Memorable CLNC® Cases

I recognized how impactful and valuable my CLNC® skills were, a realization that helped me develop and escalate my passion for medical record documentation and analysis.

This Digoxin Toxicity Case Validated How Valuable My Certified Legal Nurse Consultant Skills Are

by Caryn “CJ” Jaffe, RN, CLNC


My most Memorable CLNC® Case was the one that taught me valuable lessons that have become the foundation of my legal nurse consulting role. I was requested to review overseas claim forms and medical records with the goal of identifying inappropriate medical billing practices and investigating whether services rendered were appropriate and medically necessary.

The case highlighted the most difficult aspect of performing CLNC® work for a Special Investigations Unit (SIU); identifying negligent care within a timeline that prevented me from saving a life when its discovery occurred too late to make a positive patient impact.

My experience and training as a Nationally Registered Paramedic, RN, and CLNC consultant qualified me to review a 25-day hospital admission of a male with a history of cardiac arrhythmias reportedly controlled by taking digoxin. His symptoms which included presence of vision changes and a yellow haze were consistent with digoxin toxicity, all of which were documented by the physicians and nurses. He saw specialists including emergency department (ED) doctors, cardiologists, endocrinologists, urologists and internal medicine physicians along with three different nurses each day. There were no orders or suggestions for obtaining a blood digoxin level. None of the doctors documented consideration that his condition was worsening from a toxic drug level. Finally on inpatient day 22, an endocrinologist suggested checking his digoxin level. As I expected, the record showed an unbelievably elevated result which could not be lowered without administration of Digibind.

Digibind was never ordered by any physician for this patient. Orders were given to hold the full morning digoxin dose for a day. The following day, he was ordered to have half his normal dose. The next day he was given his full dose again. Four days post identification of the critically high drug level, he was discharged home with the same symptoms he had when he was seen in the ED 25 days prior. Six months later, his hospital claim for more than $100,000.00 landed on my desk.

I vividly remember my dramatic and unexpected reaction to reading the information in his medical record. It was one of those moments when you blurt something out before your brain acknowledges the meaning of the words you used. “Oh my god. I think they just killed this man.” I asked a colleague to check his health insurance enrollment information, specifically to determine if he was still alive. In my heart, I already knew the answer. My suspicions were spot on. He had died ten days later having never received the appropriate and available drug to bind with the excessive digoxin in his body.

I recall saying to my SIU Manager, Rod (also a Certified Legal Nurse Consultant), “If those records got to me in real time, I could have saved this man’s life.” Thankfully, Rod understood how I was feeling from an RN, CLNC standpoint. He supported me through a period when I wasn’t sure I could handle any other experiences of reviewing medical records illustrating gross negligence. Instead of trying to give me a pep talk about ‘just doing my job and going home at the end of the day,’ which nurses like me have a very hard time doing, Rod encouraged me to process and face the emotions head-on. He compared the experience to the unfinished business of EMS which I had learned to handle years before becoming an RN. I worked under Rod’s leadership, and he played an active role in my professional development, telling me once that I was a “diamond in the rough.” He offered to mentor me to become a “polished diamond.” I believe I earned my first facet that day.

Performing that claim and medical record review had a great impact on my CLNC career. It gave me the confidence to elevate my SIU nursing practice by trusting and respecting my nursing experience and intuition. If I had the chance to do the claim all over again, I don’t think I’d do anything differently. I learned valuable lessons and finally recognized how impactful and valuable my CLNC skills were, a realization that helped me develop and escalate my passion for medical record documentation and analysis.


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*The opinions and statements made by Vickie Milazzo, the founder of Medical-Legal Consulting Institute, Inc. are based on her experiences and expertise, should not be applied beyond the specific context provided, and do not guaranty or project actual results. Vickie Milazzo is no longer involved in the operations or management of the business, but is involved as an independent education consultant.

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