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Legal Tips - Minimizing Risk

2010

Constance Watkins, RN, CLNC has been with us for three years, her insight and passion for guiding nurses in minimizing their risk has helped the thousands who access this page each month.

Constance Watkins, RN, CLNC
www.cmc-llc.net
cgwatkins@sc.rr.com

If you are interested in submitting risk management tips to the website, please email Shelley Cohen directly @ educate@hru.net.

January 2010
Medical equipment, obesity and liability
Shelley Cohen RN MSN CEN

America may be home to the most obese population, however not all of our medical equipment and supplies are made/built to sustain and support certain weights. In a case brought by a patient who weighed 445 pounds against an ED nurse, the patient claimed her back was injured due to “the nurse negligently released the lower part of the examining table”. The record revealed the jury may have determined a lack of credibility in this claim. The plaintiff (patient) was unable to prove that the equipment or nurse was the cause of her injury( 2009).

Don’t let the outcome of this case cause you to believe you cannot be held accountable for not considering a patient’s weight in selection of equipment or supplies. With 34% of adults over the age of twenty being obese, nursing assessments must consider the safety aspects impacted by this group of patients (2009).

Review your exam tables, stretchers, wheelchairs, patient beds, transfer devices etc. Mark weight limits clearly so staff have ready access to the information.

Centers for Disease Control (2009). Retrieved from http://www.cdc.gov/obesity/data/index.html

Nursing Law’s Regan Report (2009). ER exam table gave way under 450 pound patient. 50 (7).

February 2010

Descriptive documentation
Shelley Cohen RN MSN CEN

Nursing documentation remains as an underpinning to validation of the care we provide to patients. Playing an intergal role in the communication processes of health care delivery, documentation deserves and requires ongoing review. The nurse needs to shift from generic terms such as lethargy, drowsy, and stable to more descriptive terms or qualifiers. The documentation is only helpful for the patient and other caregivers, when those reviewing it receive a clear message of our written intentions.

Replace statements such as "stable vital signs" with vital signs unchanged or blood pressure elevated, Dr. Jones notified. Consider what the words lethargic and drowsy mean for a particular patient. For example, patient is drowsy and only stays awake when I shake his shoulder. The child appears lethargic and does not open his eyes and only moans.

Nurses Service Organization has an excellent "toolkit" for educators and nurses to improve documentation practices. When you look to renew certifications and clinical practice specifics, don't forget about updating your documentation practices as well. The next person who has to read your notes will benefit greatly, as will your patients.

Nurses Service Organization. www.nso.com

April 2010

Child Abuse and Neglect-How to Recognize and Report
Constance Watkins RN, CLNC

April is National Child Abuse Prevention Month

What is child abuse-is it just about bruises and broken bones? Making a child feel stupid or worthless or putting a child in an unsafe situation are other forms of child abuse/neglect. The following are some additional examples of abuse and their results;

§ Emotional child abuse occurs by yelling, constant belittling, ignoring the child, or withholding hugs, kisses or other forms of affection. This results in the child having feelings of no self worth.

§ Child neglect is a pattern of failing to provide for a child's basic needs; food, clothing, hygiene, or supervision. Sometimes, a parent might become physically or mentally unable to care for a child, such as with a serious injury, untreated depression, or anxiety. The child may develop serious trust and relationship problems from this form of abuse as well as inability to express emotions or needs.

§ Physical abuse may be the result or a deliberate attempt to hurt the child, but not always. It can also result from severe discipline, such as using a belt on a child, or physical punishment that is inappropriate to the child’s age or physical condition.

§ Sexual abuse causes guilt and shame and usually occurs at the hands of someone the child knows and should be able to trust.

Signs of emotional abuse:

Withdrawn, fearful, or anxious about doing something wrong. Extremes in behavior (extremely compliant or extremely demanding). Little or no attachment to the parent or caregiver

Signs of physical abuse: Frequent injuries or unexplained bruises, welts, or cuts. Is always watchful and “on alert,” as if waiting for something bad to happen. Shies away from touch, seems afraid to go home. Wears inappropriate clothing to cover up injuries.

Signs of neglect: Clothes are ill-fitting or inappropriate or the child is dirty. Physical injuries and delay from seeking medical care. Frequently unsupervised or left alone. Frequently late or missing from school.

Signs of sexual abuse: Trouble walking or sitting. Displays knowledge or interest in sexual acts inappropriate to his or her age, or even seductive behavior. Makes strong efforts to avoid a specific person, without an obvious reason.

As a nurse you have a responsibility and duty under the Nurse Practice Act to recognize suspicion for child abuse/neglect. Reporting suspected child abuse or neglect can help families get the assistance they need and protect a child-possibly save that child's life. As a nurse your awareness and skill may alert you to potential cases outside of the workplace. When this occurs recognize that reporting may be anonymous in your state, however this does not distract from your duty to report. The following links can get help to a neglected/abused child and serve as resources for nurses;

Call the Childhelp National Child Abuse Hotline at 1-800-4-A-CHILD (1-800-422-4453)

Download a kit to distribute materials for National Child Abuse Prevention Month at http://www.childwelfare.gov/preventing/preventionmonth/

Additional reading: www.childwelfare.com, www.nursingcenter.com

May 2010

It's all about the documentation!
Shelley Cohen RN MSN CEN

     The only record of what happens to a patient from the time they arrive in our care until they depart or our care ends, is the medical record. The effectiveness of a record's ability to communicate assessment, interventions and outcomes is directly related to the pertinent and thorough content from those who use the patient chart to record these events.

     What you decide to document is as important as the decision of what not to document. Review your organizational policies related to documentation specifics such as late entries or amending a chart. The increase use of electronic medical records removes the element of poor handwriting, but brings with it opportunity for incomplete documentation unless you are trained well on the software you use.

     The push toward national use of electronic records in all areas of health care is already part of the "politics of healthcare". Embracing the technology and accepting the fact that it is the future of all documentation will allow you to focus on appropriate application of your organizations documentation tool.

     Some keys to success with electronic health records include the following;

Protect your password and always log off before you walk away from the computer station
Recognize that protection expectations for patient information remains high
Understand your downtime documentation processes
If a pre-printed prompter does not apply to your patient- don't "settle" for what is the closest! Use a narrative note entry to describe the scenario.
Document all interventions and their outcomes
Double check the screen to be sure you have the correct patient correct up in front of you
Be aware of organizational requirements for those requesting a printed copy of the record from your computer. Most organizations still require this go through medical records to assure appropriate signatures, etc.

Mosby's Surefire Documentation (2006). Missouri: Mosby Elsevier.

June 2010

Medication Errors
Constance Watkins RN, CLNC

Medication errors are still prevalent today and continue to be an area of great concern. The National Coordinating Council For Medication Error Reporting and Prevention defines a medication error as, "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer".

The American Hospital Association lists the following as common types of medication errors:

Incomplete patient information (not knowing about patient's allergies, other medicines they are taking, previous diagnoses, and lab results)
Unavailable drug information (such as lack of up- to-date warnings)
Miscommunication of drug orders, which can involve poor handwriting, confusion between drugs with similar names, misuse of zeroes/decimal points, confusion related to metric/other dosing units, and inappropriate abbreviations.
Lack of appropriate labeling as a drug is prepared and repackaged into smaller units
Environmental factors such as lighting, heat, noise, and interruptions that can distract health professionals from their medical/nursing tasks

What contributes to these errors? Improper use of abbreviations such as:

ss (sliding scale) being confused with the numbers 55
qld (every day) being confused with qid (four times per day)
HS (half-strength) mistaken as bedtime, hour of sleep
DPT (Demerol, Phenergan, Thorazine) mistaken as diphtheria-pertussis-tetanus vaccine
PCA (procainamide) mistaken as patient controlled analgesia
"Nitro" drip (nitroglycerin infusion) mistaken as sodium nitroprusside infusion

What can nurses do to prevent medication errors? Merely following the five rights; giving the right drug to the right patient in the right dose by the right route at the right time does not always ensure medication safety. These rights learned early on in nursing school do not always prevent errors. Thus, the healthcare practitioner's duty is not so much to achieve the five rights, but to follow the procedural rules designed by their institution to produce these outcomes. If the procedural rules cannot be followed due to system issues, healthcare clinicians must report the problem, so it can be remedied.

For further reading: Institute for Safe Medication Practices (ISMP)

www.ismp.org

US Department of Health and Human Services

www.hhs.gov

July 2010

Policy/Procedure Compliance
Shelley Cohen RN MSN CEN

Health care organizations rely on policies, procedures, and guidelines to direct patient care and promote consistency in practices. Standards of care, regulatory directives, patient outcomes research, and other resources direct the content of these practices set in writing.

As an employee, an expectations exists that you will comply with the policy, procedure, etc. that is relevant to the care you are delivering. Each time you elect to work around, ignore, defy, or otherwise not comply with any of these you put your license, your patient, and the organization at risk.

When a bad outcome occurs that leads to possible litigation, someone will ask the question as to whether or not policy (procedure/guidelines) were followed. You "stand alone" when you take a course of action outside of these. Make time to review organizational and departmental directives and guidelines.

Ask questions when you are unsure how to proceed and read the details for yourself, and stop relying on another person's interpretation.

Improve your practice decisions -comply with your organizational directives, policies, guidelines and other written criteria- everyone benefits when you do - especially the patient!