1. Based on my administrative and regulatory compliance experience I was able to play an important role in substantiating major deficiencies in the quality of care at the defendant hospital.
2. I learned some very important lessons about managing my CLNC^® practice effectively, particularly in cases involving two law firms.

	On the floor post-surgery the patient had a PCA MS pump. She was not monitored appropriately based on the standards of practice for a patient on a PCA pump. Documentation on the PCA record was totally inadequate and was not co-signed by two nurses. It was impossible to determine how much narcotic the patient received for any period of time.
	The PCA record was overwritten and could not be explained during deposition.
	Reassessments were not done adequately nor interpreted correctly based on nursing standards of practice for a patient on a PCA pump.
	The patient became over-sedated with MS, with the classic symptoms of respiratory depression and obtunding documented in the nurse's notes. However, the physician was not notified and standing orders were not implemented.
	A standing PCA order for Narcan was never carried out because the hospital had a policy that prohibited nurses on this particular floor from administering Narcan without the charge nurse's approval.
	The charge nurse was inexperienced in her role and on the floor. She had been an operating room nurse for 20-plus years, but had only been on the floor for about 6 months. She was, by job description, not qualified to be in a leadership role.
	A code was never called. The ER physician was phoned. Upon his arrival the patient was intubated immediately; her pulse oximeter reading was only 75%.
	The patient was administered two separate doses of Narcan with little to no effect. She was transferred emergently to the ICU where she died three days later.
	This case was never reviewed by risk management or treated as a sentinel event.

The administrative policies in question were:

	The PCA pump in question was not safeguarded after the incident to determine whether there was an equipment failure. Biomedical equipment records did not reflect that the functioning of the pump was even questioned.
	The same level of care was not assured for managing all patients on PCA pumps.
	Appropriate qualifications of charge personnel were not adhered to.
	According to in-service sign-in sheets, the charge nurse was not deemed competent to operate the PCA pump.
	The pharmacy did not conduct routine reconciliation procedures to verify appropriate documentation and usage of narcotics via a PCA pump. They were unaware of the incident.
	The hospital's policy for calling a code specified that a code was only appropriate when a patient actually arrested and did not allow nurses to call a code when they determined a code was imminent.
	Nurses were not made aware of policy changes, and hospital administration instructed the manager of the floor to inform her staff only if a policy changed significantly. The policies were in a computer database, not in hard copy, and were therefore accessible only by computer. Policies could only be pulled up by title. There was no search function to assist in referencing policies.
	Sentinel event processes were not initiated in what clearly matched the definition of a sentinel event.

My CLNC^® and Clinical Expertise Were Key to the Attorney's Confidence

My role was to determine if the hospital could be found grossly negligent because of failure to follow its own policies, failure to ensure competency of the staff and failure to ensure that negative outcomes were evaluated and acted upon to prevent harm to patients. I reviewed most of the records, looking at this case not from a nursing staff point of view but from a global patient care point of view and in light of patient safety in this particular hospital. I strongly felt that all patients receiving medications via a PCA pump were at great risk until the hospital ensured the same level of care and competency of the nursing staff on the issues raised in this case.

I was able to substantiate many of the claims the administrative firm wanted to raise as issues. My knowledge and clinical expertise in these areas of nursing gave my attorney-client the confidence to include the hospital in the suit. This truly was an attention-getter, and the administrative law firm was pleased with my review and corroboration of their views.

Open Communication Got Me Out of a Sticky Spot

I later learned that the med-mal attorney was the lead attorney. He did not give specifics to the administrative firm regarding a time limit and cost limit for this case. As a result, I was in a sticky spot because I was unaware of any limitations and my review of the large volume of records went over the budget. Fortunately, I had good relationships with both attorneys and the paralegals. They assured me that I would get paid and that they would work the issue out.

I took it upon myself to meet with the med-mal attorney to discuss the confusion and possible misdirection I had received. I honestly felt that I was in the middle of a huge communication issue between the two law firms. I told the med-mal attorney that I was not aware he was the lead attorney and that what his co-counsel had assigned to me might not have been what he wanted me to do. I also told him I wanted to make things right and would do extra research at no additional charge if he was not happy with what I presented to him. I really wanted to keep this client.

He was understanding, but he had a few questions. He wanted all the work I had presented to the other firm. I gladly made copies for him. He agreed that if I could develop three points with supporting documentation he would be satisfied: administrative, risk management and JCAHO issues.

I provided him with ample documentation on these three points as requested, and he was very satisfied and appreciative. Attached to my final payment was a note from him saying, "I do appreciate all the hard work and time you put into this case. Thank you."

The case settled on the nursing issues. The administrative issues are still unsettled. A trial date has not yet been set.

I Learned Big Lessons from This Big Case

This case taught me a big lesson. If I ever take on a case involving co-counsel, I will ask more questions up front and make certain I know who is actually calling the shots. I got caught up in an uncomfortable situation that could have been disastrous for the attorneys and for me. I was able to turn the situation around to create a positive outcome for all. By investing a few more hours, I easily found the information the med-mal attorney needed.

That few extra hours of my time was a worthwhile investment. I now have repeat cases from both attorneys, and that is what really matters.

CLNC^®s Save Lives Too

As a result of my involvement in this case, I hope the hospital will put in place the competency programs and policy changes that will help them ensure safe care for patients receiving PCA meds. If this is the only outcome of the suit against the hospital, many patients will receive better and safer care as a result. That would be a monumental accomplishment of which I'd be proud to be a part.

Many people ask me how could I participate in a lawsuit against a hospital or nurses. I tell them I do it for the sake of our patients. I do both defense work and plaintiff work, and I find satisfaction in both. Nurses are charged to be patient advocates. We have all made mistakes in our nursing practices, but when the life of a patient is lost because of issues like those in this case, I am being the best advocate I can be if I facilitate change that will benefit all patients.

Rachel Cartwright, RN, MS, LHRM, CLNC, a CLNC^® Mentor and guest faculty, owns Medical-Legal Concepts in Florida. She specializes in critical care and regulatory compliance.

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