According to the National Professional Data Bank (NPDB), more and more nurses are being named as defendants in malpractice lawsuits. For example, between 1998 and 2001 the number of malpractice payments made by nurses increased from 253 to 413 (cf.illustration 1, page 55). The trend shows no signs of stopping,1-3despite efforts by nursing educators to educate nurses and nursing students about their legal and professional responsibilities and limitations. A malpractice charge against a nurse can result from almost any act or omission that results in patient injury (most often an inadvertent failure to maintain a standard of clinical practice) and can give rise to a medical malpractice claim.
This article provides an overview of cases decided between 1995 and 2001 and identifies the acts and issues that led to allegations of malpractice that led to misconduct actions against nurses, and the areas of nursing practice most frequently mentioned in the complaints. (This article does not address criminal issues arising from intentional acts, such as assault, assault, or false imprisonment, for which nurses have been arrested and sometimes prosecuted.)
DEFINITION AND MONITORING OF BAD PRACTICE
Die Joint Commission on Accreditation of Healthcare Organizations (JCAHO) definidonegligencesuch as "failing to use the care that a reasonably prudent and prudent person would use under similar circumstances". JCAHO definedprofessional negligenceas “inappropriate or unethical conduct or improper lack of capacity on the part of the holder of a professional or official position; is often applied to physicians, dentists, lawyers, and public servants to denote negligent or improper performance of their duties when skilled workers are required. Negligence is a cause of action that is eligible for damages.”4Misconduct is defined differently in state statutes of nursing practice, institutional guidelines, and federal guidelines such as the JCAHO standards, all of which may be considered in court.
Several factors have contributed to the increase in cases of negligence against nurses.
*Delegation.As a result of cost-cutting efforts at hospitals and health plans, nurses are delegating more of their roles to unlicensed support staff. Delegation of some of these duties may be considered negligence under a specific facility's standards of care or state law of nursing practice.
*Early discharge.Patients are discharged from the hospital in the early stages of recovery and with conditions that require more acute and intensive care.5Nurses can be sued if they fail to provide care or make proper referrals about a patient's condition.
*The shortage of nurses and the reduction of hospitalscontributed to a greater workload for nurses and increased the likelihood of errors.
*technology advancementrequire caregivers to be aware of a variety of technology capabilities, limitations, and safety features.
*Greater autonomy and responsibility for nurseswhen practicing advanced nursing skills are also associated with an increased risk of error and liability.
*More informed consumersThey are more aware of neglect issues and recognize inadequate or inappropriate care.
*Definitions of extended legal liabilityThey committed all professionals to higher standards of responsibility.1For example, due to the expanded scope of duties of Advanced Practice Nurses, they have been mandated by courts to meet a standard of medical care.2
In 1990, the NPDB began collecting information on health professionals who settled malpractice lawsuits, were disciplined resulting in the revocation of their licenses or reduced professional privileges, or had to pay (or lose) financial damages that employers or insurers had to pay indemnities).1(Founded in 1986 and regulated by the Bureau of Health Professions, the U.S. Health Resources and Services Administration, and the U.S. Department of Health and Human Services, the NPDB assists qualified agencies, such as state licensing agencies, hospitals, and HMOs, in verifying the qualifications of professionals who use the agencies contract or grant clinical licenses, memberships or privileges.6)
The NPDB classifies RNs into four categories: lay RNs, anesthesiologists, midwives, and practicing nurses. According to the database, RNs have been responsible for 3,615 overpayments in the history of the NPDB (only cases reported to the NPDB between September 1, 1990 and December 31, 2001). Registered nurses paid for the most medical errors (2,311 or 63.9%), followed by anesthesiologists (820 or 22.7%) and midwives (296 or 8.2%). Nurses made the fewest payments for misconduct (188 or 5.2%). (For numbers from 198 to 2001, seeillustration 1. The NPDB's annual reports are available online athttp://www.npdb-hipdb.com.)
The acts or omissions frequently alleged by plaintiffs 20 years ago remain alleged causes of negligence in care.1,3According to the annual reports of the NPDB, from 1990 to 2001, the majority of payments in malpractice suits were due to the following nursing malpractice issues: for non-specialist registered nurses, issues related to follow-up, treatment, medication, midwifery and surgery ; in nurse anesthetists, problems related to anesthesia; in midwives, problems related to obstetrics; and among nurses, problems related to diagnosis and treatment.
A 1997 study identified the following problems in nursing malpractice as a basis for settlements or judgments in favor of plaintiffs: failure to provide appropriate information to the physician; inappropriate patient assessment, nursing interventions, or nursing care; medication errors; inadequate infection control; and unsafe or improper use of equipment.7(Similar neglect problems were identified in studies by Campazzi ,8Schmidt ,9Mayberry e Croke ,3e Smith-Pittman .10)
It is important to note that a payment or claim based on negligence should not be construed as a presumption of fault on the part of the supplier. As an NPDB fact sheet states, "The settlement of a medical malpractice claim may be made on grounds that do not necessarily adversely affect professional competence or conduct."6For example, a nurse's insurance policy may allow the insurance company to cover without the policyholder's consent.2
SUMMARY OF THE CASE REVIEW
Analyzed over 350 case summaries from trials, appeals, and high courts obtained from legal research sources such as the NPDB; regional reports and summaries; the LexisNexis database; the Internet portals FindLaw and MedLaw; secondary sources such as health insurance information; and professional newsletters, magazines and books, includingArzthaftungsrecht und -strategie, Legal Eagle Eye Newsletter para a profissão de enfermagem, Journal of Legal Nurse Consulting, Journal of Nursing Law, Legal and Ethical Issues in Nursing, Nurse's Legal Handbook,jnursing and law.Only cases that met all of the following criteria were included in the analysis: a nurse practiced nursing as defined in her state's practice nursing law; a nurse was prosecuted for an illegal act in a civil case (no criminal case was considered); and between 1995 and 2001 a trial took place.
253 case summaries were included in the analysis. The summaries contained information about the nurses' areas of expertise, the types of irregularities involved and the outcome of the case (comparison or jury verdict). Monetary rewards were paid directly by independent professionals or by employers on behalf of employees in accordance with the doctrine oflet the manager answer(Latin for "Let the Master Answer", this principle states that an employer is responsible for actions taken by an employee in the course of employment.)2
as shown inFigure 2(page 56), the most common cases of malpractice occurred in acute care hospitals (60%). Long-term care institutions (older-age homes and transitional and rehabilitation care facilities) accounted for the remainder (18%); psychiatric facilities (8%); outpatient health authorities (2%); and physician-independent practice supply facilities (2%); and advanced nurses, including registered nurses, midwives, and anesthesiologists (9%).
The large difference in the proportion between acute care units and continuing care units can be explained by the greater number of occupations specializing in acute care and the status of patients in occupations specializing in emergency services. operating rooms and recovery rooms; and obstetrics, critical care, coronary and medical-surgical wards, patients are sicker, may need immediate interventions, and may have a rapidly changing condition.10
In reviewing my case, I identified six main categories of malpractice issues that led to wrongdoing claims. Documentation describing negligent behavior often uses terms such asmissing, lacking, incomplete, ineffective,jincorrect.Negligence categories are: failure to meet standards of care, failure to use devices responsibly, failure to communicate, failure to document, failure to assess and monitor, and failure to act as a patient advocate (see p.ix Main Negligence Categories Dropping Wrongdoing Claims,page 57). (These categories are not mutually exclusive; two types of negligence are involved in one of the cases discussed below.)
The following are summaries of five randomly selected malpractice cases in which nurses were named as defendants. They illustrate the range of actions that result in breaches of standards of care.
Violation of standards of care.
Standards such as hospital policies have evolved to protect consumers from substandard care. By defining an acceptable level of care: ordinary and appropriate care needed to ensure that patients are not harmed unnecessarily.2- Standards of care provide criteria for determining whether a nurse has failed in the care due to the patient. Standards of care are derived from sources such as state boards of nursing, professional nursing associations (eg, ANA and National League of Nursing), hospital policies and procedures, and guidelines from federal organizations (eg, JCAHO and the Centers for Medicare Services). and Medicaid).
EmHall vs Artur(1998), the United States Court of Appeals for the Eighth Circuit upheld a lower court ruling that found a hospital liable for failing to meet a standard of care for an anterior cervical discectomy and fusion (ACF).11At trial, the plaintiff's argument focused on the use of an orthoblock, a ceramic substance used to replace bone in oral and maxillofacial surgery, which was implanted in the patient's spine. (The usual procedure for such an operation would be to harvest bone from a bone bank or from the patient's hip.) After four months with back problems, the patient, Mr. Hall, needed a second ACF to remove the orthoblock and his own implanted bone.
Hospital policy required that all "unusual requests" to use a product be reviewed by department heads to assess the suitability of the product.2The nurse did not request such a review and ordered the use of orthoblock in the patient's ACF. The product insert provided as evidence in the study stated that Orthoblock was specifically contraindicated for use in spinal procedures. Plaintiff's attorney argued that the nurse's failure to comply with hospital guidelines contributed to Mr. Hall.
On appeal, the hospital did not challenge the jury's negligence decision, but alleged that the plaintiff presented insufficient evidence for a jury (or "reasonable fact-setter") or judge to conclude that the nurse's negligence contributed to Mr. Hall. The Court of Appeals disagreed, stating: “[While we cannot say with certainty that Mr. Hall would not have been injured had the nurse not been negligent, we believe the jury could reasonably have concluded that his negligence played a significant role, Mr. Hall is injured using orthoblock for his ACF surgery. Here, it is enough to assume that the hospital would not have allowed the operation, and we do not consider this assumption to be a leap of faith.11
Irresponsible use of the device.
Caregivers need to be aware of the safety features, capabilities and limitations of any device they use, as well as the risks involved. Caregivers should follow the manufacturer's usage recommendations and should not modify the equipment. The Safe Medical Devices Act of 1990 requires that any medical device adverse event that results in death, illness, or serious injury be reported to the manufacturer and the Food and Drug Administration within 10 business days.2
EmQueixo no queixo Saint Louis Bernabe Medical Center(1988), the New Jersey Superior Court, Appellate Division, overturned a court's judgment against only one physician, holding that other hospital employees should also be held accountable.12The case concerned the death of a 45-year-old woman, Mrs. Chin, due to a massive air embolism during a diagnostic hysteroscopy. The woman's estate has filed a malpractice lawsuit against all service providers who may have played a role in the events leading up to her death: the physician who performed the procedure, three operating room nurses (one surgery and two circulating nurses), the hospital, and the manufacturer of the hysteroscope, an optical device with a pump used to examine the uterus. During the procedure, fluid is continuously pumped into the uterus to improve the view inside. The device requires the connection of four tubes: an irrigation tube that carries fluid into the uterus, a suction tube that draws fluid from the uterus, a tube that connects a source of compressed nitrogen to the pump, and a tube outlet. As one of the tubes was incorrectly connected to the hysteroscope, nitrogen was pumped into the patient's uterus, causing a fatal gas embolism in the coronary arteries.
At trial, all parties accepted the theory that the exhaust hose was the source of the gas that killed Mrs. Chin; Who was to blame for the incorrect placement of the hysteroscope has been a matter of debate. Evidence presented at trial showed that the two nurses assigned to the surgical procedure had no hospital training or experience in using the hysteroscope. Evidence also showed that the supervising nurse who made the assignments was unaware of the nurses' lack of experience. No expert opinion on the standard of care was presented in the study.
At the end of the trial, the judge instructed the jury to use their "common knowledge" to determine whether the nurses had deviated from their duty to care for Ms. Chin. (The common knowledge standard applies when the facts of a case are such that the common knowledge and experience of a layman would allow a juror to conclude, without consulting an expert, that a duty of care was breached.) . The judge also informed the jury that, as Ms. Chin was unconscious at the time of the trial, she was not at fault in her own death, and at least one of the defendants was clearly guilty, shifting the entire burden of proof to the plaintiff. to the defendant (i.e. each defendant had to prove that he was not at fault).
The jury awarded plaintiff $2,000,000 in damages and found that the defendants were liable in the following proportions: the physician, 20%; the experienced home nurse, 25%; the unqualified nurse 20%; and the hospital, 35%. The surgical nurse and the manufacturer are exempt from any liability.
Immediately after the verdict, the trial judge ruled in favor of the hospital's motion to challenge the validity of applying the common standard in this case; the judge attributed the responsibility solely to the doctor. In granting the hospital's request, the judge said the application of the generally accepted standard was an error. But on the doctor's appeal, the appeals court overturned the lower court's decision and essentially restored the original jury verdict, saying that neither defendant had fully established the accuracy of Ms. Chin and that the lower court made no mistakes in applying the sentence. judgment. known pattern.
Lack of evaluation and monitoring and lack of communication.
Changes in a patient's health can be gradual or sudden, and caregivers are often the first to notice changes and act. A nurse's accuracy in assessment and follow-up and her timely reporting of health changes to a physician can often mean the difference between life and death. In addition to reporting changes in a timely manner, key aspects of communication include persistence in notifying the clinician of the change and accuracy in reporting the nature and extent of the change.
EmBusta x Columbus Hospital Corporation(1996), the Montana Supreme Court upheld the judgment and orders of the District Court for the Eighth Judicial District.13
A post-op patient at Columbus Hospital in Great Falls, Mr. Busta died from injuries sustained when he fell from a third-story window; Apparently, he tried to descend with a makeshift rope. At the hearing, the nurse who treated Mr. Busta testified that she suffered an episode of tachycardia and hypertension during her last night visit with him. He had also behaved uncharacteristically, desiring isolation and refusing any care and prescription drugs known to cause adverse effects such as confusion, anxiety, and psychosis. The nurse did not share the symptoms and change in behavior with the doctor. He also testified that when he observed the patient at midnight, he appeared to be asleep; she did not reassess her vitals.
The surgeon of Mr. Busta testified that if he had been told about the change in signs and symptoms, he would have re-examined his patient due to the mind-altering side effects of the patient's medication. Experts found that the nurse negligently failed to adequately monitor Mr. Busta the night before he died and failed to report the constellation of signs and symptoms to the surgeon; and that the hospital's negligent failure to maintain a safe environment (evidence presented at trial showed that the hospital failed to act in accordance with the JCAHO's policy of restricting the opening of windows in patient rooms).
The jury concluded that Columbus Hospital's negligence in conjunction with the patient's co-negligence caused the patient's injury and death; The jury awarded 70% of the responsibility to the hospital and 30% to Mr. Busta. The jury concluded that Mr. Busta and his estate suffered $5,000 in damages and his heirs $800,000. Based on the liability assigned by the jury, the district court rendered a judgment in favor of Mr. Busta and on behalf of his heirs of $560,000.
Documentation, whose primary purpose is to share patient information among providers, must accurately reflect the nursing process and include evidence of nursing assessment and diagnosis, nursing intervention planning, delivery and evaluation of planned nursing interventions, and patient response. patient.14,15
The Louisiana Court of Appeals for the Fourth Circuit upheld the lower court's verdict inPellerin vs Humedicenters,a case in connection with the lack of documentation of care measures.sixteenThe plaintiff alleged that an emergency room nurse incorrectly administered an injection of meperidine (Demerol) and hydroxyzinpamoate (Vistaril), resulting in a lump at the injection site and persistent pain that was later diagnosed by a neurologist as including: actually happened could not be proved in court. Medical experts gave conflicting statements as to the cause of the patient's nerve damage (the hydroxyzine pamoate or the needle could have caused it). Nurse specialists felt that the lack of documentation of the site and type of injection was not in line with the standard of care. In court, the defendant testified that her usual practice was to administer an intramuscular injection and that this practice was the standard of care. The jury found in plaintiff's favor and awarded over $90,000 in damages.
On appeal, the defendants (the hospital and the nurse) argued that the evidence presented at trial showed that the breach of the standard of care by the nurse could not have caused the patient's injury. The Court of Appeals disagreed, concluding that the nurse's testimony alone was not sufficient to support the jury's decision, but when combined with other evidence presented at trial, it supported that decision.
Stop acting as a patient advocate.
Legal and ethical issues are often intertwined in healthcare, and caregivers need to be familiar with both.2Die ANAsCode of Ethics for Nurses with Interpretative Statementsprovides nurses with a framework for making ethical decisions and defines the nurse's role as patient advocate.
Laut O'Keefe inerrors of care and law,“Patient rights are the hallmark of nursing advocacy. Nurses must strive to provide excellent patient care and the inclusion of their rights in today's healthcare system.”17It is important to note that nurses, as patient advocates, may have a duty to care for patients whose medical decisions conflict with nurses' ethical beliefs.
Emrei v Eckrich(1988), the Supreme Court of South Dakota reversed a summary judgment order in favor of the Dakota Midland Hospital of the Circuit Court of the Fifth Judicial Circuit and returned it for trial.18The case concerned the death of a patient, Winnifred Scoblic, from sepsis, which supposedly developed when she was discharged home with a fever about 11 days after urinary tract surgery. The complainant, Mrs. Koeniquer, filed a malpractice lawsuit against two physicians and the Dakota Midland Hospital on behalf of her mother's estate, alleging a deviation from appropriate standards of care for a post-operative urology patient.
Mrs. Scoblic underwent surgery on January 5, 1983. Her temperature fluctuated during her postoperative hospital stay and was recorded as 100.2°F at 8:15 am on January 16, after the attending physician completed the medical visit. The patient was discharged at 10:45 am on the same day. She was rehospitalized on January 19 with a diagnosis of sepsis. On January 21, she was transferred to University of Minnesota Hospital and died on March 6 of multiple organ failure. The author's expert witness maintained that the nurses did not adequately monitor Ms. Scoblic or provided acceptable postoperative care, although they stated that they informed the physician of the patient's elevated temperature and the state of her incision and drainage informed the day of discharge, but had not documented this report; The expert also noted that allowing Ms. Scoblic is discharged with a fever and fails to provide Mrs. Scoblic discharge instructions to have your temperature monitored are examples of failure to act as a patient advocate.
Although the hospital argued that the discharge decision was a medical one, the hospital's director of nursing said in her affidavit that it is sometimes the nurse's responsibility to challenge the physician's order, particularly when the patient's condition has changed significantly. . . The director also confirmed the specialist's claims that the nurse has a responsibility to independently assess the patient's condition, report concerns to the physician, and call other authorities if the nurse believes the physician's decision is wrong.
The court accepted the hospital's argument that it was the physician's decision to discharge a patient and that therefore the hospital was an invalid defendant in the suit. However, the state Supreme Court ruled that the file contained expert testimony showing that hospital nurses had a duty to try to delay Ms. decision to dismiss you. The court ruled that nurses have a duty to challenge the physician's order if they believe it is in the patient's best interest and delay discharge if they believe the discharge deviates from acceptable standards of care.19In this case, the nurse neglected her role as an advocate.
AREAS OF PRACTICE MENTIONED IN THE COMPLAINTS
In my case analysis, I identified 13 areas of specialist practice for nurses involved in malpractice cases. As stated inFigure 3(page 61), nurses in critical care settings were more frequently named as defendants in such litigation (153 cases) than nurses employed elsewhere (100 cases). Seven areas of specialized practice were identified in critical care centers. Nurses employed in medical-surgical departments had the highest percentage of litigation involvement (32%), followed by nurses employed in obstetrics departments (16%). (Similar results were observed for medical-surgical units in the studies by Campazzi8e Mayberry e Croke.3)
Areas within intensive care units where nurses were least involved in litigation include coronary and intensive care units, operating rooms and pediatrics (each accounting for 3% of all cases), followed by recovery wards (2% ) and emergency services (1st %). (Smith9e Smith-Pittman10identified emergency departments, maternity wards, psychiatric departments, and operating rooms as specialized areas of practice associated with high rates of litigation).
In the overview, I identified six specialist areas outside critical care. Advanced practice nurses employed in independent settings had the highest percentage of litigation (9%), followed by nurses in psychiatric and transitional wards and nursing homes (8% each). Areas with the least involvement in litigation included home health care and rehabilitation facilities (2% each). (Campazzi,8Herrero,9Mayberry e Croke,3e Smith-Pittman10found that nurses employed in non-acute care settings were less likely to be named as defendants in malpractice suits than nurses employed in critical care, but their studies do not show a consistent trend in which the specialty field receives the most malpractice lawsuits represents negligence).
REDUCTION OF POSSIBILITY LIABILITY
“The nurse's judgment involves analyzing the facts and circumstances on a case-by-case basis. To avoid misconduct, it is critical that the nurse make this assessment of everything she does in the clinical setting.”14Increasingly, nurses are being held accountable to the public for their professional judgment and the results resulting from that judgment.
Misconduct litigation is professionally and emotionally devastating and can be financially disastrous. Any caregiver can take steps to reduce potential liability by exercising caution and common sense and being aware of their legal responsibilities. The following can help caregivers reduce potential liability.
Maintain open, honest, and respectful relationships and communications with patients and families.
* Patients are less likely to complain when they feel a nurse has been caring and professional.19
* Don't give opinions if a patient asks what you think is wrong; You may be hired to provide a medical diagnosis.
* Do not make any statement that a patient might interpret as an admission of guilt or guilt.
* Do not criticize healthcare professionals or their actions when they are with patients.
* Maintain confidentiality of health care.
Maintain competency in your practice specialty.
* Attend relevant continuing education courses.
* Participate in relevant hospital utilities.
* Expand your technical knowledge and skills.
Know the legal fundamentals and implement them in daily practice.
* Keep up to date on your state's nursing practice law.
* Stay current on hospital policies and procedures.
Exercise under the professional license.
* Only perform nursing skills that are permitted in your work area and that you are competent to perform.
Know your strengths and weaknesses.Do not accept clinical work for which you do not feel competent.
* Review your homework with your supervisor
* Take on only the tasks you are competent to perform
* Have an experienced nurse handle specialized tasks on the ward.
* Document all maintenance measures accurately.
* If care is not documented, the courts will assume it was not provided.
* Use the FACT mnemonic when documenting care in the patient's record: eitherFin truth,Anecessary,Ccomplete, andTopportune20
Complete CE testing for this item using the return form available in this issue or go online for CE belowhttp://www.ajnonline.com.