for safety reasons. If the patient’s condition does not improve or gets worse the clinician goes back to the differential diagnoses and starts again. Clinicians can be misled since the signs and symptoms of many diseases look alike. For example vasovagal syncope can mimic prolonged QT interval, but carrying out the necessary tests such as tilt-table test, 24 holter monitor, ECG and measuring QT interval would have helped to come up with the right diagnosis. The automated report on the ECG done in the pediatrician’s office showed “left anterior superior? Fascicular block, left axis deviation, heart block” was reported to the cardiologist over the phone. Instead of scheduling an appointment to see the patient earlier, he waited for a whole week to pass by before seeing the patient and did not bother to measure or record the QT interval. The way he handled the consult and his documentation does not show that he gave careful logical thought to T.G.’s case. Locating specialists for consult and following up on consultsIn looking for a specialist for consult in T.G’s case, essential factors are to be considered in order to attain the most optimal medical attention needed for this. Accessibility and affordability is very important since the disorder that the patient is experiencing needs a long term monitoring. Specialists who are members of the group or with professional relationship will also be helpful since it would be easier in terms of communication and record access for follow-up care. An important aspect to be considered also is the ethical values of the referred specialist, someone who is conscientious and cares about the patient. Other points to be considered are insurance, admission privileges, experience and specialization. In choosing a specialist is crucial especially with this patient since TG’s case is unique and these specialists provide a clearer picture to identify the patient’s diagnosis which is not diagnosed by the primary provider. As an FNP assigned to the patient, it is important to retrieve medical history first from both sides of the family and the patient as well. The patient was discovered having grade II heart murmur at 4 years old which has been consistent on assessment until 4 years later which is a possibility of a genetic origin. Also, in addition to the laboratory tests, as a primary provider, it would be best to add complete metabolic panel to check for glucose & electrolytes, urinalysis to check for kidney function, antinuclear antibodies, and erythrocyte sedimentation rate to check for autoimmune disease, and chest x-ray to check the lungs and for cardiomegaly (Derrer 2013). In February 08, 1989, the cardiologist cleared the patient with diagnostic results of normal exercise test and normal echocardiogram. The diagnosis was vasovagal syncope related to hyperventilation. He did not limit the patient from any physical activities and just instructed to watch the patient closely. Apparently, there was no measurement of QT interval done by the cardiologist. There was no follow up visits then after that until September 29, 1989, when the patient hit his head on the pole and fainted. In between that period, the FNP should have discussed the case with the pediatrician and informed the parents regarding the findings of the cardiologist. As the primary care providers, the FNP could have talked to the parents and ask them if they were satisfied with the cardiologist assessment right after the consult. A second opinion can be suggested if there was discontent with the findings. When the patient was brought to the clinic at the time that he hit his head and fainted, the FNP who saw the patient should have been abreast with the situation and made a referral to the neurologist right away, or order a CT head or an MRI. He could have been cognizant that the patient fainted after hitting his head and preventive tests should have been anticipated as possible. The referral to a neurologist for the first time took place the following year, September 27, 1990, when the patient was brought back again to the clinic due to a fainting spell in school accompanied with seizure. It was reported as his fourth fainting spells. After the result of normal EEG and CT head, the neurologist diagnosed the patient with vasovagal episodes due to extreme exertion. There was no follow-up made from the FNP noted after the consult. The FNP could have made a follow up right away after the scheduled EEG and CT head. A suggestion to order an MRI of the brain could have had detected some abnormalities. The FNP could talk to the family as well and extract their view of the neurologist assessment so a second opinion can be done if necessary. In those encounters with the 2 specialist, there was a lack of follow up care and discussion between the FNP and the pediatrician regarding the case. They should have sit down together with the parents in order to plan their next action such as activity limitations and close clinic follow ups. They should have educated parents on how to monitor and detect mental status alteration episodes including frequencies and triggering factors. Medical interventions could have been tried in order to avoid recurrence of the symptoms. Also the FNP could have coordinated with the school nurse in helping observe the patient when doing activities and detect signs and cause of syncope. Conclusion:Looking at the presenting details in this case, it appears that there was lack of in-depth work-up, indicative diagnostic tests and diligent assessment from the healthcare team. Close follow up from the primary care providers’ end was not very much established as well as planning and teachings after every visit from the specialists. There was no effective management and coordination between primary providers and the specialists. Documentation was poor. There was lack of information given to the patient’s family which could have helped to prevent any complications from the patient’s condition. Furthermore, the healthcare team appears negligent in diagnosing this patient and treating him appropriately. Should the problem have been determined promptly, they could have avoided T.G.’s untimely death.References:Dains, J. E., Baumann, L. C., & Scheibel, P. (2012). Advanced health assessment and clinical diagnosis in primary care (4th Ed.). St. Louis, Mo.: Elsevier Mosby. David T. Derrer, MD . Heart Rhythm Society. American Academy of Family Physicians. The Merck Manual. Retrieved from: nhlbi.meetings/sro/references.htm on March 30, 2013 Kilmer, D.M. (2007). Documentation – The nurse’s defense. Pennsylvania Nurse, 62(1), 19, 29.McLain, B. (1988). Collaborative practice: the nurse practitioner's role in its success or failure. Nurse Practitioner.; 13:31–5. 38Masters, K. (2009). Role development in professional nursing practice (2nd Ed.). Jones & Bartlett Publishers, LLC.National Organization of Nurse Practitioner Faculties. Nurse Practitioner Core Competencies. retrieved from , J., Vogelsmeier, A., McKenney, C., Rantz, M., Hicks, L., & Zellmer, D. (2006). Moving from a culture of blame to a culture of safety in the nursing home setting. Nursing Forum Volume 41, No. 3, July-September, 2006. Retrieved on June 8, 2013 ................
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