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Tony Hsieh,
the Zappos.com luminary who revolutionized the shoe
business and established a unique corporate culture along the
way, has died at age 46.
Hsieh's family confirmed his death Friday night in a text
message to friends, noting that Tony's generous spirit touched
the lives of countless people and that he left an indelible mark
on the world.
The executive died from injuries sustained in a Connecticut
house fire, according to press reports citing a family lawyer.
Hsieh, a serial entrepreneur, cofounded Zappos in 1999 and
grew it into a blockbuster business before selling it to Amazon
in 2009.
Delivering happiness was the executive's mantra. As he built
Zappos, Hsieh's chief goal was to redefine the meaning of
company culture. From the beginning, his singular vision set the
company apart as a pioneer in footwear e-commerce and
corporate America.
"The world has lost a tremendous visionary and an incredible
human being," said Zappos chief executive officer Kedar
Deshpande in a note to employees on Friday. "We recognize
that not only have we lost our inspiring former leader, but many
of you have also lost a mentor and a friend. Tony played such
an integral part in helping create the thriving Zappos business
we have today, along with his passion for helping to support
and drive our company culture."
Hsieh, who retired and stepped down from the Zappos helm this
past summer, told WWD's sister publication Footwear News last
year how much the company had evolved since it was founded
two decades ago.
"A lot of our growth and innovation moving forward will be
based on thinking about what we're in the business of
differently," Hsieh told FN last year, when Zappos celebrated
its 20th anniversary. "We used to say we're a service company
that just happens to sell shoes, and now it's turned into: We're a
service company that just happens to sell blank."
The Zappos origin story is a familiar one -- Hsieh shared it in
his speaking engagements and in the pages of his New York
Times bestseller, "Delivering Happiness: A Path to Profits,
Passion, and Purpose." And the 100,000-plus visitors who have
toured Zappos' headquarters have been regaled with the tale of a
fateful phone call.
After Zappos cofounder Nick Swinmurn latched onto the idea of
selling shoes online, he left a voicemail with Hsieh's San
Francisco venture capital fund, Venture Frogs, hooking him
with one factoid: "It was the fact that 5 percent of a $40 billion
shoe business was already being done through mail order,"
Swinmurn told FN during a 2009 interview. "That was my big
statistic. People were already buying shoes without trying them
on."
Then, after another call to the Nordstrom department store in
San Francisco, Fred Mossler eventually jumped on board, and
together the new team set out to change the industry.
Zappos was a pioneer in free shipping and returns, and it didn't
take long for the concept to take hold as e-commerce took off.
In 2009, Zappos was acquired by Amazon.com Inc. for 10
million shares of Amazon stock, which, at the time of the deal,
Hsieh said was valued at about $1.2 billion.
While many market watchers celebrated the marriage, they also
speculated that the new parent could impose its own culture on
the new division. But true to the initial agreement, Zappos has
continued to operate separately from Amazon, maintaining its
own leadership team and unique character.
Several years into the Amazon partnership, Hsieh launched The
Downtown Project, an initiative to revitalize downtown Las
Vegas.
The goal, Hsieh explained at FN's 2013 CEO Summit, was to
create a neighborhood that is walkable and community-focused.
The Downtown Project is even investing in individuals, helping
them realize their dreams of starting small businesses. "We are
thinking of the city as a start-up," he said. "We want it to be the
anti-Strip -- with bars and coffee shops."
In 2015, Zappos did away with managers in favor of a form of
self-organization called holacracy.
In a blog post at the time, Hsieh wrote, "Like all the bold steps
we've done in the past, it feels a little scary, but it also feels
like exactly the type of thing that only a company such as
Zappos would dare to attempt at this scale."
Since its early days, Zappos has functioned as something of an
incubator for testing theories about corporate culture and
productivity -- long before those ideas became the buzzwords
they are today. Much of the credit for that lies with Hsieh.
"His spirit will forever be a part of Zappos, and we will
continue to honor his memory by dedicating ourselves to
continuing the work he was so passionate about," Deshpande
wrote in the note to employees. "Our thoughts remain with him
and his loved ones. Zappos is a family, and we will continue to
hold Tony close in our hearts."
Nursing Negligence: Guidelines for Care
Video Title: Nursing Negligence: Guidelines for Care
Originally Published: 2007
Publication Date: Mar. 20, 2020
Publishing Company: Medcom Inc.
City: United States
ISBN: 9781529727906
DOI: https://dx.doi.org/10.4135/9781529727906
© Medcom Inc., 2007
www.princexml.com
Prince - Non-commercial License
This document was created with Prince, a great way of getting
web content onto paper.
https://dx.doi.org/10.4135/9781529727906
[MUSIC PLAYING]
NARRATOR: Today, there are tremendous pressures on the
time of everyone in health care,
particularly on nurses. As a result of cost-cutting efforts made
in all areas of health care, the
delegation of some traditional nursing tasks is occurring.
However, this should be done carefully so
that legal issues, such as negligence, do not arise.
NARRATOR [continued]: While damage caps in some states
have reduced negligence suits against
nurses and limited the amount of some awards for nursing
negligence, nurses are at risk for
negligence lawsuits, and more than 400 judgments are made
against nurses every year. Any act of
negligence can have serious consequences
NARRATOR [continued]: for patients, for the reputations and
licenses of the health care
professionals involved, and for the accreditation and reputation
of the whole institution.
HEALTH CARE PROVIDER: Emily is bleeding. I think she's
abrupted. Her water has broken.
HEALTH CARE PROVIDER: I think she's crashing.
HEALTH CARE PROVIDER: OK.
NARRATOR: In this program, we will discuss the legal
elements of negligence and how delegation of
tasks to unlicensed assistive personnel, such as Certified
Nursing Assistants, or CNAs, and others,
affects your liability. We will also discuss some of the most
common types
NARRATOR [continued]: of nursing negligence. Daniel Giroux
is an attorney specializing in medical
law. He has been involved in thousands of medical-malpractice
lawsuits. Nikki Lind is a practicing
registered nurse. She has been a registered nurse for eight years.
DANIEL GIROUX: I've been practicing for close to 20 years,
and currently, my specialty is medical
malpractice. So I represent individuals who've been harmed
through medical neglect. So I go after
either hospitals, health care providers, nurses, nurse
practitioners, mid-levels, anybody in the health
care
DANIEL GIROUX [continued]: field. The biggest thing, as it
relates to nurses, I think, that I can say is
that nurses are the patient advocate. I mean, they are the ears,
the eyes of the patients, and they're
the ones who have got to bring to the attention of a physician or
a mid-level, problems, or changes,
or deviations from a patient's current status.
DANIEL GIROUX [continued]: I think the biggest places where
we see harm is that when there's
not contemporaneous notes made. There's not accurate charting
that is done. There not being an
advocate for the patient. Even when they know that a
physician's not doing what they're supposed to
do, there's things that they can do, like implement what's known
as the "chain of command." I think,
from my standpoint, in my career,
DANIEL GIROUX [continued]: those are the things where we
see nurses get in trouble.
NARRATOR: In its simplest terms, "negligence" can be defined
as a "failure to exercise the degree
of care that a reasonable nurse would exercise under the same or
similar circumstances." But there's
more to it than that. Legally, negligence consists of four
elements which must be proven.
NARRATOR [continued]: First, it must be proven that you owe
a duty to the patient-- that is that a
nurse-patient relationship exists. This relationship can be
established in a number of ways. If you are
assigned to care for the patient, or if you observe any
unattended patient who obviously needs help,
you, as a nurse, owe that patient a duty to provide help.
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NARRATOR [continued]: If you are in a clinical setting, and
you give nursing advice to someone who
asks for it, in the eyes of the law, you have established a nurse-
patient relationship. Even if another
caregiver is present, if you observe a patient receiving inferior
care, you have a duty to take action,
either to help with the care
NARRATOR [continued]: yourself or summon help.
HEALTH CARE PROVIDER: All right, let's see if that works.
DANIEL GIROUX: I've had a case against a facility here in the
Midwest where a nurse was required
to follow standard postpartum orders. Within an hour after any
type of delivery, that is when a mother
is more likely to have a hemorrhage. And in that particular case,
for the first 20 minutes,
DANIEL GIROUX [continued]: every five minutes, you're
checking vitals, and every 10 minutes,
and every 15 minutes. And it's pretty standard throughout the
United States what they're supposed
to do. But in this particular case, the nurse wasn't checking
vitals for an hour. And ultimately,
what happened when she finally decided to check the vitals,
unfortunately, the patient was very
hypotensive.
DANIEL GIROUX [continued]: Her blood pressure was 80 over
40. She had a heart rate of 140. And
she was in a late-stage hemorrhage. And ultimately, she
required an emergent hysterectomy. That's
the way they control the bleeding. She had a, pretty much,
complete blood-volume resuscitation,
DANIEL GIROUX [continued]: and she ended up passing away.
HEALTH CARE PROVIDER: Her temperature is 99.
HEALTH CARE PROVIDER: And her pulse?
HEALTH CARE PROVIDER: Is 60.
NARRATOR: Your duty is to provide care that meets the legal
standard of care. This is the care that
a reasonable and prudent nurse would be expected to provide.
Many sources help define the legal
standards of care. These can include your state's board of
nursing; federal statutes, such as the
patient's bill of rights;
NARRATOR [continued]: state statutes, such as Nurse Practice
Act; and other laws setting standards
of care. Other sources of the legal standard of care are
guidelines and policies for nursing-care
delivery issued by organizations, such as the Joint Commission;
professional nursing organizations,
NARRATOR [continued]: such as the American Nurses
Association, ANA; specialty-nursing
organizations, such as the Association of Preoperative
Registered Nurses, AORN, and American
Association of Critical Care Nurses, AACN; authoritative
nursing texts and journals;
NARRATOR [continued]: your own institution's policies and
procedures manuals; and published court
cases involving similar circumstances. Many times, health care
providers are informed that there are
policies and procedures but fail to take the time actually, to
review and understand them.
NARRATOR [continued]: Policies and procedures are
commonly used in negligence claims.
Standards of care can be variable and can change on a yearly, or
even monthly, basis. With that said,
nurses have been sued for such things like failing to follow a
fall protocol; failing to follow procedures
for a specific skill,
NARRATOR [continued]: such as administering medications or
inserting a nasogastric tube; or failure
to make use of equipment correctly or responsibly. If you have
set up equipment for anything other
than a manufacturer's intended purpose, or against policy and
procedure, you could be liable. You
could also be sued for malpractice for using equipment that
you're not familiar with
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NARRATOR [continued]: or haven't been trained to use.
NIKKI LIND: You follow your orders. They're there for a
reason. Those things are in place because
we've ironed out the kinks. They figured out what we need to
do, and that's why we do what we do.
We need to follow those procedures. We follow our orders sets.
You have lots of education when
you're in those areas, as well, why we're doing what we're
doing,
NIKKI LIND [continued]: and that's why they're important
because there could be bad outcomes. And
we never want that to happen.
NARRATOR: The second legal element of negligence that must
be proven is that you breached your
duty to the patient.
HEALTH CARE PROVIDER: We'll be gone for just a little bit.
Call us if you need something, OK?
PATIENT: All right.
HEALTH CARE PROVIDER: OK.
NARRATOR: A breach is any act that falls below the standard
of care. The breach may be by an act
or failure to act, Either giving care in an unsafe manner or
omitting necessary care. A breach of duty
may also be an error in assessment or planning that causes
damage to the patient.
HEALTH CARE PROVIDER: OK, look straight ahead. Head up.
NARRATOR: An assessment error, for example, might be as
simple as improperly gathering
information or not monitoring a patient's condition as frequently
as needed. Or a breach may involve
more complex issues of judgment, such as not recognizing the
significance of a symptom, or a
change in the patient's condition,
NARRATOR [continued]: or not communicating this effectively
to the physician or your supervisor.
An assessment error or breach can be not reporting, in a timely
manner, critical values, vital signs,
assessment findings, and lack of results for medications or
interventions.
NARRATOR [continued]: A planning error might be developing
an inadequate patient care plan that
fails to address one of the patient's needs. For example, a
planning error occurs when a care plan for
a bedridden patient does not include enough repositioning. This
places the patient at risk for pressure
sores and blood
NARRATOR [continued]: clots. The third element of negligence
that must be proven is that your
breach of duty caused injury or damages to the patient. It is
important to recognize that it isn't
necessary for your action to enforce the patient to sustain an
injury.
PATIENT: Nurse?
NARRATOR: An action or omission that simply allowed it to
happen is enough. For example, if you
are caring for a patient in a post-op unit who has received
medications that caused disorientation or
confusion, as in this scene, and you leave the bed rail down, you
have created a condition
NARRATOR [continued]: that makes it foreseeable that the
patient could fall out of bed. Even if other
factors contribute to the patient's injury, as long as your breach
of duty was a substantial causative
factor, it is enough under the law. The fourth element of
negligence that must be proven is that there
was actual harm to the patient.
NARRATOR [continued]: Some injury or a worsening of the
patient's condition must occur as a
consequence of your breach of duty. In this case, the actual
harm of the arm injury is a direct
consequence of the fall.
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DANIEL GIROUX: And there's a lot of things that go into that.
When you're talking about, what's their
personal exposure, well, it depends on the potential harm to a
particular patient. Obviously, more
harm, a debilitating injury that is a life-sustaining injury that's
going to require a medical expense for
the remainder of their life--
DANIEL GIROUX [continued]: typically the higher those types
of cases will draw in terms of a verdict
or some type of settlement. So you've got to balance that with
what level of insurance do they have?
What are their limits on their policy? And if they have a policy
that is not high enough, then potentially,
they can expose their personal assets.
WOMAN: Well, not specifically. It's been quite a while ago.
NARRATOR: If all of these conditions are proven in court, the
patient can recover what are called
"compensatory damages." These are monies that are meant to
compensate the patient for the cost
of care, lost wages, and pain and suffering. In rare cases, if the
negligence was especially reckless,
NARRATOR [continued]: some states allow patients to be
awarded punitive damages as well to
punish the reckless caregiver. Many insurance policies do not
cover punitive damages, and a
caregiver may be personally liable for them.
DANIEL GIROUX: I've had a case against a facility here in the
Midwest where a nurse was required
to follow standard postpartum orders. Within an hour after any
type of delivery, that is when a mother
is more likely to have a hemorrhage. And in that particular case,
for the first 20 minutes,
DANIEL GIROUX [continued]: every five minutes, you're
checking vitals, and every 10 minutes,
and every 15 minutes. And it's pretty standard throughout the
United States what they're supposed
to do. But in this particular case, the nurse wasn't checking
vitals for an hour. And ultimately,
what happened when she finally decided to check the vitals,
unfortunately, the patient was very
hypotensive.
DANIEL GIROUX [continued]: Her blood pressure was 80 over
40, she had a heart rate of 140, and
she was in a late-stage hemorrhage, and she ended up passing
away. And in that case, it was just a
matter of had the vital signs have been properly recorded when
they were supposed to and brought
to the attention of the physician, there's things at the early
stages of hemorrhage, that could have
been done to abate the ultimate problem
DANIEL GIROUX [continued]: and the death in that particular
case.
NIKKI LIND: Well I actually used to work in labor and
delivery. And so it's highly important, especially
in that area, you're doing vitals, and fundal checks, and
everything you're supposed to do. And if you
don't do it, that's one of the scary stories that could come about.
And you just follow your orders.
NIKKI LIND [continued]: They're there for a reason. Those
things are in place because we've ironed
out the kinks. They figured out what we need to do, and that's
why we do what we do. We need to
follow those procedures, we follow our orders sets. You have
lots of education when you're in those
areas,
NIKKI LIND [continued]: as well-- why we're doing what we're
doing. And that's why they're important
because there could be bad outcomes. And we never want that to
happen.
HEALTH CARE PROVIDER: After you pump up, you slowly
release the valve.
NARRATOR: In an attempt to keep health care costs under
control, more of the work of nursing is
being shifted to unlicensed assistive personnel and CNAs. By
taking over some of the lesser-skilled
and less-critical tasks, CNAs free up registered nurses for
supervision and to concentrate on the
critical portions of the nursing process itself.
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NARRATOR [continued]: The use of more licensed vocational
and licensed practical nurses, certified
nursing assistants, feeding assistants, and even personnel with
limited training, such as orderlies
and hospital volunteers, has created, in many facilities, more of
a team approach to nursing, with
more tasks delegated
NARRATOR [continued]: to the lesser-skilled personnel. But
even with delegation, responsibility
remains largely with a registered nurse. In general, unlicensed
assistive personnel must be under
the supervision of a registered nurse and can only do tasks that
a registered nurse has
NARRATOR [continued]: delegated to them. However,
effective delegation extends far beyond the
act of simply telling someone to go do a task. It requires a high
level of critical thinking and
professional judgment. According to the American Nurses
Association and the National Council of
State Boards of Nursing,
NARRATOR [continued]: the guidelines for effective
delegation can be summarized using the five
Rs-- the delegation or assignment must be the right task given
under the right circumstances to the
right person using the right instructions. And the person
delegating must also
NARRATOR [continued]: provide the right supervision and
evaluation. The nurse must determine
the right tasks for delegation to assistive personnel. It is
important to remember that the registered
nurse may never delegate any portion of the nursing process
that depends on his or her professional
judgment.
NARRATOR [continued]: for example, the assessment of a
patient, developing and evaluating the
nursing plan of care for the patient, and interpreting and
analyzing data are the responsibility of the
registered nurse and cannot be delegated because they require
the nurse's knowledge, expertise,
and judgment.
HEALTH CARE PROVIDER: How is her temperature doing?
NARRATOR: To ensure the right circumstances, the nurse must
always take into account the
patient's condition, the setting, and the available resources when
delegating any task.
HEALTH CARE PROVIDER: Her temperature is 99.
HEALTH CARE PROVIDER: Heart rate?
HEALTH CARE PROVIDER: Is 60.
NARRATOR: When dealing with a critical patient, the nurse
should not be assigning duties that he or
she should be assessing themselves. Of course, when selecting a
person to delegate to, the nurse
must take into account the knowledge and skill level of that
individual. And once a task is delegated
to an unlicensed person,
NARRATOR [continued]: that person may not subdelegate the
task to someone else. The delegated
task must be clearly described, including all the details about
what, when, and why. Delegation does
not end a nurse's responsibility.
NARRATOR [continued]: The person delegating must either
supervise the task or assure that
supervision is available. If necessary, the registered nurse must
teach the skill being delegated to the
person and supervise the performance of the task. There can be
no delegation unless there is an
appropriate level of supervision.
NARRATOR [continued]: Supervision means initial and
ongoing direction, including direct
observation if necessary. And the nurse must remain available
for procedural guidance and
evaluation of the task. Remember, it is negligence on the part of
the nurse if the nurse fails to
delegate or supervise properly.
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HEALTH CARE PROVIDER: Call the doctor. I need to have
help in here right now.
NARRATOR: In some states, the nurse also may be found
legally responsible for any harm to the
patient that results.
HEALTH CARE PROVIDER: And we've upped her IV?
HEALTH CARE PROVIDER: We have upped her IV.
HEALTH CARE PROVIDER: OK.
HEALTH CARE PROVIDER: Emily, Can you hear us?
[INTERPOSING VOICES]
HEALTH CARE PROVIDER: Can you hear us?
HEALTH CARE PROVIDER: Can you please call her doctor
straight away, please? We need an OR
right away.
NARRATOR: Studies have identified the most common legal
allegations that have resulted in
successful negligence lawsuits filed against nurses. The most
common is patient falls. According to
the Centers for Disease Control, more adults over 65 die from
fall-related injuries
NARRATOR [continued]: than any other condition. Guidelines
have been established for mitigating
the risk of patient falls. Many hospitals have established
frameworks for assessing risk factors for
patient falls, implementing intervention for reducing the risk of
falling and protecting the patient from
injury if a fall should occur.
NARRATOR [continued]: Staff must maintain responsibility for
patient safety at all times, even when
family is present. Always refer to the most up-to-date policies
and procedures of your institution.
Another common problem leading to negligence lawsuits is the
improper technique and maintenance
of IV lines. One example would be a failure to use proper
ascetic technique
NARRATOR [continued]: when starting the IV. And another
would be failure to monitor the IV-
insertion site often enough, allowing the development of an
infection or infiltration. Other patient-
safety issues are also a problem. One example is not contacting
the physician prior to the placement
of restraints and ensuring
NARRATOR [continued]: that you have followed the
institutional policy by not properly assessing the
patient or documenting the use of alternative interventions to
restraints. A major source of negligence
lawsuits is medication errors. According to one study in 56
facilities, the most common types of
medication errors
NARRATOR [continued]: are administering the improper
dosage, or administering a medication to
the wrong patient, or failing to administer a needed medication.
Medication errors are most often
caused by distractions, and especially heavy workloads. But that
is no excuse for a very serious
breach of duty.
NARRATOR [continued]: Additional breaches involving
medications may include such things as
failure to recognize signs and symptoms of drug toxicity, failure
to request an order for drug levels,
failure to use aseptic technique, failure to document the
injection site, failure to check for drug
allergies,
NARRATOR [continued]: and failure to identify potential
medications side-effects that placed the
patient at risk-- for example, giving an antihypertensive agent
to a patient who already has low
blood pressure, or giving antiplatelet medication to a patient
who has active bleeding. Administering
medication according
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NARRATOR [continued]: to the doctor's orders is a common
nursing task. If the nurse fails to follow
the orders, she or he will be liable for malpractice if the patient
is injured. The nurse may also be
liable for negligently following otherwise proper orders, like
injecting a medication into muscle instead
of a vein, or injecting the wrong patient.
DANIEL GIROUX: I just had a case three years ago against a
facility, wherein a physician's letter--
or his number 1 actually look like a 4. And my client ended up
getting 4 micrograms of dilaudid rather
than 1 microgram of dilaudid.
DANIEL GIROUX [continued]: And she went into respiratory
distress within 20 minutes and died
within 60 minutes.
NIKKI LIND: It's hard to question a doctor when they're giving
you an order or they are in a situation,
because sometimes I've come in-- like when I work with
residents or less-seasoned doctors, they
sometimes are put into situations where they're not always
100%,
NIKKI LIND [continued]: and they don't have 100% of the
knowledge that they need to take care of
that situation. And so there have been instances where the nurse
has more experience, and so they
will question what their orders are and what their follow-up
processes, or what their plan of care is.
And you can suggest seeking another doctor's opinion
NIKKI LIND [continued]: or just bringing to light, this is what
I think is going on, or this is what I think
might be the outcome if we don't look at this.
HEALTH CARE PROVIDER: Oh, hi. I'm glad you're here. I was
going to show--
NARRATOR: Another source of negligence lawsuits is
improperly performing a treatment. This can
be from equipment that is set up or used improperly or from
simple procedures in which the nurse
did not follow the proper standards of care. You should always
stay current on the procedures and
equipment used in your field of practice.
NARRATOR [continued]: A further source of negligence claims
is failure to respond to a patient's call
for assistance. You have a duty to respond in a timely manner,
especially for patients whose condition
may change rapidly, who might have a severe drug reaction, or
who may have self-destructive
tendencies.
NARRATOR [continued]: And finally, one of the common
forms of nursing negligence is failing to
properly supervise someone to whom you have delegated a task.
Remember that the whole process
of delegation is one of judging the skill level of the unlicensed
person you have selected; teaching
the skill, if necessary; and providing adequate supervision
NARRATOR [continued]: to be sure that the task is performed
properly. Many other problems stem
from inadequate communication, improper documentation,
improper techniques, and other failures to
exercise the degree of care that a reasonable nurse would be
expected to exercise under the same
circumstances.
NARRATOR [continued]: Failure to communicate and failure to
document can be grounds for a
malpractice suit against an individual nurse.
NIKKI LIND: Usually these cases-- things like this-- they're
happening months, years after the event.
So charting is huge because if you don't chart it, it didn't
happen. So clear, concise non-emotional,
the facts of what's going on-- that's what you need to put in
your charting, making sure that you're
not only doing what you're supposed to do,
NIKKI LIND [continued]: but advocating for your patient. But
you need to make sure that that's
documented that you did it because you can't prove later that
you did something if it's not charted.
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NARRATOR: If you fail to communicate all patient information
to a physician, to provide a patient
with relevant discharge information, or to communicate
assessment findings to the nurse on the next
shift, you could be liable. Proper charting and documentation
are incredibly important for ensuring
that a patient
NARRATOR [continued]: receives the care they need. As far as
the court is concerned, if it wasn't
documented, it never happened. In the next program in this
series, we will discuss practical steps you
can take to prevent acts of negligence. This program also
contains several brief scenes of nursing
activities that may or may not involve negligence,
NARRATOR [continued]: so you can test your understanding.
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Nursing Negligence: Guidelines for Care
It was never going to be easy to succeed Tony Hsieh, the
celebrated chief executive of Zappos, who turned a tiny online
shoe seller into a $1 billion behemoth through an obsessive
focus on corporate culture and happy employees. But Kedar
Deshpande took over at a particularly fraught time.
Zappos, which is owned by Amazon, was already navigating
remote work and grappling with pandemic-driven changes in
how people shop when Mr. Hsieh abruptly retired in August
after two decades, which led Mr. Deshpande to be named C.E.O.
Then in November, tragedy struck: Mr. Hsieh, 46, died from
injuries suffered in a house fire in New London, Conn., sending
shock waves throughout the roughly 1,500-person company, as
well as tech and entrepreneurial circles.
Since then, it has been reported that Mr. Hsieh had been
behaving erratically for months and that friends had considered
staging an intervention last summer. The revelations brought
new scrutiny to the circumstances of his exit from Zappos.
Mr. Deshpande, who was previously Zappos's chief operating
officer, said that when Mr. Hsieh told him last summer that he
wanted to pursue other projects, he did not push back.
"From my experience working with Tony, Tony always believed
in the things that he wanted to change," Mr. Deshpande said in
an interview, his first as chief executive. "I asked him, 'Hey,
Tony, are you sure?' And he said, 'Yes, I want to retire' -- so
that was the end of the conversation."
Now, Mr. Deshpande, 42, is tasked with shepherding Zappos
through the late stages of the pandemic and into the company's
next phase as an online retailer, without Mr. Hsieh's guidance.
He must also show whether the company's culture of "fun and a
little weirdness" in Las Vegas can survive without its chief
architect.
"The Covid situation and everything else going on makes it very
tough, particularly with a culture that is built on physical
proximity and happiness associated with that," Mr. Deshpande
said in the Zoom interview, from his home in Henderson, Nev.
But he said he was optimistic about the future, especially given
the decade he had spent at Zappos in different roles.
"The culture is not just one person or two people," he said.
There was apparently no long-term succession plan when Mr.
Hsieh stepped down. Zappos's board, which consists of Amazon
and Zappos employees, elevated Mr. Deshpande to the role. The
company, founded in 1999, has long functioned as an
independent unit within Amazon, which acquired it for $1.2
billion in July 2009 and does not disclose its financials.
It's tough for a person to replace a C.E.O. with an outsize
personality like Mr. Hsieh, said Erik Gordon, a professor at the
University of Michigan Ross School of Business, who
anticipated that Zappos's culture will face some changes under
new leadership.
"The person who takes over from the founder who created the
culture doesn't have the authenticity or moral authority that the
founder had," Mr. Gordon said. "Can he maintain the same
spirit of fun and a little weirdness and positive team spirit?"
(Mr. Hsieh did not found the company, but has been referred to
as a founder based on his involvement as an investor and chief
executive from its earliest days.)
Mr. Deshpande, who is from Aurangabad, India, came to the
United States for a master's degree in computer engineering,
and joined Zappos after stints at General Electric and PepsiCo.
He joins a growing list of South Asian chief executives in the
United States, at companies like Microsoft; Google's parent
company, Alphabet; and Gap.
Zappos, which derives its name from "zapatos," the Spanish
word for shoes, was an early e-commerce success story under
Mr. Hsieh, who wrote a best-selling book in 2010, "Delivering
Happiness: A Path to Profits, Passion, and Purpose." It argued
that a company's top priority should be its culture and that
keeping employees happy translated into success with
customers.
The company, which moved from the Bay Area to southern
Nevada in 2004 and now has a campus in downtown Las Vegas,
developed a reputation for being a fun, almost cultlike place to
work, where employees regularly socialized at work and outside
the office. The company has claimed that it is harder to get a
job at Zappos than it is to get into Harvard.
Mr. Deshpande said Zappos employees had become closer in
some ways in the past year as they brought family or pets into
the remote-work fold.
"When we have Halloween contests, it's the entire family that is
participating," said Mr. Deshpande, who has two young
daughters. He described packages Zappos sent to employees and
their families for activities like planting herb gardens or
performing science experiments.
He guessed that employees would start returning to the office
after July 1 and were likely to develop hybrid schedules with
some remote and some in-person work.
While Zappos did not have to struggle with the drop-off at
physical stores that so many other retailers did, it did take a hit
early on in the pandemic as shoes and clothing became an
afterthought; few people were buying high heels last March.
Sales have recovered since, fueled by demand in the so-called
performance and home categories -- think running and hiking
shoes, pajamas, athleisure and slippers.
Mr. Deshpande said he was unsure when demand for high heels
would return, but anticipated that people would continue to
want comfort as the economy reopened.
Zappos has introduced and expanded ways to smooth out the
kinks of online shopping during the pandemic, like allowing
some customers to make returns through UPS home pickups,
and making it easier to exchange items. It also observed that the
average length of calls with customer service representatives
had increased as people had more time in a closed-off world.
They also left more detailed reviews on products.
One of the company's biggest goals, and a top priority for Mr.
Deshpande in coming years, is figuring out how to make online
shopping less transactional and more like the browsing
experiences that people seek out in malls and department stores.
That includes developing new digital magazinelike "verticals" --
much like what media companies create -- such as "The Ones,"
which is tailored for female sneakerheads and advertised as
"powered by Zappos."
Zappos is also behind VRSNL, a luxury site that has its own
web address and no visible link to the shoe site. It features
wares from designers like Dolce & Gabbana and Proenza
Schouler. The company has been pouring new effort into
product detail pages and informational videos catered to
audiences like new runners, and even co-developing
merchandise and campaigns with the brands it carries.
"What online fails to deliver, which physical delivers today, is
around these different experiences," Mr. Deshpande said. "Until
you actually go and deliver on these experiences, people will go
back to the physical, in my opinion, and they will stay online
for only transactional experiences."
The company refers to these efforts as "experience commerce,"
and said the category was driving 25 percent of its investments.
Outside of prompting consumers to explore more, Zappos is also
trying to make online shopping more cohesive -- all with the
aim of getting consumers to spend more money over time.
"One of the challenges has been that when somebody walks into
'online,' somebody looking for a jacket, for example, we show
them inventory next to each other -- like a $30
jacket, $50, $100, $300," Mr. Deshpande said. "This is a very
disorienting experience."
In his view, all of the efforts are in line with Zappos's obsessive
focus on service for the past 20 years, which he anticipates
remaining its focus for the next 20 years.
While the company is still grieving Mr. Hsieh, Mr. Deshpande
said, employees will continue to embody the values that he
championed. He pointed to an instance during the holidays when
one employee mentioned children missing out on meeting Santa
Claus during the pandemic, leading to a multidepartment effort
to set up Santa Zoom meetings for children around the country.
"To me, Tony's legacy is around delivering this happiness to
everybody," Mr. Deshpande said. "This culture he has created or
pioneered, it's going to be alive."

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Tony Hsieh, the Zappos.com luminary who revolutionize.docx

  • 1. Tony Hsieh, the Zappos.com luminary who revolutionized the shoe business and established a unique corporate culture along the way, has died at age 46. Hsieh's family confirmed his death Friday night in a text message to friends, noting that Tony's generous spirit touched the lives of countless people and that he left an indelible mark on the world. The executive died from injuries sustained in a Connecticut house fire, according to press reports citing a family lawyer. Hsieh, a serial entrepreneur, cofounded Zappos in 1999 and grew it into a blockbuster business before selling it to Amazon in 2009. Delivering happiness was the executive's mantra. As he built Zappos, Hsieh's chief goal was to redefine the meaning of company culture. From the beginning, his singular vision set the company apart as a pioneer in footwear e-commerce and corporate America. "The world has lost a tremendous visionary and an incredible human being," said Zappos chief executive officer Kedar Deshpande in a note to employees on Friday. "We recognize that not only have we lost our inspiring former leader, but many of you have also lost a mentor and a friend. Tony played such an integral part in helping create the thriving Zappos business we have today, along with his passion for helping to support and drive our company culture." Hsieh, who retired and stepped down from the Zappos helm this past summer, told WWD's sister publication Footwear News last year how much the company had evolved since it was founded two decades ago. "A lot of our growth and innovation moving forward will be based on thinking about what we're in the business of differently," Hsieh told FN last year, when Zappos celebrated
  • 2. its 20th anniversary. "We used to say we're a service company that just happens to sell shoes, and now it's turned into: We're a service company that just happens to sell blank." The Zappos origin story is a familiar one -- Hsieh shared it in his speaking engagements and in the pages of his New York Times bestseller, "Delivering Happiness: A Path to Profits, Passion, and Purpose." And the 100,000-plus visitors who have toured Zappos' headquarters have been regaled with the tale of a fateful phone call. After Zappos cofounder Nick Swinmurn latched onto the idea of selling shoes online, he left a voicemail with Hsieh's San Francisco venture capital fund, Venture Frogs, hooking him with one factoid: "It was the fact that 5 percent of a $40 billion shoe business was already being done through mail order," Swinmurn told FN during a 2009 interview. "That was my big statistic. People were already buying shoes without trying them on." Then, after another call to the Nordstrom department store in San Francisco, Fred Mossler eventually jumped on board, and together the new team set out to change the industry. Zappos was a pioneer in free shipping and returns, and it didn't take long for the concept to take hold as e-commerce took off. In 2009, Zappos was acquired by Amazon.com Inc. for 10 million shares of Amazon stock, which, at the time of the deal, Hsieh said was valued at about $1.2 billion. While many market watchers celebrated the marriage, they also speculated that the new parent could impose its own culture on the new division. But true to the initial agreement, Zappos has continued to operate separately from Amazon, maintaining its own leadership team and unique character. Several years into the Amazon partnership, Hsieh launched The Downtown Project, an initiative to revitalize downtown Las Vegas. The goal, Hsieh explained at FN's 2013 CEO Summit, was to create a neighborhood that is walkable and community-focused. The Downtown Project is even investing in individuals, helping
  • 3. them realize their dreams of starting small businesses. "We are thinking of the city as a start-up," he said. "We want it to be the anti-Strip -- with bars and coffee shops." In 2015, Zappos did away with managers in favor of a form of self-organization called holacracy. In a blog post at the time, Hsieh wrote, "Like all the bold steps we've done in the past, it feels a little scary, but it also feels like exactly the type of thing that only a company such as Zappos would dare to attempt at this scale." Since its early days, Zappos has functioned as something of an incubator for testing theories about corporate culture and productivity -- long before those ideas became the buzzwords they are today. Much of the credit for that lies with Hsieh. "His spirit will forever be a part of Zappos, and we will continue to honor his memory by dedicating ourselves to continuing the work he was so passionate about," Deshpande wrote in the note to employees. "Our thoughts remain with him and his loved ones. Zappos is a family, and we will continue to hold Tony close in our hearts." Nursing Negligence: Guidelines for Care Video Title: Nursing Negligence: Guidelines for Care Originally Published: 2007 Publication Date: Mar. 20, 2020 Publishing Company: Medcom Inc. City: United States ISBN: 9781529727906
  • 4. DOI: https://dx.doi.org/10.4135/9781529727906 © Medcom Inc., 2007 www.princexml.com Prince - Non-commercial License This document was created with Prince, a great way of getting web content onto paper. https://dx.doi.org/10.4135/9781529727906 [MUSIC PLAYING] NARRATOR: Today, there are tremendous pressures on the time of everyone in health care, particularly on nurses. As a result of cost-cutting efforts made in all areas of health care, the delegation of some traditional nursing tasks is occurring. However, this should be done carefully so that legal issues, such as negligence, do not arise. NARRATOR [continued]: While damage caps in some states have reduced negligence suits against nurses and limited the amount of some awards for nursing negligence, nurses are at risk for negligence lawsuits, and more than 400 judgments are made against nurses every year. Any act of negligence can have serious consequences NARRATOR [continued]: for patients, for the reputations and licenses of the health care professionals involved, and for the accreditation and reputation of the whole institution.
  • 5. HEALTH CARE PROVIDER: Emily is bleeding. I think she's abrupted. Her water has broken. HEALTH CARE PROVIDER: I think she's crashing. HEALTH CARE PROVIDER: OK. NARRATOR: In this program, we will discuss the legal elements of negligence and how delegation of tasks to unlicensed assistive personnel, such as Certified Nursing Assistants, or CNAs, and others, affects your liability. We will also discuss some of the most common types NARRATOR [continued]: of nursing negligence. Daniel Giroux is an attorney specializing in medical law. He has been involved in thousands of medical-malpractice lawsuits. Nikki Lind is a practicing registered nurse. She has been a registered nurse for eight years. DANIEL GIROUX: I've been practicing for close to 20 years, and currently, my specialty is medical malpractice. So I represent individuals who've been harmed through medical neglect. So I go after either hospitals, health care providers, nurses, nurse practitioners, mid-levels, anybody in the health care DANIEL GIROUX [continued]: field. The biggest thing, as it relates to nurses, I think, that I can say is that nurses are the patient advocate. I mean, they are the ears, the eyes of the patients, and they're the ones who have got to bring to the attention of a physician or a mid-level, problems, or changes, or deviations from a patient's current status.
  • 6. DANIEL GIROUX [continued]: I think the biggest places where we see harm is that when there's not contemporaneous notes made. There's not accurate charting that is done. There not being an advocate for the patient. Even when they know that a physician's not doing what they're supposed to do, there's things that they can do, like implement what's known as the "chain of command." I think, from my standpoint, in my career, DANIEL GIROUX [continued]: those are the things where we see nurses get in trouble. NARRATOR: In its simplest terms, "negligence" can be defined as a "failure to exercise the degree of care that a reasonable nurse would exercise under the same or similar circumstances." But there's more to it than that. Legally, negligence consists of four elements which must be proven. NARRATOR [continued]: First, it must be proven that you owe a duty to the patient-- that is that a nurse-patient relationship exists. This relationship can be established in a number of ways. If you are assigned to care for the patient, or if you observe any unattended patient who obviously needs help, you, as a nurse, owe that patient a duty to provide help. SAGE © Medcom Inc., 2007 SAGE Video Page 2 of 9 Nursing Negligence: Guidelines for Care
  • 7. NARRATOR [continued]: If you are in a clinical setting, and you give nursing advice to someone who asks for it, in the eyes of the law, you have established a nurse- patient relationship. Even if another caregiver is present, if you observe a patient receiving inferior care, you have a duty to take action, either to help with the care NARRATOR [continued]: yourself or summon help. HEALTH CARE PROVIDER: All right, let's see if that works. DANIEL GIROUX: I've had a case against a facility here in the Midwest where a nurse was required to follow standard postpartum orders. Within an hour after any type of delivery, that is when a mother is more likely to have a hemorrhage. And in that particular case, for the first 20 minutes, DANIEL GIROUX [continued]: every five minutes, you're checking vitals, and every 10 minutes, and every 15 minutes. And it's pretty standard throughout the United States what they're supposed to do. But in this particular case, the nurse wasn't checking vitals for an hour. And ultimately, what happened when she finally decided to check the vitals, unfortunately, the patient was very hypotensive. DANIEL GIROUX [continued]: Her blood pressure was 80 over 40. She had a heart rate of 140. And she was in a late-stage hemorrhage. And ultimately, she required an emergent hysterectomy. That's the way they control the bleeding. She had a, pretty much,
  • 8. complete blood-volume resuscitation, DANIEL GIROUX [continued]: and she ended up passing away. HEALTH CARE PROVIDER: Her temperature is 99. HEALTH CARE PROVIDER: And her pulse? HEALTH CARE PROVIDER: Is 60. NARRATOR: Your duty is to provide care that meets the legal standard of care. This is the care that a reasonable and prudent nurse would be expected to provide. Many sources help define the legal standards of care. These can include your state's board of nursing; federal statutes, such as the patient's bill of rights; NARRATOR [continued]: state statutes, such as Nurse Practice Act; and other laws setting standards of care. Other sources of the legal standard of care are guidelines and policies for nursing-care delivery issued by organizations, such as the Joint Commission; professional nursing organizations, NARRATOR [continued]: such as the American Nurses Association, ANA; specialty-nursing organizations, such as the Association of Preoperative Registered Nurses, AORN, and American Association of Critical Care Nurses, AACN; authoritative nursing texts and journals; NARRATOR [continued]: your own institution's policies and procedures manuals; and published court cases involving similar circumstances. Many times, health care providers are informed that there are
  • 9. policies and procedures but fail to take the time actually, to review and understand them. NARRATOR [continued]: Policies and procedures are commonly used in negligence claims. Standards of care can be variable and can change on a yearly, or even monthly, basis. With that said, nurses have been sued for such things like failing to follow a fall protocol; failing to follow procedures for a specific skill, NARRATOR [continued]: such as administering medications or inserting a nasogastric tube; or failure to make use of equipment correctly or responsibly. If you have set up equipment for anything other than a manufacturer's intended purpose, or against policy and procedure, you could be liable. You could also be sued for malpractice for using equipment that you're not familiar with SAGE © Medcom Inc., 2007 SAGE Video Page 3 of 9 Nursing Negligence: Guidelines for Care NARRATOR [continued]: or haven't been trained to use. NIKKI LIND: You follow your orders. They're there for a reason. Those things are in place because we've ironed out the kinks. They figured out what we need to do, and that's why we do what we do.
  • 10. We need to follow those procedures. We follow our orders sets. You have lots of education when you're in those areas, as well, why we're doing what we're doing, NIKKI LIND [continued]: and that's why they're important because there could be bad outcomes. And we never want that to happen. NARRATOR: The second legal element of negligence that must be proven is that you breached your duty to the patient. HEALTH CARE PROVIDER: We'll be gone for just a little bit. Call us if you need something, OK? PATIENT: All right. HEALTH CARE PROVIDER: OK. NARRATOR: A breach is any act that falls below the standard of care. The breach may be by an act or failure to act, Either giving care in an unsafe manner or omitting necessary care. A breach of duty may also be an error in assessment or planning that causes damage to the patient. HEALTH CARE PROVIDER: OK, look straight ahead. Head up. NARRATOR: An assessment error, for example, might be as simple as improperly gathering information or not monitoring a patient's condition as frequently as needed. Or a breach may involve more complex issues of judgment, such as not recognizing the significance of a symptom, or a change in the patient's condition,
  • 11. NARRATOR [continued]: or not communicating this effectively to the physician or your supervisor. An assessment error or breach can be not reporting, in a timely manner, critical values, vital signs, assessment findings, and lack of results for medications or interventions. NARRATOR [continued]: A planning error might be developing an inadequate patient care plan that fails to address one of the patient's needs. For example, a planning error occurs when a care plan for a bedridden patient does not include enough repositioning. This places the patient at risk for pressure sores and blood NARRATOR [continued]: clots. The third element of negligence that must be proven is that your breach of duty caused injury or damages to the patient. It is important to recognize that it isn't necessary for your action to enforce the patient to sustain an injury. PATIENT: Nurse? NARRATOR: An action or omission that simply allowed it to happen is enough. For example, if you are caring for a patient in a post-op unit who has received medications that caused disorientation or confusion, as in this scene, and you leave the bed rail down, you have created a condition NARRATOR [continued]: that makes it foreseeable that the patient could fall out of bed. Even if other factors contribute to the patient's injury, as long as your breach of duty was a substantial causative
  • 12. factor, it is enough under the law. The fourth element of negligence that must be proven is that there was actual harm to the patient. NARRATOR [continued]: Some injury or a worsening of the patient's condition must occur as a consequence of your breach of duty. In this case, the actual harm of the arm injury is a direct consequence of the fall. SAGE © Medcom Inc., 2007 SAGE Video Page 4 of 9 Nursing Negligence: Guidelines for Care DANIEL GIROUX: And there's a lot of things that go into that. When you're talking about, what's their personal exposure, well, it depends on the potential harm to a particular patient. Obviously, more harm, a debilitating injury that is a life-sustaining injury that's going to require a medical expense for the remainder of their life-- DANIEL GIROUX [continued]: typically the higher those types of cases will draw in terms of a verdict or some type of settlement. So you've got to balance that with what level of insurance do they have? What are their limits on their policy? And if they have a policy that is not high enough, then potentially, they can expose their personal assets.
  • 13. WOMAN: Well, not specifically. It's been quite a while ago. NARRATOR: If all of these conditions are proven in court, the patient can recover what are called "compensatory damages." These are monies that are meant to compensate the patient for the cost of care, lost wages, and pain and suffering. In rare cases, if the negligence was especially reckless, NARRATOR [continued]: some states allow patients to be awarded punitive damages as well to punish the reckless caregiver. Many insurance policies do not cover punitive damages, and a caregiver may be personally liable for them. DANIEL GIROUX: I've had a case against a facility here in the Midwest where a nurse was required to follow standard postpartum orders. Within an hour after any type of delivery, that is when a mother is more likely to have a hemorrhage. And in that particular case, for the first 20 minutes, DANIEL GIROUX [continued]: every five minutes, you're checking vitals, and every 10 minutes, and every 15 minutes. And it's pretty standard throughout the United States what they're supposed to do. But in this particular case, the nurse wasn't checking vitals for an hour. And ultimately, what happened when she finally decided to check the vitals, unfortunately, the patient was very hypotensive. DANIEL GIROUX [continued]: Her blood pressure was 80 over 40, she had a heart rate of 140, and she was in a late-stage hemorrhage, and she ended up passing away. And in that case, it was just a
  • 14. matter of had the vital signs have been properly recorded when they were supposed to and brought to the attention of the physician, there's things at the early stages of hemorrhage, that could have been done to abate the ultimate problem DANIEL GIROUX [continued]: and the death in that particular case. NIKKI LIND: Well I actually used to work in labor and delivery. And so it's highly important, especially in that area, you're doing vitals, and fundal checks, and everything you're supposed to do. And if you don't do it, that's one of the scary stories that could come about. And you just follow your orders. NIKKI LIND [continued]: They're there for a reason. Those things are in place because we've ironed out the kinks. They figured out what we need to do, and that's why we do what we do. We need to follow those procedures, we follow our orders sets. You have lots of education when you're in those areas, NIKKI LIND [continued]: as well-- why we're doing what we're doing. And that's why they're important because there could be bad outcomes. And we never want that to happen. HEALTH CARE PROVIDER: After you pump up, you slowly release the valve. NARRATOR: In an attempt to keep health care costs under control, more of the work of nursing is being shifted to unlicensed assistive personnel and CNAs. By taking over some of the lesser-skilled
  • 15. and less-critical tasks, CNAs free up registered nurses for supervision and to concentrate on the critical portions of the nursing process itself. SAGE © Medcom Inc., 2007 SAGE Video Page 5 of 9 Nursing Negligence: Guidelines for Care NARRATOR [continued]: The use of more licensed vocational and licensed practical nurses, certified nursing assistants, feeding assistants, and even personnel with limited training, such as orderlies and hospital volunteers, has created, in many facilities, more of a team approach to nursing, with more tasks delegated NARRATOR [continued]: to the lesser-skilled personnel. But even with delegation, responsibility remains largely with a registered nurse. In general, unlicensed assistive personnel must be under the supervision of a registered nurse and can only do tasks that a registered nurse has NARRATOR [continued]: delegated to them. However, effective delegation extends far beyond the act of simply telling someone to go do a task. It requires a high level of critical thinking and professional judgment. According to the American Nurses Association and the National Council of State Boards of Nursing,
  • 16. NARRATOR [continued]: the guidelines for effective delegation can be summarized using the five Rs-- the delegation or assignment must be the right task given under the right circumstances to the right person using the right instructions. And the person delegating must also NARRATOR [continued]: provide the right supervision and evaluation. The nurse must determine the right tasks for delegation to assistive personnel. It is important to remember that the registered nurse may never delegate any portion of the nursing process that depends on his or her professional judgment. NARRATOR [continued]: for example, the assessment of a patient, developing and evaluating the nursing plan of care for the patient, and interpreting and analyzing data are the responsibility of the registered nurse and cannot be delegated because they require the nurse's knowledge, expertise, and judgment. HEALTH CARE PROVIDER: How is her temperature doing? NARRATOR: To ensure the right circumstances, the nurse must always take into account the patient's condition, the setting, and the available resources when delegating any task. HEALTH CARE PROVIDER: Her temperature is 99. HEALTH CARE PROVIDER: Heart rate? HEALTH CARE PROVIDER: Is 60.
  • 17. NARRATOR: When dealing with a critical patient, the nurse should not be assigning duties that he or she should be assessing themselves. Of course, when selecting a person to delegate to, the nurse must take into account the knowledge and skill level of that individual. And once a task is delegated to an unlicensed person, NARRATOR [continued]: that person may not subdelegate the task to someone else. The delegated task must be clearly described, including all the details about what, when, and why. Delegation does not end a nurse's responsibility. NARRATOR [continued]: The person delegating must either supervise the task or assure that supervision is available. If necessary, the registered nurse must teach the skill being delegated to the person and supervise the performance of the task. There can be no delegation unless there is an appropriate level of supervision. NARRATOR [continued]: Supervision means initial and ongoing direction, including direct observation if necessary. And the nurse must remain available for procedural guidance and evaluation of the task. Remember, it is negligence on the part of the nurse if the nurse fails to delegate or supervise properly. SAGE © Medcom Inc., 2007 SAGE Video
  • 18. Page 6 of 9 Nursing Negligence: Guidelines for Care HEALTH CARE PROVIDER: Call the doctor. I need to have help in here right now. NARRATOR: In some states, the nurse also may be found legally responsible for any harm to the patient that results. HEALTH CARE PROVIDER: And we've upped her IV? HEALTH CARE PROVIDER: We have upped her IV. HEALTH CARE PROVIDER: OK. HEALTH CARE PROVIDER: Emily, Can you hear us? [INTERPOSING VOICES] HEALTH CARE PROVIDER: Can you hear us? HEALTH CARE PROVIDER: Can you please call her doctor straight away, please? We need an OR right away. NARRATOR: Studies have identified the most common legal allegations that have resulted in successful negligence lawsuits filed against nurses. The most common is patient falls. According to the Centers for Disease Control, more adults over 65 die from fall-related injuries NARRATOR [continued]: than any other condition. Guidelines have been established for mitigating
  • 19. the risk of patient falls. Many hospitals have established frameworks for assessing risk factors for patient falls, implementing intervention for reducing the risk of falling and protecting the patient from injury if a fall should occur. NARRATOR [continued]: Staff must maintain responsibility for patient safety at all times, even when family is present. Always refer to the most up-to-date policies and procedures of your institution. Another common problem leading to negligence lawsuits is the improper technique and maintenance of IV lines. One example would be a failure to use proper ascetic technique NARRATOR [continued]: when starting the IV. And another would be failure to monitor the IV- insertion site often enough, allowing the development of an infection or infiltration. Other patient- safety issues are also a problem. One example is not contacting the physician prior to the placement of restraints and ensuring NARRATOR [continued]: that you have followed the institutional policy by not properly assessing the patient or documenting the use of alternative interventions to restraints. A major source of negligence lawsuits is medication errors. According to one study in 56 facilities, the most common types of medication errors NARRATOR [continued]: are administering the improper dosage, or administering a medication to the wrong patient, or failing to administer a needed medication. Medication errors are most often caused by distractions, and especially heavy workloads. But that
  • 20. is no excuse for a very serious breach of duty. NARRATOR [continued]: Additional breaches involving medications may include such things as failure to recognize signs and symptoms of drug toxicity, failure to request an order for drug levels, failure to use aseptic technique, failure to document the injection site, failure to check for drug allergies, NARRATOR [continued]: and failure to identify potential medications side-effects that placed the patient at risk-- for example, giving an antihypertensive agent to a patient who already has low blood pressure, or giving antiplatelet medication to a patient who has active bleeding. Administering medication according SAGE © Medcom Inc., 2007 SAGE Video Page 7 of 9 Nursing Negligence: Guidelines for Care NARRATOR [continued]: to the doctor's orders is a common nursing task. If the nurse fails to follow the orders, she or he will be liable for malpractice if the patient is injured. The nurse may also be liable for negligently following otherwise proper orders, like injecting a medication into muscle instead of a vein, or injecting the wrong patient.
  • 21. DANIEL GIROUX: I just had a case three years ago against a facility, wherein a physician's letter-- or his number 1 actually look like a 4. And my client ended up getting 4 micrograms of dilaudid rather than 1 microgram of dilaudid. DANIEL GIROUX [continued]: And she went into respiratory distress within 20 minutes and died within 60 minutes. NIKKI LIND: It's hard to question a doctor when they're giving you an order or they are in a situation, because sometimes I've come in-- like when I work with residents or less-seasoned doctors, they sometimes are put into situations where they're not always 100%, NIKKI LIND [continued]: and they don't have 100% of the knowledge that they need to take care of that situation. And so there have been instances where the nurse has more experience, and so they will question what their orders are and what their follow-up processes, or what their plan of care is. And you can suggest seeking another doctor's opinion NIKKI LIND [continued]: or just bringing to light, this is what I think is going on, or this is what I think might be the outcome if we don't look at this. HEALTH CARE PROVIDER: Oh, hi. I'm glad you're here. I was going to show-- NARRATOR: Another source of negligence lawsuits is improperly performing a treatment. This can be from equipment that is set up or used improperly or from
  • 22. simple procedures in which the nurse did not follow the proper standards of care. You should always stay current on the procedures and equipment used in your field of practice. NARRATOR [continued]: A further source of negligence claims is failure to respond to a patient's call for assistance. You have a duty to respond in a timely manner, especially for patients whose condition may change rapidly, who might have a severe drug reaction, or who may have self-destructive tendencies. NARRATOR [continued]: And finally, one of the common forms of nursing negligence is failing to properly supervise someone to whom you have delegated a task. Remember that the whole process of delegation is one of judging the skill level of the unlicensed person you have selected; teaching the skill, if necessary; and providing adequate supervision NARRATOR [continued]: to be sure that the task is performed properly. Many other problems stem from inadequate communication, improper documentation, improper techniques, and other failures to exercise the degree of care that a reasonable nurse would be expected to exercise under the same circumstances. NARRATOR [continued]: Failure to communicate and failure to document can be grounds for a malpractice suit against an individual nurse. NIKKI LIND: Usually these cases-- things like this-- they're happening months, years after the event. So charting is huge because if you don't chart it, it didn't
  • 23. happen. So clear, concise non-emotional, the facts of what's going on-- that's what you need to put in your charting, making sure that you're not only doing what you're supposed to do, NIKKI LIND [continued]: but advocating for your patient. But you need to make sure that that's documented that you did it because you can't prove later that you did something if it's not charted. SAGE © Medcom Inc., 2007 SAGE Video Page 8 of 9 Nursing Negligence: Guidelines for Care NARRATOR: If you fail to communicate all patient information to a physician, to provide a patient with relevant discharge information, or to communicate assessment findings to the nurse on the next shift, you could be liable. Proper charting and documentation are incredibly important for ensuring that a patient NARRATOR [continued]: receives the care they need. As far as the court is concerned, if it wasn't documented, it never happened. In the next program in this series, we will discuss practical steps you can take to prevent acts of negligence. This program also contains several brief scenes of nursing activities that may or may not involve negligence,
  • 24. NARRATOR [continued]: so you can test your understanding. SAGE © Medcom Inc., 2007 SAGE Video Page 9 of 9 Nursing Negligence: Guidelines for Care Nursing Negligence: Guidelines for Care It was never going to be easy to succeed Tony Hsieh, the celebrated chief executive of Zappos, who turned a tiny online shoe seller into a $1 billion behemoth through an obsessive focus on corporate culture and happy employees. But Kedar Deshpande took over at a particularly fraught time. Zappos, which is owned by Amazon, was already navigating remote work and grappling with pandemic-driven changes in how people shop when Mr. Hsieh abruptly retired in August after two decades, which led Mr. Deshpande to be named C.E.O. Then in November, tragedy struck: Mr. Hsieh, 46, died from injuries suffered in a house fire in New London, Conn., sending shock waves throughout the roughly 1,500-person company, as well as tech and entrepreneurial circles. Since then, it has been reported that Mr. Hsieh had been behaving erratically for months and that friends had considered staging an intervention last summer. The revelations brought new scrutiny to the circumstances of his exit from Zappos. Mr. Deshpande, who was previously Zappos's chief operating officer, said that when Mr. Hsieh told him last summer that he wanted to pursue other projects, he did not push back. "From my experience working with Tony, Tony always believed in the things that he wanted to change," Mr. Deshpande said in an interview, his first as chief executive. "I asked him, 'Hey, Tony, are you sure?' And he said, 'Yes, I want to retire' -- so that was the end of the conversation."
  • 25. Now, Mr. Deshpande, 42, is tasked with shepherding Zappos through the late stages of the pandemic and into the company's next phase as an online retailer, without Mr. Hsieh's guidance. He must also show whether the company's culture of "fun and a little weirdness" in Las Vegas can survive without its chief architect. "The Covid situation and everything else going on makes it very tough, particularly with a culture that is built on physical proximity and happiness associated with that," Mr. Deshpande said in the Zoom interview, from his home in Henderson, Nev. But he said he was optimistic about the future, especially given the decade he had spent at Zappos in different roles. "The culture is not just one person or two people," he said. There was apparently no long-term succession plan when Mr. Hsieh stepped down. Zappos's board, which consists of Amazon and Zappos employees, elevated Mr. Deshpande to the role. The company, founded in 1999, has long functioned as an independent unit within Amazon, which acquired it for $1.2 billion in July 2009 and does not disclose its financials. It's tough for a person to replace a C.E.O. with an outsize personality like Mr. Hsieh, said Erik Gordon, a professor at the University of Michigan Ross School of Business, who anticipated that Zappos's culture will face some changes under new leadership. "The person who takes over from the founder who created the culture doesn't have the authenticity or moral authority that the founder had," Mr. Gordon said. "Can he maintain the same spirit of fun and a little weirdness and positive team spirit?" (Mr. Hsieh did not found the company, but has been referred to as a founder based on his involvement as an investor and chief executive from its earliest days.) Mr. Deshpande, who is from Aurangabad, India, came to the United States for a master's degree in computer engineering, and joined Zappos after stints at General Electric and PepsiCo. He joins a growing list of South Asian chief executives in the United States, at companies like Microsoft; Google's parent
  • 26. company, Alphabet; and Gap. Zappos, which derives its name from "zapatos," the Spanish word for shoes, was an early e-commerce success story under Mr. Hsieh, who wrote a best-selling book in 2010, "Delivering Happiness: A Path to Profits, Passion, and Purpose." It argued that a company's top priority should be its culture and that keeping employees happy translated into success with customers. The company, which moved from the Bay Area to southern Nevada in 2004 and now has a campus in downtown Las Vegas, developed a reputation for being a fun, almost cultlike place to work, where employees regularly socialized at work and outside the office. The company has claimed that it is harder to get a job at Zappos than it is to get into Harvard. Mr. Deshpande said Zappos employees had become closer in some ways in the past year as they brought family or pets into the remote-work fold. "When we have Halloween contests, it's the entire family that is participating," said Mr. Deshpande, who has two young daughters. He described packages Zappos sent to employees and their families for activities like planting herb gardens or performing science experiments. He guessed that employees would start returning to the office after July 1 and were likely to develop hybrid schedules with some remote and some in-person work. While Zappos did not have to struggle with the drop-off at physical stores that so many other retailers did, it did take a hit early on in the pandemic as shoes and clothing became an afterthought; few people were buying high heels last March. Sales have recovered since, fueled by demand in the so-called performance and home categories -- think running and hiking shoes, pajamas, athleisure and slippers. Mr. Deshpande said he was unsure when demand for high heels would return, but anticipated that people would continue to want comfort as the economy reopened. Zappos has introduced and expanded ways to smooth out the
  • 27. kinks of online shopping during the pandemic, like allowing some customers to make returns through UPS home pickups, and making it easier to exchange items. It also observed that the average length of calls with customer service representatives had increased as people had more time in a closed-off world. They also left more detailed reviews on products. One of the company's biggest goals, and a top priority for Mr. Deshpande in coming years, is figuring out how to make online shopping less transactional and more like the browsing experiences that people seek out in malls and department stores. That includes developing new digital magazinelike "verticals" -- much like what media companies create -- such as "The Ones," which is tailored for female sneakerheads and advertised as "powered by Zappos." Zappos is also behind VRSNL, a luxury site that has its own web address and no visible link to the shoe site. It features wares from designers like Dolce & Gabbana and Proenza Schouler. The company has been pouring new effort into product detail pages and informational videos catered to audiences like new runners, and even co-developing merchandise and campaigns with the brands it carries. "What online fails to deliver, which physical delivers today, is around these different experiences," Mr. Deshpande said. "Until you actually go and deliver on these experiences, people will go back to the physical, in my opinion, and they will stay online for only transactional experiences." The company refers to these efforts as "experience commerce," and said the category was driving 25 percent of its investments. Outside of prompting consumers to explore more, Zappos is also trying to make online shopping more cohesive -- all with the aim of getting consumers to spend more money over time. "One of the challenges has been that when somebody walks into 'online,' somebody looking for a jacket, for example, we show them inventory next to each other -- like a $30 jacket, $50, $100, $300," Mr. Deshpande said. "This is a very disorienting experience."
  • 28. In his view, all of the efforts are in line with Zappos's obsessive focus on service for the past 20 years, which he anticipates remaining its focus for the next 20 years. While the company is still grieving Mr. Hsieh, Mr. Deshpande said, employees will continue to embody the values that he championed. He pointed to an instance during the holidays when one employee mentioned children missing out on meeting Santa Claus during the pandemic, leading to a multidepartment effort to set up Santa Zoom meetings for children around the country. "To me, Tony's legacy is around delivering this happiness to everybody," Mr. Deshpande said. "This culture he has created or pioneered, it's going to be alive."