NRSG 669
WEEK 7: Legal Case Study
Nurse Practitioners Medical Malpractice Case Study with Risk Management Strategies
Case Study: Failure to identify and address concerns or questions regarding patient care; failure
to complete documentation in a timely manner; failure to act as the patient’s advocate; failure to
maintain 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 $230,000
Summary
The pediatric patient was a 12-year-old male brought into a walk-in clinic by his parents shortly
after falling and lacerating his knee. The patient sustained a six centimeter elliptical laceration
above his right knee. The patient was examined by the nurse practitioner who documented a
normal physical examination, except for evidence of a six centimeter elliptical laceration. The
nurse practitioner cleansed the site with Betadine, anesthetized the area and sutured the wound
using nylon sutures.
The patient was discharged with a prescription for acetaminophen with codeine and a
prescription for augmentin, although the healthcare information record stated he was allergic to
penicillin. The nurse practitioner did not counsel the parents on dressing or wound care at
discharge, 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 noticed
that a skin rash was resulting. Later, she testified in her deposition that she neither called the
walk-in clinic nor the nurse practitioner about a new antibiotic for the child. Two days after the
fall, he was admitted to the local hospital with a diagnosis of cellulitis, possibly due to
methicillin resistant staphlococcus aureus (MRSA) and was given intravenous antibiotics.
Three days after the fall, his right extremity appeared edematous, slightly discolored and he
complained of pain with movement. He was taken to surgery with a diagnosis
of an abscess of the right thigh. During the operation, the sutures were removed with
serosanguinous drainage noted. The tissue surrounding the wound appeared gray and
discolored. Four days after the fall, his extremity appeared completely
discolored, severely edematous, and he had very limited movement. He was taken back to
surgery for a reexploration, further debridement and insertion of a central
venous catheter. After the re-exploration, the patient was transferred to a children’s hospital
several miles away via helicopter for further treatment and observation.

While in the children’s hospital, the patient underwent multiple fasciotomies and surgeries to
repair and re-route muscles, tendons and ligaments to his extremity and sacral area due to the
advancing necrotizing fasciitis. His condition continued to deteriorate, resulting in a comatose
state responding only to painful stimuli. While in this comatose state, he was noted to have
recurrent uncontrolled seizures. The patient slowly recovered. Six weeks after the injury
occurred, 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 with
emotional and intellectual development. The bacterial infection and subsequent treatment
impaired movement with his right leg, requiring several skin graphs
and physical therapy.
Risk Management Comment
There was no documentation on wound irrigations or discharge teaching. When the nurse
practitioner learned of the patient’s hospital admission, she documented a self-serving addendum
to the clinic’s healthcare information record.
None of the defense expert reviewers fully supported the nurse practitioner’s care. It was
determined that she failed to prescribe the appropriate antibiotic, failed to appropriately suture
the 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 testimony
noted that the sutures were too tight, creating an anaerobic environment which contributed to the
growth of the necrotizing fasciitis.
Reprinted with permission from Nurses Service Organization (NSO); 1100 Virginia Drive, Suite
250, Fort Washington, PA 19034-3278, 1-800-247-1500. Failure to identify and address
concerns or questions regarding patient care; failure to complete documentation in a timely
manner; failure to act as the patient’s advocate; failure to maintain clinical competencies; failure

1. Critique the medications prescribed for this child’s condition.
2. Explain what may have been more appropriate to prescribe.
3. Support your answer with evidence-based clinical guidelines and standards of care. Outline the teaching the nurse practitioner should have given to the parents for this child.

answer these questions based on this above case study.

ANSWER

Medication Prescription and Appropriate Alternatives in Pediatric Patient Care

The case study involves a pediatric patient who suffered significant complications following a laceration injury and subsequent infection. The prescribed medications for the patient’s condition, including acetaminophen with codeine and augmentin, raise concerns about the appropriateness of the treatment plan. In light of evidence-based clinical guidelines and standards of care, a critical analysis of the medications and their alternatives is necessary.

Acetaminophen with codeine is often used for pain management in various conditions, including post-operative pain. However, in this case, the patient’s condition deteriorated with signs of an evolving bacterial infection. The mother noted a skin rash after administering one dose of the antibiotic augmentin, which is consistent with an allergic reaction. Given the patient’s documented allergy to penicillin, prescribing augmentin, a penicillin derivative, was contraindicated.

A more appropriate prescription could have been a non-penicillin antibiotic such as a second-generation cephalosporin, which is effective against a wide range of skin infections and cellulitis. In line with evidence-based guidelines, choosing an antibiotic that does not cross-react with penicillin allergies is essential to prevent adverse reactions.

Furthermore, it is evident that the nurse practitioner failed to provide comprehensive discharge teaching to the parents. The teaching should have included proper wound care instructions and signs of infection to watch for at home. This would have empowered the parents to monitor the wound site, recognize signs of worsening infection, and seek prompt medical attention. Additionally, the importance of adhering to prescribed antibiotics and seeking medical advice if any adverse reactions occur should have been emphasized.

In conclusion, the case study highlights the critical need for precise medication prescription and comprehensive patient education. Evidence-based clinical guidelines and standards of care should be followed to ensure appropriate treatment choices, considering factors such as allergies and potential adverse reactions. Effective discharge teaching empowers parents to actively participate in their child’s care, promoting early detection of complications and timely interventions.