Attorneys appreciate honesty and objectivity, but more importantly they need honesty and objectivity with their medical-related cases. That’s why it’s important for Certified Legal Nurse Consultants to never hold back their opinions. The attorney is investing time, money and sweat into every case and must understand the good, the bad and the ugly. This is the only way the attorney can make intelligent decisions about whether to take a case or reject it and whether to settle or to go to trial. It doesn’t help for you to sit on the fence about an issue or to suck up to the attorney, only giving information that agrees with the attorney’s own opinion, especially if it’s a case that he’s convinced himself is a winner.

I used to joke with one attorney-client that he was getting my opinion – warts and all! He loved it and he often turned away cases that were marginal because I called it the way I saw it. My job wasn’t to shade a poor position as favorable. Have I always been right in the stands that I’ve taken? Probably not, but I’d rather be proven wrong in our favor than proven wrong by the other party.

When you’re providing a screening opinion or writing a CLNC^® report, remember that honesty and objectivity aren’t just the best policy – they’re the only policy.

Success Is Inside!

Certified Legal Nurse Consultants get paid big bucks. To get paid those big bucks, we have to get off the fence and take a stand, even if that means not always being right. Every successful CLNC^® consultant has had that cliff-hanging moment of doubt. Here’s what one Certified Legal Nurse Consultant, Dale Barnes, learned from one of those experiences.

“Early in my CLNC^® career I researched a case and concluded it was meritorious. Well into the case, what I thought was impossible occurred. The plaintiff started to improve, and the damages started to disappear before our eyes. The case was not as tragic and not quite as “slam dunk” as I had led my attorney-client (and myself) to believe.

Once I overcame my embarrassment, I immediately confronted the issue and was honest with the attorney. He was obviously not happy. Based on my opinion, he had put a lot of his own money into the case. I told him that I had not foreseen a recovery and that I would assist him in developing a new strategy. We altered our strategy for damages by focusing strictly on the losses during the shorter time the plaintiff had been affected. The attorney canceled the life care planner and scaled down our demands. This strategy worked and the case was resolved.

This case taught me to peel away many more layers before formulating a definitive opinion on merit and outcome. I learned to confer with my colleagues and with experts and to research every possible foreseeable outcome extensively.

My attorney-client shared that because I was honest with him about what I should have done differently and because I tried to help him resolve the dilemma, he was able to trust me and to this day we still work together.”

Dale Barnes, RN, MSN, CLNC

Like Dale, go ahead and take a stand. Like her, you won’t always be right. The moment you identify that you’re having a cliff-hanger moment, notify your attorney-client and determine how you will prevent it the next time. The only thing wrong with mistakes is not admitting it or not taking corrective action to prevent the next one. Remember, the person who doesn’t make mistakes often doesn’t make anything. While you don’t want to embody the phrase “often wrong but never in doubt,” you do want to be willing to take that stand based on the information you have. Like Dale’s attorney-client, you’ll end up with a better relationship afterwards.

Success Is Inside (the guardrails)!

P.S. Comment and share how you’ve realized success from a mistake you’ve made in your CLNC^® business.

Screening medical-related cases is one of the most important legal nurse consulting services you will provide as a Certified Legal Nurse Consultant. Not only is it one of my favorite CLNC^® services but it is the first CLNC^® service you usually provide for new attorney-clients. Do it well and the attorneys keep coming back for more. Here are 16 screening strategies to keep your attorney-clients coming.

Stay Focused on the Essentials

1. Give the attorney an objective, candid and honest opinion without regard for what you think the attorney wants to hear. Put aside interests in personal gain (e.g., more billable hours) and focus only on what is ultimately best for the attorney, the client and the case.
2. Discuss the issues and theme of the case with the attorney-client and ascertain the date of the incident (when known) to help you focus quickly on the important events. If the case has been filed, request a copy of the complaint or petition. You will screen many cases in which the attorney knows little about the facts and has formed no opinion. If the attorney does have an opinion and you believe he is focusing on the wrong issues or your opinion is different, be sure to communicate your reasoning right away.
3. If you do not have time to do the screening as soon as you receive the case, at least read the cover letter and scan the medical records. This helps you to establish deadlines, determine the basic issues of the case and assure you have all the necessary records. If relevant records are missing, inform your attorney-client immediately.
4. Scan all relevant medical records and, where appropriate, note important observations and opinions. Avoid excessive writing at the screening stage, especially if you haven’t yet identified the essential issues and themes of the case. Your goal at the screening stage is to be efficient, and until you’ve reviewed all relevant records and identified key issues, it is very easy to go down unnecessary rabbit trails.
5. Use the screening form to track all possible defendants, types of experts needed, additional documents needed and recommended research. When you give your screening opinion to the attorney, you can incorporate some of these into recommendations for the next indicated steps.
6. Screening a case is similar to reading a mystery novel. You may even be surprised by the outcome because the focus may shift from something obvious, like a patient fall, to a less obvious issue, such as medication administration or safety policies and procedures. As new and more relevant issues arise, determine their significance and how they impact the essence of the case.
7. Do not overlook the obvious by overanalyzing the records. Likewise do not assume that the issues will automatically jump out at you. If you become overwhelmed by the task at hand or the volume of medical records, walk away for a while, or a day or two, then come back fresh and start again.
8. Do not assume the case has no merit simply because a physician reviewed the records and found no merit. Physicians tend to limit their reviews to doctors’ records and in so doing, they often miss vital information. For example, many MD experts do not review the nursing records and often it’s the nursing notes that shed the most light on what really happened to the patient. Always review the records completely and look for discrepancies in documentation by different providers.
9. If you were hired by the plaintiff attorney, look at the case from the defendant’s viewpoint. (What are the defenses or rationales in this case?) If you were hired by the defense attorney, look at the case from the plaintiff’s viewpoint. (What went wrong, if anything? Could anything have been done differently? Were any standards of care or practice guidelines breached?)

Efficiency Saves You Time and Saves Your Client Money

10. Don’t organize the medical records before you screen and you will save valuable time in the initial review process. If organizing the records is necessary before screening, do not organize them for comprehensive review and analysis, but organize only with the objective of making screening easier.
11. Do not do a formal report during the screening stage – just complete the screening form to facilitate communicating your opinion clearly and concisely. More comprehensive reports are only indicated once you have communicated your screening opinion and both you and the attorney agree that a comprehensive review and analysis of the medical records is indicated.
12. Access relevant healthcare references as needed while you are reviewing but don’t overdo it at this stage. Unless you need some piece of information before you can move on, make a list of topics to search on the Internet and do all your searching at once. This will keep you focused as you read through the record. Narrow your searches to match the factors in your particular case (e.g., octogenarian, female, femur fracture, mortality). Be sure to research any articles and publications authored by all the relevant players in the case.
13. Consider subcontracting the screening if the issues are outside your area of expertise. Make the decision to subcontract quickly, then act on it. Don’t wait until you need a CLNC^® subcontractor to try to find one. Develop a pool of CLNC^® subcontractors who are ready to respond to your needs. All successful CLNC^® consultants know what they don’t know and wisely tap the expertise of their peers.
14. Use a magnifying glass (buy the best one you can afford) so you can read those little squiggles and impress the attorney with your knowledge of hieroglyphics. You may determine the outcome of the case by being able to decipher something illegible to the average eye.
15. Keep a calendar of the year in question close by. Look for weekends and holidays when short staffing is common.
16. Pay particular attention when operative notes, admission history and physicals, discharge summaries and autopsy reports are dictated and transcribed. If an unusually long period of time elapsed between the event and the transcription, note that for future consideration.

Use these 16 strategies to make screening medical-related cases one of your most popular and satisfying CLNC^® services. Keep your attorney-clients coming back for more.

Success Is Inside!

Really, I mean that. Tom says that being around so many nurses has taught him one thing (well, two if you count never turn your back on a proctologist). Hospitals are great places to visit loved ones when you’re well, but they’re a horrible place to be when you’re sick. Studies have shown the longer you’re in a hospital recovering, the more likely you are to develop an infection, iatrogenic injury or even die.

Tom usually blogs about technology, but this one was too good for me to pass up. ECRI has come up with a list of the Top 10 Health Technology Hazards! That just sounded like fun. For your legal nurse consulting business, this is an eye-opening list of just what can (and will probably) go wrong with healthcare technology. ECRI even ran the list in order of importance. Here we go:

1. Alarm Hazards. You know you ignore them or worse – turn them off.
2. Needlesticks and other Sharps Injuries. This is really low-tech. We’ve been maliciously sticking unsuspecting patients with needles for years.
3. Air Embolism from Contrast Media Injectors. This I read AFTER my MRI?
4. Retained Devices and Unretrieved Fragments. Suddenly patients find themselves setting off the metal detectors at the airport or they are billed for a missing forceps.
5. Surgical Fires. Another reason why CRNAs shouldn’t smoke at work.
6. Anesthesia Hazards Due to Inadequate Pre-Use Inspection. More likely due to pre-use use by the CRNA and/or the anesthesiologist.
7. Misleading Displays. Especially the one showing brain activity.
8. CT Radiation Dose. Everyone else leaves the room during the x-ray, why shouldn’t the patient?
9. MR Imaging Burns. You stick a damaged headset and goggles on the patient, then ram him into the magnetic bore and wonder why he comes out with his hair on fire?
10. Fiber-Optic Light-Source Burns. Another way to set a patient on fire is by resting a hot “cold light source” on him during surgery.

The ECRI report also lists five of last year’s hazards that didn’t cause enough harm to make this year’s Top 10. They are still described as “significant” concerns. ECRI has taken the time to identify problems that any Certified Legal Nurse Consultant realizes are avoidable. I’d get a copy of this list and keep it handy when screening your medical malpractice cases. For a limited time, you can use the link above to visit ECRI and download a free copy of the report.

It’s like Tom always tells me “Technology is fun – in the right hands.”

Success Is Inside!

P.S. Have you seen any med-mal or products liability cases in your legal nurse consulting business related to these topics? What, in your opinion, is the biggest health technology hazard? Comment here.

A headline in the January 8, 2009, issue of The Wall Street Journal “Hospital Scrubs Are a Germy, Deadly Mess,” caught my eye. The article discusses how hospital scrubs and other garments carry infection, not only around the hospital but outside it too.

A headline in the December 2008 issue of Lawyers USA reads “Hospitals Face Infection Suits.” This article covers, guess what, the increased number of infection suits facing hospitals.

The Center for Medicare and Medicaid Services (CMS) adds certain SSIs and other infections to its list of nonreimbursible “Never Events.”

And, can you guess what the cover article is in the January 2009 issue of Nursing Management (the journal of excellence in nursing leadership)? It’s an article discussing the debate over nursing uniform colors, combinations and identity (as well as patient preference and perception).

Give me a break. I don’t care what you wear as long as you’re not killing me with it. I cannot stand to see a doctor, nurse or even someone who’s probably a med-tec standing around my local Starbucks in their scrubs. Even worse –
a healthcare provider in scrubs or lab coat fondling the veggies in my local supermarket. I can’t assume she’s taking that cucumber to work, so I’m guessing she’s just spreading germs on her way home.

The CDC estimates that more than 2,000,000 hospital-acquired infections result in over 90,000 deaths. What about the civilians who are being infected outside of the hospital? Talk about an issue ripe for Certified Legal Nurse Consultants – I feel like a pig at a feeding trough.

When I entered nursing the color was white (the color of purity). Nurses wore clean white uniforms. We shined our shoes (not “Crocs”) and yes, even wore (anyone remember this?) caps. What’s the point? We looked clean, we were clean and you didn’t see a nurse in white outside the hospital. I constantly tell Tom those nurses you see collecting money outside the mall AREN’T REALLY NURSES.

Today, we’ve got multiple piercings, exposed midriffs and our choice of uniform – if you can call it that. I call some of it inappropriate wear.

I’m not calling to revert back to aprons (although they are being tried in Britain). But I am asking that hospitals go back to laundering scrubs and not allowing them out of the hospital.

The same nurse who won’t touch the door handle in the restroom thinks nothing of wearing those Ebola-ridden scrubs when she picks up her kids to hug them.

Study after study shows that where docs and nurses go infection follows. Why aren’t our nursing executives discussing a real issue – infection, disease and death – instead of the colors of our scrubs? You tell me. And, if you’re one of the offenders, stay out of my neighborhood Denny’s.

Success Is Inside!

Whether you are screening medical malpractice cases for plaintiff or defense, as a Certified Legal Nurse Consultant, you should be on the lookout for those obvious meritorious cases. When you see them, the red flags go up as long as there is significant injury or death. For example, maternal death gets everyone’s attention. The plaintiff CLNC^® consultant’s response is – this is one the plaintiff attorney should absolutely represent. The defense CLNC^® consultant’s initial response is – the defense should settle and settle fast.

Plaintiff attorneys usually want to see significant injuries, even in obvious cases of medical malpractice. They have to weigh the cost of litigation against the return. They must consider if it makes sense. They don’t want to spend $150,000 to win back $250,000.

The Centers for Medicare and Medicaid Services (CMS) recently made it so easy for plaintiff attorneys to successfully litigate 13 types of medical malpractice cases that plaintiff attorneys may be more willing to take on these 13, even if the damages do not meet their usual expected criteria.

To start at the beginning, the National Quality Forum (NQF) endorses a list of 27 serious, preventable and reportable “Never Events.” CMS, issued a ruling last year, effective October 1, 2008: CMS would no longer reimburse for 10 selected “Never Events” – events that should never happen and which are clearly caused by the hospital and/or its staff. Then, effective January 15, 2009, CMS issued another ruling adding three additional, surgery-related “Never Events.” In other words, CMS is trying to save lives by saving money.

Cases involving “Never Events” account, according to AON, for a large percentage (12.2% or more) of medical malpractice claims and will be difficult to defend and easy for the plaintiff attorney to settle fast, thus reducing their litigation costs. Insurance companies will fear taking these cases to trial and losing at great expense. They can settle out of court cheaper.

“Never Eventland” provides the perfect playground for a law firm’s new, young and inexperienced associate attorneys to practice on.

Add these 13 CMS “Never Events” to your “Plaintiff Alert Signal” list.

1. Unintentional retention of a foreign object after surgery.
2. Air embolism.
3. Blood incompatibility.
4. Pressure ulcers (Stages III and IV).
5. Hospital-acquired injuries from falls and certain traumas (fracture, dislocation, intracranial injury, crushing injury, burns and/or electric shocks).
6. Manifestations of poor glycemic control.
7. Catheter-associated urinary tract infections (UTI).
8. Vascular catheter-associated infection.
9. Deep vein thrombosis (DVT) or pulmonary embolism following total knee replacement and hip replacement procedures.
10. Surgical-site infections following certain orthopedic procedures, mediastinitis following coronary artery bypass graft (CABG) and/or following bariatric surgery for obesity.
11. Surgery on the wrong body part.
12. Surgery on the wrong patient.
13. Wrong surgery performed on a patient.

Educate your attorney-clients about “Never Events.” Offer to do a 20-minute presentation for all of the attorneys in the law firm. Even with attorneys, small wins are good.

Success Is Inside!