Those of you who are nurse practitioners and either work in your own clinic or in a physician’s office often get calls during afterhours concerning an ill client of the clinic/office. Unfortunately, sometimes such a call results in the death of the patient when the underlying problem prompting the call is not identified.
In one after hour’s call to a physician’s office at 8:00 p.m., a father reported that his nine-year-old son was not well and had been feeling ill for about three days. The on-call nurse practitioner listened as the father described his son’s symptoms: nausea, vomiting, little oral intake, lethargy, and weakness. The father also told the nurse practitioner that his son was sleeping a lot, was able to drink some ginger ale, and did feel better than the day before, but the young boy also had some rectal bleeding and some bleeding from the mouth. 1
The nurse practitioner believed that most of the symptoms sounded like the flu but was concerned about the rectal bleeding. She triaged for additional patient symptoms with the father: alertness?, able to urinate?, did the boy have a fever or a rash? (the only “no” response was to the presence of a rash).
The nurse practitioner then asked if the father thought his son should be seen right away in the ED or would he be “O.K” during the night. The father replied he thought his son would be OK until the next morning but was concerned that he hadn’t eaten any food. 2 The nurse practitioner told the father to “push the ginger ale and make sure he is urinating periodically” and to call if anything changed. 3
At about 4:00 a.m. the next morning, the father checked on his son and noticed his breathing had increased. At 8:30 a.m., he checked again and his son was not breathing. 911 was called and the father started CPR. When the paramedics arrived, they found the nine-year-old apneic, pulseless, pupils fixed and dilated, and his corneas cloudy. The boy was pronounced dead at 9:30 a.m. 4
An autopsy revealed the cause of death as diabetic ketoacidosis. The young boy had undiagnosed diabetes mellitus. His blood sugar at death was 1,165 and his HgA1C was 15.3%.
The parents sued the nurse practitioner alleging her negligence lead to their son’s death because of the delay in the diagnosis and treatment of his diabetic ketoacidosis. The wrongful death case was settled against the nurse practitioner for a “high amount” of money. 5
This case is a tragic one and the young boy’s death could possibly have been averted. Although it is true that the boy had symptoms for three days prior to the father’s call to the physician’s office, it was the duty of the nurse practitioner to carefully assess the symptoms she was told existed at the time of the call. Although difficult to do over the phone, it appears this nurse practitioner did not evaluate the boy’s symptoms as she should have. 6
Second, when a nurse practitioner, based on her assessment and clinical judgment, is concerned about the symptoms being experienced, it is always safer to have the patient seen in the office immediately or to have the patient go directly to an ED rather than “wait” and see how things are in the morning, despite a family member’s comment that a family member should be fine during the night. A nurse practitioner’s instructions that the patient be seen right away must be clear, must be emphasized, and must be documented in the patient record. 7
Telephone triage is not easy under most circumstances. Even so, a nurse practitioner must adhere to applicable standards of care in the role of an advanced practice nurse.8 Accountability for not doing so rests on his or her shoulders.
- Debbie LaValley, (2012), “Boy Dies After Call To NP For Flu Symptoms”, 1. Available at: https://www.rmf.harvard.edu/Clinician-Resources/Case-Study/2012/Boy-9-Dies-After-Offhours-Call-To-NP-For-Flu-Symptoms . Accessed February 9, 2014.
- Id., at 2
- Id., at 2, 3.
- American Association of Nurse Practitioners (2013). Standards of Practice For Nurse Practitioners. Available at https://www.aano.org/.
(Point the clicker on Publications, then click on the Position Statements and Papers from the drop-down menu). (Accessed February 9, 2014).
THIS BULLETIN IS FOR EDUCATIONAL PURPOSES ONLY AND IS NOT TO BE TAKEN AS SPECIFIC LEGAL OR OTHER ADVICE BY THE READER. IF LEGAL OR OTHER ADVICE IS NEEDED, THE READER IS ENCOURAGED TO SEEK ADVICE FROM A COMPETENT PROFESSIONAL.
February 2014 Avoiding Liability Bulletin