Reference no: EM133528203

Case Study: Nurse Practitioners Medical Malpractice Case Study with Risk Management StrategiesCase Study: Failure to identify and address concerns or questions regarding patient care; failureto complete documentation in a timely manner; failure to act as the patient's advocate; failure tomaintain clinical competencies; failure to follow the standard of care.This case study involves a licensed nurse practitioner working in a walk-in clinic.Indemnity Settlement Payment: Policy limits.(Monetary amounts represent only the payment made on behalf of the insured nurse practitioner)Legal Expenses: In excess of $230,000SummaryThe pediatric patient was a 12-year-old male brought into a walk-in clinic by his parents shortlyafter falling and lacerating his knee. The patient sustained a six centimeter elliptical lacerationabove his right knee. The patient was examined by the nurse practitioner who documented anormal physical examination, except for evidence of a six centimeter elliptical laceration. Thenurse practitioner cleansed the site with Betadine, anesthetized the area and sutured the woundusing nylon sutures.The patient was discharged with a prescription for acetaminophen with codeine and aprescription for augmentin, although the healthcare information record stated he was allergic topenicillin. The nurse practitioner did not counsel the parents on dressing or wound care atdischarge, but communicated to follow up in 7-10 days for suture removal.The mother filled the antibiotic prescription, but only gave the child one dose after she noticedthat a skin rash was resulting. Later, she testified in her deposition that she neither called thewalk-in clinic nor the nurse practitioner about a new antibiotic for the child. Two days after thefall, he was admitted to the local hospital with a diagnosis of cellulitis, possibly due tomethicillin resistant staphlococcus aureus (MRSA) and was given intravenous antibiotics.Three days after the fall, his right extremity appeared edematous, slightly discolored and hecomplained of pain with movement. He was taken to surgery with a diagnosisof an abscess of the right thigh. During the operation, the sutures were removed withserosanguinous drainage noted. The tissue surrounding the wound appeared gray anddiscolored. Four days after the fall, his extremity appeared completelydiscolored, severely edematous, and he had very limited movement. He was taken back tosurgery for a reexploration, further debridement and insertion of a centralvenous catheter. After the re-exploration, the patient was transferred to a children's hospitalseveral miles away via helicopter for further treatment and observation.

While in the children's hospital, the patient underwent multiple fasciotomies and surgeries torepair and re-route muscles, tendons and ligaments to his extremity and sacral area due to theadvancing necrotizing fasciitis. His condition continued to deteriorate, resulting in a comatosestate responding only to painful stimuli. While in this comatose state, he was noted to haverecurrent uncontrolled seizures. The patient slowly recovered. Six weeks after the injuryoccurred, he was discharged from the hospital with home health and wound care services.Following discharge, the child had to re-learn simple activities of daily living, e.g.,walking,running and bathing. Due to the seizures and coma, the child has encountered problems withemotional and intellectual development. The bacterial infection and subsequent treatmentimpaired movement with his right leg, requiring several skin graphsand physical therapy.Risk Management CommentThere was no documentation on wound irrigations or discharge teaching. When the nursepractitioner learned of the patient's hospital admission, she documented a self-serving addendumto the clinic's healthcare information record.None of the defense expert reviewers fully supported the nurse practitioner's care. It wasdetermined that she failed to prescribe the appropriate antibiotic, failed to appropriately suturethe wound and failed to irrigate the wound as standard protocol would require.Experts were also critical of the suturing technique that the defendant used. Their testimonynoted that the sutures were too tight, creating an anaerobic environment which contributed to thegrowth of the necrotizing fasciitis.Reprinted with permission from Nurses Service Organization (NSO); 1100 Virginia Drive, Suite250, Fort Washington, PA 19034-3278, 1-800-247-1500. Failure to identify and addressconcerns or questions regarding patient care; failure to complete documentation in a timelymanner; failure to act as the patient's advocate; failure to maintain clinical competencies; failure

Questions:

1. Identify health history (subjective) and physical examination (objective) information for this patient.
2. Critique the medications prescribed for this child's condition.
3. Explain what may have been more appropriate to prescribe.
4. Support your answer with evidence-based clinical guidelines and standards of care.