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5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
5530: Chapter 9
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5530: Chapter 9

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  • 1. Chapter 9Nursing and the Law 2
  • 2. Broadening Scope of Practice• Refers to permissible boundaries of practice for health care professionals, defined in state statutes, which define the actions, duties, & limits of nurses in their particular roles.• Role of nurse continues to expand due to – shortage of primary care physicians – ever-increasing specialization – improved technology – public demand – expectations within the profession itself. 3
  • 3. Nursing Practice - I1901 – NY begins to organize passage of nurse practice legislation1903 – NC, 1st nurse registration act1905 – Columbia U., Certification for nurse leaders1937 – ANA recommendsuse their professional org. to improve working conditions 4
  • 4. Nursing Practice - II1938 – NY requires mandatory licensure1946 – ANA Convention calls for higher wages1952 – All states enacted nurse practice acts1955 – ANA approves model definition for nursing1957 – California: Nurses supported to perform venous punctures 5
  • 5. Nursing Practice - III1966 – Michigan: Use of defibrillators by nurses1968 – Hawaii: Nurses perform cardio-pulmonary resuscitation1970 – ANA: Nursing practice to include “nursing diagnosis”1971 – Idaho: Scope of practice for NPs includes Diagnosis & treatment 6
  • 6. Nursing Practice - IV1972 – New York: Expanded Nurse Practice Act, Broader definition of nursing1973 – ANA: 1st Guidelines for geriatric NPs1975 – Missouri: Nursing diagnosis scope expands1980 – ANA publishes model NP act for state legislators to provide consistency for state nurse practice acts 7
  • 7. Nursing Practice - V1985 – New York: Nurses provide primary health care services1989 – New York: NPs diagnose, treat, write prescriptions1990 – ANA amends model definition of nursing to include advanced NPs 8
  • 8. Nursing Diagnosis – I• Defendant physicians ignored nurses assessment of patients diagnosis, which contributed to delay in treatment & injury to the patient. Nurse testified that she told the physician that patients signs & symptoms were not those associated with indigestion. Defendant physician objected to this testimony, indicating that such a statement constituted a medical diagnosis by a nurse. The trial court permitted the testimony to be entered into evidence. What do you think happened on appeal? 9
  • 9. Nursing Diagnosis – IIMissouri Court of Appeals affirmed lower courts ruling, holding that evidence of negligence presented by a hospital employee, for which an obstetrician was not responsible, was admissible to show events that occurred during patients hospital stay. – See text case: Cignetti v. Camel 10
  • 10. Nurse Licensure IRequirements for Licensure – Reciprocity • agreement between states whereby a nurse licensing board in one state recognizes licensees of another state. – Endorsement • boards determine whether out-of-state nurses qualifications are equivalent to their own state requirements at the time of initial licensure. 11
  • 11. Nurse Licensure IIRequirements for Licensure cont. – Waiver • When applicants do not meet all the requirements for licensure but have equivalent qualifications, the specific prerequisites of education, experience, or examination may be waived. – Examination • Some states will not recognize out-of state licensed nurses & make it mandatory that all applicants pass a licensing examination.
  • 12. Suspension & Revocation• Violations may include – procurement of a license by fraud – unprofessional, dishonorable, immoral, or illegal conduct – performance of specific actions prohibited by statute – malpractice. 13
  • 13. Practicing without a License• Health care orgs are required to verify each nurses license is current.• Mere fact that an unlicensed practitioner is hired will not generally in & of itself impose additional liability unless a patient suffered harm as a result of an unlicensed nurses negligence. 14
  • 14. American Nurses Association• National professional organization of graduate RNs.• Membership is available to all graduate nurses who are licensed in any jurisdiction of the United States.• Purpose of the ANA is to – foster high standards of nursing practice – promote professional & educational advancement of nurses & welfare of nurses to the end that all people may have better nursing care. 15
  • 15. National League for NursingPurpose to foster develop & improve hospital, public health, & other organized nursing services & nursing education through coordinated action of nurses, allied professional groups, citizens, agencies, & schools. 16
  • 16. NURSING NEGLIGENCE 17
  • 17. Nurse Anesthetist - I• Administration of anesthesia by a nurse anesthetist requires special training and certification.• Nurse-administered anesthesia was the first expanded role for nurses requiring certification.• Oversight & availability of an anesthesiologist are required by most organizations. 18
  • 18. Nurse Anesthetist - II• Major risks for nurse anesthetists include – improper placement of an airway – failure to recognize significant changes in a patients condition – improper use of anesthetics• Nurse Anesthetist: Medical Supervision Require 19
  • 19. Nurse Practitioner• RNs who have completed the necessary education to engage in primary health care decision making.• Trained in delivery of primary health caare & assessment of psychosocial & physical health problems such as the performance of routine examinations & ordering of routine diagnostic tests.• NPs negligence imputed to physician – See text case: Adams v. Krueger 20
  • 20. Clinical Nurse Specialist – I• Clinical nurse specialist is a professional RN with an advanced academic degree, experience, and expertise in a clinical specialty (e.g., obstetrics, pediatrics, psychiatry).• CNS acts as a resource for the management of patients with complex needs and conditions.• The CNS participates in staff development activities related to his or her clinical specialty & makes recommendations to establish standards of care for those patients. 21
  • 21. Clinical Nurse Specialist – II• CNS functions as a change agent by influencing attitudes, modifying behavior, & introducing new approaches to nursing practice.• CNS collaborates with other members of the health care team in developing and implementing the therapeutic plan of care for patients.ard of care 22
  • 22. Nurse Midwife – I• Nurse midwives provide comprehensive prenatal care including delivery for patients who are at low risk for complications.• They often manage normal prenatal, intrapartum, & postpartum care.• Provided that there are no complications, normal newborns are also cared for by a nurse midwife. 23
  • 23. Nurse Midwife – II• Nurse midwives often provide primary care for womens issues from puberty to postmenopaus• Text Cases – Practicing Without a License – Standard of Care Required of a Nurse Midwife 24
  • 24. Nurse Managers• Chief nursing officer has responsibility for: – maintaining standards of practice – maintaining current p & ps – recommending staffing levels – coordinating & integrating nursing services with other patient care services – selecting nursing staff – developing orientation and training programs.• Failure to supervise – can lead to disciplinary action 25
  • 25. Special-Duty Nurse• A health care professional employed by a patient or patients family to perform nursing care for the patient• If a master-servant relationship exists between the org & special-duty nurse, doctrine of respondeat superior may be applied to impose liability on the org for nurses negligent acts 26
  • 26. Float Nurse• Nurse who rotates from unit to unit based on staffing needs• “Floaters” can benefit an understaffed unit, but they also may present a liability as well if they are assigned to work in an area outside their expertise• If a patient is injured because of a floaters negligence, the standard of care required of the floater will be that required of a nurse on the assigned patient care unit 27
  • 27. Nursing Assistant• An aide who has been certified & trained to assist patients with activities of daily living under the direction & supervision of an RN or LPN• Nursing assistants help with positioning, turning, lifting & performing a variety of tests * treatments• Failure to follow policy & safe practices – patient scalded – patient fall – patient transfer – Leaving Patient Unattended 28
  • 28. Agency Staff• Orgs are at risk for negligent conduct of agency staff.• Important that org be sure that agency workers have necessary skills & competencies to carry out duties & responsibilities assigned by org. 29
  • 29. Student Nurses• Student nurses are entrusted with the responsibility of providing nursing care to patients.• Students are personally liable for their own negligent acts, & the facility is liable for their acts on basis of respondeat superior.• Student nurse are held to the standard of a competent professional nurse when performing nursing duties 30
  • 30. Medications Errors - I• Failure to administer• Failure to document wastage• Administering unprescribed meds• Administering wrong meds• Failure to clarify orders• Case: Negligent Drug Overdose 31
  • 31. Medications Errors - II• Administration of the wrong dosage• Negligent drug overdose• Administering by the Wrong Route• Failure to Discontinue a Med• Failure to Identify the Correct Patient• Failure to Note an Order Change 32
  • 32. Negligent Injection• Nurse negligently injected the tetracycline into or adjacent to the sciatic nerve, causing the patient to permanently lose the normal use of the right foot. – ED – Permanent injuries – Negligent injection of Tetracycline 33
  • 33. Failure to Follow Physician’s Orders• Nurses caused permanent drop foot to the patient.• They failed to follow the doctor’s verbal orders to watch the patient closely & to place him in one continuous passive motion machine at a time during physical therapy. 34
  • 34. Failure to Record Patient’s CareNurse admitted she failed to record site & mode of injection in ED records. According to testimony of two experts, failing to record this information is below standard of care for nursing. Although these omissions could not have affected administration of the injection, they tend to indicate that in this instance the nurse did not follow accepted procedure while performing her job. 35
  • 35. Failure to identify Correct Patient• Surgical staples removed-wrong patient Meena v. Wilburn – Chart was not checked – Wrist band was not checked – Wrist band was not checked against chart 36
  • 36. BURNSNegligent use of a Bovie plate led to liability in Monk v. Doctors Hospital, in which a nurse had been instructed by the physician to set up a Bovie machine. The nurse placed the contact plate of the Bovie machine under the patients right calf in a negligent manner and the patient suffered burns. The patient introduced instruction manuals, issued by the manufacturer, supporting a claim that the plate was placed improperly placed. These manuals had been available to the hospital. 37
  • 37. Infections• Cross Contamination• Failure to Notify Physician• Failure to follow established procedures – Infection control – Sterile technique – Decubitus ulcers 38
  • 38. Inappropriate Care – I• Plastic cup as arm guard? – Morris alleged from personal observation that the laceration to her daughters arm was caused by the jagged edges of a plastic cup that had been split & placed on her arm to guard an IV site. • Text case: Morris v. Children’s Hospital Medical Ctr. • Was this a breach of the standard of care for nurses? 39
  • 39. Inappropriate Care – IIA nurse, in her affidavit, who stated her qualifications as an expert, expressed her opinion that the practice of placing a split plastic cup over an IV site as a guard constituted a breach of the standard of nursing care. 40
  • 40. Delay in Treatment• When minutes count!• Nurses Delay contacting obstetrician – Text Case: Howerton v. Mary Immaculate – Patient suffers – At trial, expert witness opined that labor & delivery room nurses should have immediately gone to the patient when they were notified of worsening pain, evaluate her condition, & notify her physician. 41
  • 41. Leaving Patients Unattended• Navy Veteran Left Unattended – Suffered anoxic brain injury following a complication with his endotracheal tube – Left permanently disabled – Court awarded $3,500,000 42
  • 42. Failure to Follow Instructions• Failure of a nurse to follow the instructions of a supervising nurse to wait for her assistance before performing a procedure can result in revocation of the nurses license.• Heart monitor was connected incorrectly & resulted in an electrical shock to the infant.• Dangers of electric cords are within the realm of common knowledge.• Record showed the nurse failed to exercise ordinary care in connecting the infant. – Text Case: Cafiero v. North Carolina Board of Nursing 43
  • 43. DILEMMA OF TWO STANDARDSWhen faced with dilemma of 2 standards for rendering patient care, an org may find it more attractive to adopt the 1 least restrictive or labor intensive. This could prove to be a costly decision for both patient & org by increasing – the risk of patient injury – organizations exposure to corporate liability for any injury suffered from following the less restrictive standard. • See text case: Edwards v. Brandywine Hosp. 44
  • 44. Failure to Monitor Vital Signs• Evidence presented indicated that the standard of care would require that fetal heartbeats be monitored every 10 minutes following removal of the fetal monitor. The evidence presented indicated that this did not occur. – See text case: McCann v. ABC Insurance Co.• Failure to Repeat Vital Signs – Porter v. Lima Mem’l Hosp. 45
  • 45. Failure to Report: Physician’s Negligence• Note changes in patient’s condition• Report changes in patient’s condition – Prompt notification required – Physician failure to respond – Need to report “all” patient symptoms 46
  • 46. Failure to Question Discharge• Premature Discharge – A nurse has a duty to question the discharge of a patient if he or she has reason to believe that such discharge could be injurious to the health of the patient. • See text case: Koeniguer v. Eckrich 47
  • 47. Failure to Question Discharge Swollen Beyond Recognition• The hospitals negligence is based on acts of omission, by failing to have the patient examined by a physician and by discharging her in pain.• The evidence presented a woman conscious of her last days on earth, swollen beyond recognition, tubes exiting almost every orifice of her body, in severe pain, and who deteriorated to the point where she could not verbally communicate with loved ones. – See text case: NKC Hosps., Inc. v. Anthony 48
  • 48. Failure to Note Changes in Patient’s Condition – I• Nurses have responsibility to observe the condition of patients under their care & report any pertinent findings to the attending physician.• Failure to note changes in a patients condition can lead to liability on the part of the nurse & organization. 49
  • 49. Failure to Note Changes in Patient’s Condition – IINurse assigned to monitor a postsurgical patient, left the patient, & failed to recognize the patient stopped breathing. The nurse had been assigned to monitor the patient in the recovery room. She delegated that duty to another nurse & failed to verify the nurse accepted the responsibility. – See text case: Eyoma v. Falco 50
  • 50. Prompt Notification Required• Physician inserted a catheter into the wrong artery in the patient’s right leg. This compromised the blood flow to the leg, causing loss of pulse & sensation.• This error was compounded when hospital nurses on the patients floor were unable to reach the physician for 6 hours & never attempted to reach a backup physician, to alert them of the patient’s deteriorating condition. – See text case: Cuervo v. Mercy Hospital, Inc. 51
  • 51. Failure to Report Deteriorating ConditionAn organizations policies & procedures should prescribe guidelines for staff members to follow when confronted with a physician or other health care professional whose action or inaction jeopardizes the well-being of a patient. – See text case: Goff v. Doctors General Hospital 52
  • 52. Timely Reporting of Patient SymptomsCourt held that there was sufficient evidence to authorize the jury to find that the nurse was negligent in failing to timely notify the physician that delivery of plaintiffs child was imminent. This delay resulted in an unattended childbirth with consequent injuries. The trial court had awarded the plaintiff $15,000. 53
  • 53. Failure to Report Patient SymptomsHospitals nurse was negligent in failing to inform the physician of all the patients symptoms, to conduct a proper examination of the plaintiff, & to follow the directions of the physician. – See text case: Citizens Hospital Association v. Schoulin 54
  • 54. Failure to Report Defective Equipment• Failure to report defective equipment can cause a nurse to be held liable for negligence if the failure to report is the proximate cause of a patients injuries.• The defect must be known & not hidden from sight. 55
  • 55. Incorrectly Transcribing Telephone Orders• Periodic contradictions between what physicians claim they ordered & what nurses allege they ordered.• Orders should be read back for verification purposes.• Questionable orders must be verified with prescribing physician.• Physicians must authenticate their verbal order(s) by signing the written order in the medical record.• Nurses who disagree with a physicians order should not carry out an obviously erroneous order.• Report to the supervisor concerns with a particular order. 56
  • 56. Misidentifying Infants• Inadvertent or negligent switching of infants can lead to liability for damages. Damages in the amount of $110,000 were awarded for the inadvertent switching of two babies born at the same time in De Leon Lopez v. Corporacion Insular de Seguros.• Follow org p & p in patient identification process.• Always verify infant’s identification badge with mother’s. 57
  • 57. Patient Falls & Restraints• Among senior citizens, falls represent the fifth leading cause of death, and the mortality rate from falls increases significantly with age.• Text cases – Failure to Follow Policy – Failure to Raise Bedrails – Nurse Followed Safe Procedures – Fall from Examination Table 58
  • 58. Negligent Care - I Brandon v. HMA, Inc. v. Bradshaw• Failure to – properly monitor patient – report vital information to patient • Allowed condition to deteriorate – to critical stage – before implementing urgent care – Implementing life support 59
  • 59. Foreign Objects: Left in Patients• Surgical Instrument Left in Patient – See text case: Ross v. Chatam• Sponge & Instrument Miscount – See text case: Romero v. Bellina – Whose responsibility? Discuss. – Nurses & Surgeons Responsible? 60
  • 60. Improper Sterilization• The patient in Howard v. Alexandria Hosp. brought a medical malpractice action against the hospital, seeking damages arising out of an operation performed with unsterile instruments.• Nurse in charge of the autoclave used to sterilize instruments was alleged not to have properly monitored the sterilization process. – See text case: Howard v. Alexandria Hosp. 61
  • 61. Negligent Procedure Cutting IV Tube – I• A nurse employed by the defendant amputated nearly one third of a one-month-old infant’s index finger while cutting an IV tube.• $87,000 for past pain & suffering & $50,000 for future damages.• Defendant moved to set aside the verdict & sought a new trial. – What do you think the final outcome of this case was? • See text case: Ahmed v. Childrens Hospital of Buffalo 62
  • 62. Negligent Procedure Cutting IV Tube – IIThe appellate court found that the jurys award of damages did not deviate materially from what would be reasonable compensation. 63
  • 63. Monitor Alarm Inappropriately Disconnected• Monitor should have been on but was, however, disconnected by the staff & caused patient’s death. – See text Case: Odom v. State Department of Health and Hospitals 64
  • 64. REVIEW QUESTIONS - I1. Describe how the scope of nursing is changing.2. Describe how the roles of a nurse anesthetist, clinical nurse specialist, nurse practitioner, and nurse midwife differ.3. Describe the various legal risk for nurses.4. Describe the various medication errors that can occur in the administration of medications. 65
  • 65. REVIEW QUESTIONS - I5. If a nurse disagrees with a physicians written orders, discuss what action the nurse should take to protect the patient’s safety.6. Discuss why it is important to report significant changes in a patient’s condition to the treating physician.7. If a nurse knows that a piece of equipment is defective, should the nurse attempt to fix the problem? Discuss your answer. 66

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