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Risk Management Tips 2008 |
2008 Tips To Minimize Risk
Rene' Jackson and Constance Watkins have agreed to continue to provide you with pertinent and timely advise through our Legal Beagle page. You can email questions to them through us at educate@hru.net. Let us know what topics for 2008 you would like addressed.
Health Resources Unlimited thanks both Rene' and Constance for their commitment to mentoring Nurses on issues related to patient care and risk management.
Rene' Jackson RN BSN MS LHRM
http://www.rjacksonrn.com/
rene@jacksonrn.com
Constance Watkins RN CLNC
http://www.cmc-llc.net/
cgwatkins@sc.rr.com
November 2008
Advance Medical Directives
Constance Watkins, RN, CLNC
What is an Advance Medical Directive and why do we need one?
An Advance Medical Directive means that you have placed in writing specific details that can be used in making medical decisions when you are unable to do so on your own.
Advance directives generally fall into three categories: living will, power of attorney and health care proxy/agent.
Living Will: Outlines your preferences for health care and medical treatment. You specify what extent and type of treatment you desire should you become unable to direct these specifics yourself.
This also protects your rights in areas such as medications, feeding and life-support equipment.
Health Care Agent: This legal document allows you to choose another person to make medical decisions if you become incapable of doing so on your own. This agent is privileged with the same rights you would have to request or refuse treatment.
Durable Power of Attorney: This category enables an individual to legally appoint another person to make bank transactions, sign your checks, pay bills, apply for disability benefits, etc., should you become incapacitated.
As long as you have the capacity to make your wishes known about medical treatment, your advance directives are not used.
You have the right to change or revoke your directives at any time.
For further reading review the following websites:
www.webmd.com
www.medicinenet.com
October 2008
Job Descriptions
Shelley Cohen RN BS CEN
Although the writing and reviewing of job descriptions is a time consuming task, the reality is that it serves an important role. The power of the written word is undeniable and you want to assure what is in writing for your job description represents the truth about what you deliver. On an annual basis, even if your manager does not review these details, take it upon yourself to do so. In particular look at the following;
- Do you meet the educational requirements and if not is there a clause in writing with a deadline date you must achieve these in?
- Are your required certifications and other credentials up to date?
- Look for specific tasks that are no longer performed by your job and request your manager to consider removing them
- Identify the common tasks and skills you perform and assure those are in the job description
- Are there new responsibilities that have been added to your role? If so, be sure those are also added to the job description
Remember, you accepted the job and it is then implied you agreed to all aspects of the written job description unless noted otherwise. Be proactive by reviewing this on a regular basis, it serves as an ongoing reminder of your responsibilities to the organization.
September 2008
How and When to make a “Late Entry”
Constance Watkins RN, CLNC
Late entries in charting should be avoided if possible as they could infer neglect or even abandonment. A late entry may be inserted in the medical record within a reasonable amount of time, but there should be no gaps in chronology. The late entry should be recorded carefully, completely and accurately; thus raising no suspicion of ulterior motive. Late entries could become suspect if individuals practice writing such notes, thus lending a reason to suspect their competency or integrity.
Your late entry documentation should included the following;
The fact that it is a late entry
The date and time you are entering the documentation along with your signature
The date and time you are referencing in your documentation
If you suspect there may be legal action pending, do not place the late entry in the chart without notifying the proper authorities within your organization; your manager or the legal department. A late entry may be construed altering a medical record and this is a criminal offense, so be extremely clear and precise.
Example:
August 12, 2008 1445 Late entry
On August 12, 2008 at 1108 patient ambulated to the bathroom with assistance, was unable to void at that time. S Cohen RN
Additional information:
Marden, Carol. The Nurse and The Law. Marden Educational Services, LLC
Marden, Carol. Delegation and Documentation, retrieved from www.marden-ed.com
Sharp, Charles C. (1999). Nursing Malpractice. Auburn House.
Chain of Command
Shelley Cohen RN BS CEN
Many nurses feel unempowered to resolve concerns or prevent concerns from occurring. In the moment of recognition of a scenario of concern or potential concern, always recognize and be aware of what the chain of command is for your organization. For example, the steps below maybe familiar to some of you:
Charge Nurse > Supervisor > Department Manager > Director of Nursing
Some scenarios due to the day of week or time of day may require the following steps:
Charge Nurse > Supervisor > Administrator on call
In clinical specific areas that involve provider concerns, you may find your chain of command includes the Medical department head or the chief of staff. In teaching facilities, the chain may include a senior resident and/or attending physician.
Regardless of your practice setting (inpatient, outpatient, correctional facility, home health, school nurse, etc), it is each nurse's responsibility to be familiar with their change of command. When bad outcomes occur in patient care, a common questions that is raised during the investigation is one related to who else was made aware or notified? Another question that may be posed to the nurse is, if you were uncomfortable with the response from your director, who did you notify next in your chain of command?
Be cautious in that you do not skip steps in this process and be professionally courteous by alerting the last person you collaborated with that you feel a need to go to the next level.
Look Mary- I respect your position as the night supervisor, however I am not comfortable sending this patient home tonight. As the advocate for this patient, I feel a need to connect with the on call administrator about this situation for their input as well.
July 2008
Challenging Documentation Scenarios – What to Write
Constance Watkins RN, CLNC
No matter how skilled a nurse you are, improper documentation could find you in a negligence lawsuit if your patient's chart ends up in court. Your patient's medical record tells the story of his hospital treatment provided by you and other hospital caregivers.
One documentation pitfall is inappropriate comments about a patient or labeling the patient. The following examples of do's and don'ts will help improve your nursing documentation.
Don't chart – “Patient is Angry”
Do chart – Patient swears at me in loud voice when I ask questions, he has clinched fists, and a reddened face.
Don't chart – “Patient is under the influence”
Do chart – Patient has slurred speech with ataxia and when inquired of recent alcohol use, he responds, “ I only had three”
Don't chart – “Patient displays drug-seeking behavior”
Do chart – “Patient biting nails, unable to sit still, repeatedly asking what physician has ordered for pain and how often. This is patient's 3rd visit to the hospital in two weeks for complaints of severe headache with no relief at home.”
Don't chart – “Patient appears impaired”
Do chart – “Patient staggers when walking, repetitious speech patterns, slurred speech, flight of ideas”.
When charting on your patient always chart specifically what you see, feel, smell and hear. Be objective in your charting and provide short but detailed data. Always – chart with a jury in mind. That is, people who were not there at the time you were with the patient need to be able to picture in their mind what you experienced. The only thing they have to go by is what you write.
Reference/Resources:
Assessment made Incredibly Easy, 2nd edition(2006). Springhouse Books.
Nursing 2006. “Would Your Documentation Stand Up in Court”?
Duclos-Miller, Patricia (2004). Managing Documentation Risk: A Guide for Nurse Managers. Marblehead: HCPro, Inc.
Mosby's Surefire Documentation (2006). St Louis: Mosby Elsevier.
June 2008
Drug Diversion
Rene' Jackson, RN BSN MS
Drug diversion is the use of prescription drugs for recreational purposes – diverting of legally obtainable drugs into illegal channels or the acquiring or obtaining of a controlled substance by an illegal method. Felony charges can range from fines of $1000 – 250,000 to a prison term of up to 20 years. The Drug Enforcement Administration (DEA) Task Force has been known to arrest patients, general staff and licensed professionals for drug diversion.
Drug diversion occurs from all levels of controlled distribution and the person responsible can be pharmacists, physicians, nurses, office staff, and patients. Methods of diversion vary from theft, accompanied by record falsification, to requesting a script to be filled or obtained for someone other than the person it was written for.
The DEA and Centers for Medicare and Medicaid Services (CMS) have the authority to inspect the record keeping and security of any facility or registrant, or applicant for registration. Their inspections may be in conjunction with a state licensure or facility compliance survey.
Scope of practice issues are also within the authority of the DEA. Allegations related to questionable prescribing, solicitation of prescriptive medication, diversion and dispensing patterns are usually referred to the appropriate licensing boards and authorities.
Facilities should not only have adequate polices and procedures in place to prevent diversion, they should routinely review the practices of employees to guarantee compliance. The pharmacy department is responsible for all activities related to controlled substances in that facility. Any staff member of a healthcare facility should immediately notify his/her supervisor or Risk Manager of the suspected activity. When violations of controlled substance requirements are identified, administrative action may result against the facility as well as the individual practitioner, depending on the situation. Reporting of drug diversion by fellow employees is not only a necessary part of an overall employee security program but also serves the public interest at large.
May 2008
Causation and Nursing Malpractice
Constance Watkins RN, CLNC
The number of disciplinary actions for medical malpractice among nurses has risen significantly in the last five years. Nurses should be concerned about this as we are held liable for our own negligence and could even find ourselves being sued for malpractice.
There are four key elements of a medical malpractice case:
§ Standard of Care: The care a reasonable, careful or prudent health care practitioner would provide in similar circumstances. Breach of that standard of care occurs when someone deviates from that standard of care. An example of a failure to meet this standard would be:
o Failing to perform a procedure
§ Duty: By a nurse accepting assigned patients, the nurse has assumed a duty to treat the patient with the degree of skill, care and diligence exercised by competent and careful nurses.
§ Legal Causation: The plaintiff must establish that had standards of care been followed, the injury or damages to the patient would have been avoided. A legal cause of action for negligence usually exists when it is determined that the breach of the standard of care caused damages, usually physical or emotional, to the victim.
§ Damages: Was unreasonable care, carelessness, or inappropriate behavior on the part of the nurse, hospital or other health care provider the proximate cause of injury or damages to the patient/client?
Causation: In order to prove medical malpractice, the cause of a patient's injury must be directly related to the care (or lack of care) given by that medical professional. A nurse may have been negligent in providing care to a patient, but sometimes that negligence is not the cause of the injury suffered by the patient. A patient may be treated by a number of doctors, nurses and medical technicians in the course of a hospital stay. Determining causation in nursing medical malpractice is often very complicated. The law requires a connection between fault and injury.
Additional information:
National Council of State Boards of Nursing: https://www.ncsbn.org/index.htm
MEDI-SMART – Nursing Education Resources http://medi-smart.com/
April 2008
The Role of the Registered Nurse in Moderate Sedation
Rene' Jackson, RN BSN MS
According to the American Society of Anesthesiologists (ASA) and the Joint Commission(JC), moderate sedation is a drug-induced depressed level of consciousness achieved with the administration of sedatives, hypnotics, and/or opiods. During this altered state of consciousness, the patient:
- retains protective airway reflexes
- independently and continuously maintains a patent airway and spontaneous ventilations
- can respond purposefully and appropriately to physical and verbal stimuli. 1 2
Each US state board of nursing deals with the administration of moderate sedation differently. Many state boards do not have a specific position statement and require only education and competency, while others do have position statements. However, no state board has determined that moderate sedation is not within the scope of practice for a registered nurse. Registered nurses administering moderate sedation must:
- Know the different levels of sedation/analgesia
- Be competent with the nursing care before, during, and after procedures
The patient could progress to a deeper level of sedation than intended at any time during the procedure. This not always predictable change in patient status may require support while the sedation is reversed to a more desirable level.
The goal of moderate sedation is to achieve an altered state of consciousness with minimal risk and obtain relief of pain and anxiety. Opiods such as Fentanyl and Morphine and Benzodiazipines such as
midazolam/Versed and diazepam/Valium, produce a reduced level of anxiety. They also produce analgesia and a minimally depressed level of consciousness, and in many cases, amnesia.
The registered nurse's role in moderate sedation is to monitor the effects of the sedatives given and relive patient anxiety. The nurse should not have any other duties while monitoring the patient. Patient assessment includes:
- Monitoring airway and gas exchange
- Cardiovascular response
- Level of consciousness
- Control of pain and anxiety
It is common practice for acute care hospitals to have policies regarding moderate sedation.These policies provide guidelines for clinicians providing care for patients when they receive sedation in conjunction with invasive, manipulative, or diagnostic procedures. The policy should incorporate a mechanism whereby the registered nurse must perform a yearly competency, which should be documented in his/her file. Be aware that these policies do not apply to medication administered for pain control, seizure control, mechanical ventilation sedation, or emergency intubation.
1. JCAHO.Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace, IL: JCAHO, 2005.
2. ASA. guidelines for sedations and analgesia by non-anesthesiologists: AN updated report by the ASA task force on sedation and analgesia by non-anesthesiologists. Anethesol. 2002;96:1004-1017.
March 2008
Delegating to a UAP
Constance Watkins RN CLNC
Who is a UAP? UAP stands for Unlicensed Assistive Personnel. The major role that a UAP performs is to free professional nurses from tasks that do not require independent thinking and professional judgment. Examples of UAP are orderlies, nurse technicians, or aides, and attendants. Indirect patient care examples are; making a bed, taking a temperature, feeding a patient, or weighing a patient.
When is a nurse liable for improper delegation of duties? One example is when the nurse assigns a UAP a task that should not be delegated, such as medication administration. Another example is when the UAP is assigned a task and the nurse does not provide the required supervision. Proper delegation involves assigning the right person to the right task and giving clear directions and proper supervision.
When is the UAP liable for their own actions? UAP who perform tasks that are beyond those delegated or outside their competencies are liable for their own actions and for the consequences of these actions. The UAP should never accept a delegated task that he/she is unsure of or not trained to perform. They should request additional training and support or decline the delegations. A UAP should never perform duties that require they hold a license as a professional.
Who or what decides what duties a UAP can perform? The State Board of Nursing, institutional policies,
and external agencies such as ANA and NCSBN can set standards of performance.
For additional information, please see the following;
Legal and Ethical Issues
Authored by Susan Westrick Killion, Katherine Dempski, 2000.
Professional Issues in Nursing: Challenges and Opportunities
Authored by Carol Jorgensen, 2006.
National Council State Board of Nursing (NCSBN)
http://www.ncsbn.org/
February 2008
Patient Complaints
Rene' Jackson RN BSN MS
The emphasis on encouraging customer comments should be consistent with a healthcare organization's framework for performance improvement and the organization's policy on patient grievances. The acceptance of those comments/concerns should be expected of all employees. If a concern is not resolved immediately, it should follow the organization's grievance process and be documented through the event reporting system. All actions taken in response to customer concerns or comments should be undertaken with the goal of improving care and service delivery, and should include:
- investigation and resolution of customer concerns
- routing of positive comments to the appropriate departments
- identifying trends in care, service delivery, and system organization
- developing solutions, implementing changes to improve care and service
Patient grievances are formal or informal, written or verbal complaints made to the hospital by a patient or the patient's representative when prompt resolution is not possible. When a complaint cannot be resolved promptly by staff present or is referred to the risk manager or administrator it is considered to be a grievance. Billing issues are not normally considered a grievance unless the patient or his/her representative requests that it be treated as such.
Follow-up responses can include written or telephone responses or formal meetings with administrative staff addressing the identified concerns. The organization event reporting policy should include tracking and trending the concerns and the corrective action. Risk/patient safety issues should be forward to the organization's patient safety committee for evaluation and recommendation as appropriate.
It is extremely important to know your organization's policy with regard to grievances. Patients admitted to acute care hospitals are afforded the protection of a number of rights established under state and federal law. Information about patient rights and the hospital grievance procedure is normally provided to the patient upon admission to the hospital and is communicated in both oral and written form. Acute care hospitals want all of their patients to have a safe, satisfactory experience while there and provide the highest quality service to patients and their families.
January 2008
Decisions of Boards of Nursing to restrict/Remove Nurse Licensure
Constance Watkins RN CLNC
Registered Nurses are the primary sentinels of patient care, providing rapid intervention for those too sick to help themselves. But, Nurses are human and sometimes make mistakes that result in injury or death to their patients or injury to themselves.
According to the South Carolina State Board of Nursing, of the Nurses who have had their license either suspended or revoked, 90% of the occurrences are due to substance abuse.Thus, substance abuse hurts not only the Nurse but also the patients' he/she cares for. The following is an
example of how a Nurse violated the Nurse Practices Act and had her license suspended indefinitely:
In August of 2006, T. Brown, RN, signed a consent agreement to settle all charges against her for
diversion of controlled substances, and documentation and medication errors. This nurse agreed to be an active participant in a Recovering Professional Program (RPP). Unfortunately, T. Brown never contacted or attended the RPP program. Therefore, this nurse failed to comply with a directive or order of the department or the board. The respondent's license to practice Nursing was indefinitely suspended until she agrees to comply with the Consent Agreement which she signed.
The following link will direct you to the Board of Nursing for your state: http://www.NCSBN.org/ this link is to the National Council of State Boards Nursing.
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