Is `electronic charting' really the answer? Case on point: Breeden v. Anesthesia West, 656 N.W.2d 913 -NE (2003). (Nursing Law Case of the Month).
CASE FACTS: Michael Breeden was admitted to Methodist Hospital in Omaha, Nebraska, for gallbladder surgery on August 14, 1994. During the evening of August 14, Dr. Doug Rennels, an anesthesiologist, conducted a pre anesthetic evaluation of the patient. The examination disclosed, inter alia, no evidence of "peripheral neurological deficits." On the morning of August 16, Nurse Joyce Clark, who was employed by the hospital, again assessed the patient's condition. As a result of this assessment, Nurse Clark made an entry in the patient's electronic chart that the patient was experiencing "TINGLING OF RT LEG, RT SIDE OF BODY TO MID CHEST." This was on file in the hospital's computer system The nurse's entry reflected that she observed the symptoms at 9:50am. At approximately 10:35am, the patient was taken to the pre-operative holding area in order for general anesthesia to be administered. There, the patient's condition was again evaluated by Dr. Wesley Hubka, an anesthesiologist. Subsequently, Dr. Hubka and Jennet Lemonds, a nurse anesthetist, administered general anesthesia to the patient. The operation proceeded, the patient emerged from the operation allegedly suffering permanent brain damage as a result of a TIA. The patient and her spouse brought suit against the anesthesiologists and the hospital as well as the attending physician and nurse anesthetist. After a trial, a jury returned a verdict for all defendants. The plaintiffs' motion for a new trial was denied. The plaintiffs appealed. The defendants crossappealed.
COURT'S OPINION: The Supreme Court of Nebraska reversed the judgment of the lower court and remanded the case to the District Court for a new trial for the plaintiff. However, the court found in favor of the defendants on their cross appeal. It held that the trial court erred by holding that Nurse Clark's statement given in her first deposition was to be considered to the exclusion of the statement given at her second deposition
LEGAL COMMENTARY: Despite the fact that Nurse Clark gave two inconsistent statements, the trial court erred in allowing only her first statement admitted into evidence. It was for the jury to determine which of the two statements was the more credible and be given greater weight. Further, testimony revealed that there were "at least three computers in the pre-operative holding area on which Nurse Clark's nursing notes could have been accessed by Dr. Hubka." However, no one attempted to access them. The plaintiffs expert witness, Dr. Richard Fields, testified that the "tingling" in the patient's right side and right leg may have reflected a TIA and the administration of general anesthesia to a patient suffering a TIA "puts [the patient] at extreme risk.." Editor's Note: The time indicated in the electronic chart showed that Nurse Clark's assessment was done at 9:50 am. When first deposed, she clearly and unequivocally testified that the time was 9:50am. In a subsequent deposition, she testified that her pre-operative assessment "might" have been done "after" the pre-operative assessment. Dr. Hubka and CRNA Lemonds failed to check the patient's chart (This would be the situation whether the chart were in written form or electronic form). Was Nurse Clark testifying accurately that the nursing assessment was done at 9:50 am? Charting, whether written or electronic, is only as good as those who do the charting. Electronic charting may have its advantages. However, accurate charting and truthful testimony are indispensable to quality care!
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|Title Annotation:||a case in Nebraska rules on the use of electronic charting done by a nurse assessing a patient's symptoms of a transient ischemic attack|
|Author:||Tammelleo, A. David|
|Publication:||Nursing Law's Regan Report|
|Date:||Mar 1, 2003|
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