Drug Test You Again Fourth Module Nursing

This standing-education offer is sponsored by Nurses Service Arrangement and provided by Lippincott Williams & Wilkins, an accredited ANCC provider.

Nurse'south Guide to Malpractice: Module 1

Nursing malpractice: Understanding the risks

Short of giving up nursing, there are no certain means to avert a malpractice suit. But you lot tin accept steps to cut the odds considerably. The start pace is to understand the ways your risk of a malpractice suit increases. Here's what you demand to know.

AN OUNCE OF prevention is worth a pound of cure—if Benjamin Franklin hadn't coined that expression, surely a nurse would have. That's because a key function of your nursing skill is the ability to foresee what could become incorrect and to keep it from happening. You practise that by knowing the areas where your patient is at run a risk and monitoring them diligently.

The same applies to the potential for a malpractice adjust. Your best protection is to know the circumstances where you lot're most at chance, then make certain you avert any mistakes when functioning in them. This won't make you immune to malpractice charges, but it will strengthen your protection against them and fortify your defense if one occurs.

In this module, we'll expect at 2 means your take a chance of malpractice increases: by not doing what you're expected to and past doing what you're not expected to exercise. With the kickoff, we'll focus on medication errors and common nursing failures. With the second, we'll look at specific deportment that could put you at risk for a malpractice charge in dealing with a patient.

Not giving meds properly

You've heard information technology a hundred times: correct patient, right drug, correct road, correct dose, correct time. Any difference from these "five rights" paves the way for a malpractice suit. Hither are 3 aspects of drug administration particularly at gamble for lawsuits:

not understanding what is ordered

not administering what is ordered

not documenting what is administered.

Let'southward take them one at a time.

Get-go, the police expects that you have a bones agreement of whatsoever drug yous administer. This means you lot know what the drug is intended to treat, its adverse effects and contraindications, the expected outcomes, its therapeutic and toxic doses, and its usual road. Unless an order is questionable, the police also expects that you lot administrate the drug as ordered. Here are some circumstances that put those expectations at risk and how you can avoid liability:

You don't recognize the drug. Never give a drug that y'all aren't familiar with. Instead, find a reliable source (the package insert, a chemist, a reference manual) and learn about the drug. Also, be familiar with your facility'south list of drugs that nurses can administer. If the drug isn't on the list, don't give it, and be certain to immediately inform the prescriber who ordered the drug that you lot're not permitted to administer information technology. The prescriber can then choose to administer it himself or prescribe another drug.

The order isn't clear. An unclear order is any order that you or another health care professional person—oftentimes the pharmacist—has questions near. Y'all don't need "prove" that the order is unclear; fifty-fifty a gut feeling that something is incorrect (maybe the road or dose seems unusual) warrants questioning the presciber who wrote the society. Recall, you aren't protected from liability just considering you followed the prescriber's order.

Second, the law expects you to administer the drug as ordered. Hither's where the five rights come into play, with the final iii (route, dose, and fourth dimension) being the ones most often violated.

Make sure you lot don't utilise the wrong site—for case, inadvertently administering a drug through an intravenous line that was meant to be given through a feeding tube. As well check that you lot don't confuse abbreviations such as I.Thou. and I.Five. Besides pay close attending to your technique. Many lawsuits arise from injections given in the inner quadrant of the buttocks (where the risk of nerve damage is peachy) and from the Z-track method used on inappropriate sites, such as with smaller muscles.

Exist especially vigilant for conversion errors when yous don't have the exact dose or form of medication that'south ordered. Problems oft arise when the volume of the adjusted dose isn't significantly larger than the original amount—for instance, doubling 0.05 ml compared with doubling 5.0 ml. This can hands happen when converting from an developed form (large dose) to a child's form (pocket-sized dose).

Timely administration is particularly crucial with drugs that must maintain a therapeutic level—antibiotics, for example. Here, the worse danger is an omitted dose. The only acceptable reason for an omitted dose (aside from patient refusal) is that the patient or the medication wasn't available. (Of course, the nurse needs to persist in her efforts to obtain the drug and document those actions.) Annihilation else (the order wasn't transcribed, the drug was overlooked in preparing or administering the medications, so forth) is a medication error that can easily notice its mode into court if an injury occurs.

Tertiary, the law expects y'all to document the drug as administered. This volition be covered in greater detail in the second module in this serial, How to Protect Yourself from Malpractice. For at present, keep in listen that poor record keeping is a common cause of duplicate and omitted doses; as such, it shares the responsibility for whatsoever harm that such mistakes might produce. This is a particular trouble with hurting medications.

Allergies and at-risk populations

Finally, two areas where drug administration is producing numerous nursing malpractice suits are allergies and at-risk populations. Make sure you lot inquire about allergies and document your findings—initials such every bit NKA (no known allergies) or NKAD (no known allergies to drugs) are commonly used. Be sure to use your facility's canonical abbreviation.

Enquire about over-the-counter every bit well as prescription drugs; many patients don't think of nonprescription drugs equally "medicine." Be alert for nondrug allergies that have a drug connection; for example, people allergic to shellfish frequently can't tolerate the contrast dye used in diagnostic tests.

Finally, decide the drug class your patient is allergic to, non just the drug name. If he's allergic to one drug course, he may besides be allergic to a related course of drug.

Populations at high adventure for medication errors—especially when receiving multiple medications—include the young, the elderly, and the mentally ill. With their limited or compromised comprehension and their potential disability to communicate effectively, these patients tin easily fall victim to overdose or toxicity.

For this reason, the law expects you to watch them closely for adverse reactions and the signs and symptoms of drug toxicity. Y'all're probably giving them this extra attention anyway—and not just with medications. Knowing that the police force expects more than of you with these at-take a chance populations is an added incentive to practice safely.

Common forms of failure

Too medication errors, malpractice suits sally from failures in the threefold duty to discover, intervene, and protect. Permit's await at each of these, focusing on the specific failures that commonly announced in nursing malpractice suits.

Failure to notice. The nigh sophisticated monitoring equipment notwithstanding, nurses are all the same the indispensable early alert system of health care. The constabulary recognizes this and holds nurses answerable for information technology. Hither are common situations where nurses have been liable for failure to observe:

when the patient's condition underwent rapid alter, such as after surgery or during labor

after the patient had suffered an injury while in the facility

when the patient possessed known cocky-destructive tendencies.

With each status, advisable monitoring would have defenseless the complication or change in the patient'southward condition. By failing in this regard, the nurse shares in the liability for subsequent related injury. (Equally discussed in Module ii, accusations of failure to monitor can exist substantially countered by accurate, detailed documentation. A nurse who tin demonstrate appropriate monitoring is less likely to exist held liable because the patient took a turn for the worse.)

Failure to observe. Nurses have a duty to intervene on the patient's behalf. This duty should be based on the facility's policies and procedures besides as the nurse's grooming and expertise, which should exist in accordance with national standards. If you don't intervene (and we'll see in a moment just what that involves) where the institution says you should, you tin be liable for injuries that the intervention would take prevented. Similarly, if you practice intervene and injury results from your lack of training and skill, yous tin can be equally liable.

Frequently, your intervention consists of contacting the health care provider about a change in the patient's condition, and then conveying out whatever the wellness care provider prescribes. But that's not a foolproof guarantee that the requirements of intervention take been met. Your duty to a patient demands more than just carrying out the prescribed handling. If, in your professional judgment, y'all consider the treatment inappropriate, yous're expected to intervene on the patient's behalf and analyze the treatment with the health care provider.

A number of contempo malpractice cases have hinged on whether the nurse was persistent enough in her try to notify the health care provider or to convince him of the seriousness of the patient's status. A nurse who evidences a lack of such persistence (for example, not working through the facility's bureaucracy) can be held liable for failure to arbitrate because the intervention was below what'due south expected of her equally a patient advocate.

As well persistence, constructive intervention involves thorough and accurate communication of all significant data to the health care provider and other appropriate persons. These can include the patient and the patient's family, other caregivers (therapists, technicians, and the like), members of the nursing staff, and, when necessary, the hospital authorities.

A crucial element in all these communications is timeliness. Courts are quick to recognize that after-the-fact communication is tantamount to no communication and ends up being some other form of failure to timely intervene. About nurses know how to observe a center ground between passing forth every change the patient undergoes and property back until the situation becomes a crunch. If a gray expanse remains, keep in mind that yous're much less likely to be accused of failure to timely arbitrate if you lot call too soon rather than too late.

Besides interventions that attain out to others, nurses besides intervene past reaching into themselves. This involves those situations where you deed on your own considering you've judged that the health care provider needn't or can't be contacted.

Here you lot're on safe footing as long as you're acting inside the confines of your education, expertise, appropriate standards of intendance, and your state's nurse practice act. If yous become beyond them, or fail to recognize that the situation calls for skills and experience you don't possess, you're liable for any injury that might result from your intervention. The same is true if y'all're capable of intervening but don't.

Failure to protect. Your obligation to safeguard a patient from harm tin can betrayal y'all to a lawsuit on 2 fronts: if the patient injures himself or if something injures the patient. As for patient-inflicted injuries, lawsuits frequently arise from falls and from the use of restraints. Amongst the injuries inflicted from outside, burns and equipment malfunction frequently pb to allegations of malpractice.

Falls are bound to happen, especially among the elderly. To safeguard your patient, you need to assess his condition advisedly, implement protective measures according to your facility's policies and procedures (such as constructive toileting) for the times when he's non on his anxiety, and provide appropriate assistance and supervision when he is. To safeguard yourself, you need to document these measures, plus the fact that the patient or a family unit member was told—and acknowledged understanding—that the patient should stay in bed or not walk unassisted.

Intended to prevent damage, restraints tin themselves cause impairment. Your health care facility has policies and procedures for using restraints that are based on the law; brand sure yous know them and comport them out—especially the conditions required for restraining a patient, how often the restraints should exist checked and released, who may guild restraints, and when a patient can decline to be restrained. Because of the inherent dangers of restraints, ofttimes monitor a restrained patient for skin integrity, circulation, and respiratory status. Document all of your actions.

Burns are a common source of liability claims against nurses. Any source of heat is a potential danger: heating pads, bathing water, enemas and sitz baths, lamps, warming beds, and electrocautery equipment. As well your own protective measures—testing the h2o, regulating the heating pad—you lot tin usually rely on your patient'south reactions to unacceptable heat. But patients with decreased sensitivity to heat, ones who are sedated or unconscious, or ones in the at-risk category regarding medications mentioned earlier all require extra vigilance.

Equipment-related injuries where a nurse is at fault tin can involve a failure either to monitor the equipment or to note and correct a problem. Because you can't exercise these unless y'all're familiar with the equipment, you lot accept a duty to seek proper orientation—just every bit the facility has a duty to provide it.

Much more often than equipment failure, patients are injured because of human being error: haste, carelessness, or misuse of equipment. In such instances, the failure to protect is compounded, for example, by changing the settings so the machine harms rather than helps the patient.

The aforementioned danger arises from making modifications to patient equipment. Most facilities take specific policies regarding when, how, and past whom a slice of equipment can be modified. Follow them; it's better than following an attorney into court.

Adhering to country regulations

Even broader than the responsibility to observe, intervene, and protect is your obligation to adhere to your state'due south nurse practice act and state's nurse practice guidelines. This is another area that is generating more than nursing malpractice suits. Because these requirements may differ past state, be sure to get a copy of the ones for your licensing country. Familiarizing yourself with them can protect y'all from being blindsided by a malpractice accommodate or in an administrative hearing with your state's regulatory authorisation for disciplinary action.

Doing what y'all shouldn't do

Now we'll look at some examples of how you can get into problem by doing something you lot shouldn't. Though less common than the mistakes that arise from non doing what you should, they're equally fraught with legal danger.

No nurse thinks of herself every bit capable of abandonment, assault, battery, defamation, or imprisonment. But nurses have been institute liable for these actions. Patients tin file criminal charges or civil actions (asking for monetary damages).

Every bit yous read these definitions, proceed in mind ii things. Get-go, these are intentional wrongs done to another person (the legal term is torts). The individual doing them knows or should know that they'll crusade harm, such as loss of reputation, esteem, or coin. Second, though your purpose in reading about these intentional torts is to avoid committing them, your role equally patient advocate includes preventing them from happening to your patients.

Abandonment involves unilateral premature termination of the professional treatment relationship by the wellness care provider without detect given to the patient or the patient'due south consent. This would be the case, for example, if a dwelling health care nurse stopped visiting a patient who still needs care without giving any notification or providing alternative sources of care.

In the hospital, claims of abandonment commonly ascend from patients going untreated in an emergency department. But patients may also sue if they're released without appropriate belch or transfer planning or discharge instruction. Indeed, any patient left unmonitored or unattended tin can sue for abandonment if damages occur; he must be safely transferred to another professional when a continuing need for care exists.

For case, suppose you're assigned to monitor a postoperative patient but a physician calls y'all to come up and help with another patient. If you lot comply and something happens to your patient while you're gone, you could be liable for a accuse of abandonment.

Assault is any human action designed to brand a person fearful and produce a reasonable apprehension of harm. Assault doesn't require touching, striking, or actual harm; a threatening argument such as "Accept your medicine or I'll put you in restraints" can be considered assail.

Bombardment is whatsoever intentional and wrongful physical contact with a person that entails an injury or offensive touching. In a health care setting, medical battery occurs when an intervention that the patient expressly rejected, or that lacks prior informed consent, is washed anyway. That holds truthful fifty-fifty if the intervention is a sincere try to aid and may benefit the patient (for case, inserting or removing a catheter).

A patient can't consent to a handling without start being duly informed of the elements of disclosure. These include the nature of his status, the benefits and risks of the proposed treatment, significant alternatives to the treatment, and the consequences of non receiving the handling. The duty to disembalm these elements is present in all situations except these four:

— an emergency

— the patient has waived the right to be informed (he doesn't want to know the risks, benefits, and so on)

— the health care provider believes the information would harm the patient or prevent him from receiving lifesaving treatment (chosen therapeutic privilege)

— the patient has already given informed consent on the same type of handling and doesn't want to become through the informed-consent process again.

In those situations, appropriate handling without informed consent shouldn't be construed every bit bombardment.

Legally, the person responsible for obtaining informed consent is the individual providing the treatment—usually the physician or, in some cases, the nurse practitioner, not the nurse. Even the nurse who signs the consent document is but witnessing the patient's signature, non the validity of the consent. Still, you should check that the patient understood everything the health care provider said to him and that he has no boosted questions. If you remember the patient didn't understand the informed consent discussion, or if there's a linguistic communication barrier y'all're obliged to notify the health care provider and your supervisor.

Sometimes, the patient may give unsaid consent. In other words, he indicates his consent past his deportment—for example, voluntarily exposing an injection site. Generally, however, the more intrusive or potentially harmful the treatment, the more than likely the need for written consent.

Breach of promise is any failure to live upwardly to the obligations created by an agreement or contract between oneself and another person. The contract can be overt or implied. A patient under your care has an unsaid contract with the facility that he'll receive appropriate intendance. Every bit a facility employee, you have an obligation to honor that contract.

Conversion is a legal term for stealing; information technology involves any unauthorized deed that deprives an owner of his property. It requires demonstrating that ane person has taken possession of objects previously in the possession of and property of another.

Defamation is communicating to a third party false information that injures a person's reputation; causes economic harm; diminishes the esteem, respect, goodwill, or confidence that others have for the person; or causes adverse, derogatory, or unpleasant opinions of him. It tin be spoken (slander) or written (libel).

Courts more often than not hold that injurious information is faux unless proved otherwise. Truth, then, is the best defense force, just it too has limits. As you might imagine, truth is no defense against such charges every bit invasion of privacy, breach of confidentiality, or inflicting emotional distress.

What's the safest path? Stick to the facts; avoid opinion and characterization. A common source of defamation—whether well-nigh patients or staff—is gossip. For staff, this includes allegations related to disciplining or terminating an employee.

False imprisonment describes any unlawful solitude within fixed boundaries. The confinement tin can be produced by physical, emotional, or chemical means. Physical confinement, the most common, usually involves restraints or barred access or get out. Emotional confinement tin take the form of intimidation: creating a fear that keeps the patient riveted to one place. Chemical solitude results when drugs are given not for their therapeutic value merely to continue a patient inside an establishment. Fifty-fifty preventing a patient from signing out against medical advice is risking a claim of faux imprisonment. (Of course, the court will consider why the patient was existence confined.)

Most at risk for false imprisonment are the elderly, the physically or mentally impaired, and others who can't speak or act for themselves. Specially with the mentally ill, state laws are frequently quite specific; failure to understand or comply with those laws can be grounds for legal action.

Fraud is any intentional misrepresentation of factual information. It can involve words, equally in documenting a service that wasn't provided, or beliefs, as in concealing medical records from someone who has legal access to them. A health care provider who charges for services that weren't provided tin can exist accused of fraud.

Infliction of emotional distress is any extreme and outrageous conduct aimed at attacking a person's peace of listen. Legally, it must be judged to exceed ordinary rude or insulting conduct, only the courts are highly subjective in making such a judgment. One unexpected source of emotional distress is comments fabricated in the presence of a seemingly unconscious patient who is all the same able to hear.

Invasion of privacy involves a violation of a person's right to be left lonely and not subjected to unreasonable interference with his personal life. It may involve inappropriate exposure of a patient's body or condition. As for the body, patients who are improperly draped shouldn't exist in the sight of visitors or staff members not connected to their intendance. Nor should unauthorized persons be permitted to view patients who are considered famous or notorious.

As for their status, patient confidentiality precludes comments in public places such as elevators, cafeterias, or parking lots and improper disclosure of medical records. Many institutions now have specific guidelines for confidentiality regarding human immunodeficiency virus status, drug and alcohol abuse, and other sensitive information.

Not much dissimilar

So far, we've looked at ways nurses can avert legal trouble for things they did or didn't do. As you lot read, perhaps you felt that the precautions suggested are nothing more than what a competent, conscientious nurse would do anyway.

If so, you got an important message. Guarding confronting malpractice isn't some better-you-than-me grade of self-protection or an insidious plot to sweep blame nether the carpet or into someone else'south lap. Rather, information technology'southward a professional response to increased wellness care complexity and patient protection—all within the jurisdiction of a less-than-perfect legal system.

Just don't conclude that only being competent and conscientious means you'll never be served a malpractice adjust. It doesn't—not in today'south health intendance environment. In the next module, nosotros'll look at ways you can fend off the devastating furnishings of beingness sued for malpractice.

SELECTED REFERENCES

Fiesta, J.: "Nursing Malpractice: Cause for Consideration," Nursing Management. xxx(2):12-13, February 1999.

Nurse'south Legal Handbook, 4th edition. Springhouse, Pa., Springhouse Corporation, 2000.

Tonia Dandry Aiken, RN, BSN, JD, president and master executive officer, RN Evolution, Inc., New Orleans, La., served every bit nursing/legal consultant for this series. She has served as a consultant and speaker for NSO.

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Copyright � 2003 Nurses Service Organization, 159 E. Canton Line Rd., Hatboro, PA 19040-1218. This article may non be reproduced without written permission of Nurses Service Organization.

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