Nurse Practitioner Fails To Adequately Attend Tracheostomy Patient

Case Overview

This case involves an elderly female patient who had a tracheostomy tube placed following a neck surgery. The patient was transferred to a skilled nursing facility and placed under the care of a nurse practitioner. The nurse practitioner did not inform the team that the patient’s airway was tenuous due to her recent surgery. The nurse practitioner also failed to formulate a plan for handling potential airway problems in this particular patient. During the patient’s time at the facility, a floor nurse suspected that the patient’s tracheostomy tube had become displaced. In spite of this suspicion, no X-rays were taken. The floor nurse called the respiratory therapist about the displaced tube and the respiratory therapist attempted to advance the tube. The nurse practitioner was present for this. The patient began to desaturate and a code was called but the nurse practitioner did not arrive. In spite of resuscitation attempts, the patient passed away.

Questions to the Education expert and their responses

What is your experience caring for patients with tracheostomy tubes status post neck or airway surgery?

I am a board-certified family nurse practitioner with 17 years of experience in trauma, ED, primary care and addictions medicine. I have registered nurse-level experience caring for patients in acute care settings s/p neck or airway surgery and nurse practitioner-level experience in the primary care setting with this type of patient.

How is the primary care provider supposed to communicate to the team about a patient with a tenuous airway?

There should be a written plan of care posted in the patient's chart and should be reviewed by the patient/family, primary care physician, and the entire caregiving team. The care plan needs to be based on established clinical practice guidelines for post-surgical patients with a tracheostomy.

If a patient with a tenuous airway needs to have that airway manipulated, what are the appropriate precautions and personnel that need to be available?

There should be emergency resuscitation staff called on site as soon as possible before manipulation of the airway and the provider on call should be notified and called to the bedside.

What safeguards are in place to mitigate against the complications that occurred in this case?

In terms of safeguards to mitigate against these complications, there should be a specific protocol in place: x-ray to confirm placement, routine recording of O2 saturation, routine and documented assessments of the patient's airway.

About the expert

This expert has 20 years of experience in the field of nursing, specializing as a family nurse practitioner. She earned her BS in nursing from Virginia Commonwealth University, her MSN as a family nurse practitioner from the University of South Carolina, and her PhD in nursing from the University of Maryland. Today, she is a licensed registered nurse and family nurse practitioner in the state of Maryland. She remains active in her field as a member of several professional associations, such as the American Academy of Nurse Practitioners and the National Organization of Nurse Practitioner Faculties. This expert previously served as a family nurse practitioner at Arizona State University, Harford Primary Care, West Cecil Health Center, and ARS Treatment Center. Currently, she is an associate professor of nursing at a top nursing school and a family nurse practitioner at a healthcare group in Maryland.

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Victoria Negron has extensive experience in journalism and thought leadership in the legal space, with a background crafting content, whitepapers, webinars, and current event articles pertaining to the role of expert witnesses in complex litigation matters. She is a skilled professional specializing in B2B product marketing and content marketing. Currently, she serves as an Enterprise Product Marketing Manager at Postman, and previously held the position of Technical Product Marketing Manager at Palantir Technologies, where she developed her skills in launch strategies, go-to-market strategy, and competitive analysis.

Her expertise in content marketing was further refined during her tenure at the Expert Institute, where she progressed from a Marketing Writer to Senior Content Marketing Manager, and eventually to Associate Director of Content & Product Marketing. In these roles, she honed her abilities in digital marketing, SEO, content strategy, and thought leadership.

Educationally, Victoria holds a Master of Business Administration from the University of Florida - Warrington College of Business and a Bachelor of Arts in Literature, Art, and Hispanic Studies from Hamilton College. Her diverse educational background and professional experience have equipped her with a robust skill set in product marketing, content development, and strategic marketing initiatives.