Risk Management Tips 2007 | Health Resources Unlimited

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Risk Management Tips 2007

2007 Legal Tips

We would like to thank Rene' Jackson and Constance Watkins for continuing

to provide our readers with valuable insight into

risk management concerns related to patient care.

Rene' Jackson RN BSN MS LHRM

www.rjacksonrn.com

rene@jacksonrn.com

Constance Watkins RN CLNC

www.cmc-llc.net

cgwatkins@sc.rr.com

December 2007

Informed Consent

Rene Jackson RN BSN MS

Informed consent can be confusing for nurses. It varies from state to state and is usually governed by statute. In Florida, the informed consent is process, and the law requires that the patient be told, by the physician performing the procedure, of the nature of the procedure, the risks and benefits of the procedure, and the reasonable alternatives to the procedure including, when appropriate, the option of doing nothing. The patient should be legally and mentally capable of making such a decision. After verbalizing understanding, if a patient consents to the procedure, then informed consent has taken place. The patient should be given sufficient time to ask questions and think about the proposed procedure. A signed consent form in and of itself is not conclusive; it is just part of the process that proves informed consent might have been given. The consent form itself may not contain all the important information it should, or was signed without explanation before the patient had full understanding of the procedure. Doctors have in the past written an order for a nurse to have the consent form signed, and they think that is obtaining informed consent, but this is not the case. Informed consent only takes place if and when the required information is given to the patient, and the patient then consents. It can be oral or written, but it must be complete. To augment the process, the physician should be charting the discussion in the progress notes. If the health care provider does not obtain informed consent, the patient may have a legal claim for damages. In emergency situations, where the patient is unconscious or unable to communicate, consent may be implied if there is risk to the patientís life. The rationale here is that the patient would have consented to emergency treatment if faced with a life-threatening situation.

November 2007

Receiving and Accepting Gifts From Patients

Constance Watkins RN, CLNC

The word ìgiftî can be defined as:

1. Something given voluntarily without payment in return, as to show favor toward someone, honor an

occasion, or make a gesture of assistance; present.

2. Something bestowed or acquired without any particular effort by the recipient or without its being

earned.

Patients give gifts for a variety of reasons. It is possible that the act of giving represents an exchange process; gift giving elevates them above the next patient so they have a better chance of getting special treatment from the clinician or physician. Large monetary gifts such as expensive theater tickets, large sums of money or an all expense trip to a ski resort are considered unacceptable and represent a serious boundary transgression.

Small parting gifts such as a box of chocolates or flowers are felt to mark the boundary between the patient and the non-patient roles, the start of a new life status and the end of dependency. In this case, accepting the gift may be acceptable.

By accepting gifts, does the clinician run the risk of becoming a ìfriendî, losing the ability to separate the patient-clinician relationship? This could be detrimental to a patientís progress with his/her healing.

Patient gifts can certainly lift our spirits and bring a sense of satisfaction to our jobs. However, it is the clinicianís responsibility to be aware of the policies and guidelines of their institutionís acceptance and refusal of such gifts. Most institutions have defined policies on gift acceptance and the value of an acceptable gift. These policies should also clearly outline the proper procedure of gift acceptance before we are faced with the situation. We as clinicians should focus on the ethical implications of our actions and whether or not the gift changes the patientís treatment privileges or the patient-clinician relationship.

References:

Capozzi J, Rhodes R (2004): Ethics in practice: gifts from patients. The Journal of Bone and Joint Surgery, 86A(10) 2339-40.

Salladay S (2001): Accepting gifts: a thoughtful ìtipî, Nursing, 31(8)66.

October 2007

Nurses Can't Practice Medicine

Rene' Jackson RN BSN MS

State nurse practice acts are laws that are designed to set standards for the profession of nursing, define their practice, help to guide the scope of practice, and protect the public. However, none of those laws give the nurse the authority to practice medicine.

For example, take patient falls. A night nurse hears a commotion in a patient room. She goes to the room and finds a patient on the floor next to the bed. The patient, who is alert and oriented, stated he just needed to go to the bathroom, but didnít want to bother anyone. He slipped and fell. The nurse takes the patientís vital signs, asks him if heís ok. When he says he is, she helps him back to bed. She records the event in a patientís chart, even fills out an incident report.

As risk manager of an acute care hospital, I review a lot of patient fall events. A common thread in these reports is that the nurse writes ìno apparent injury,î and either fails to inform the attending physician, or if the fall occurred on the night shift, she doesnít call the physician until the next morning because sheís afraid to wake him in the middle of the night. From a legal standpoint, the nurse is practicing medicine. It is not in her scope of practice to diagnose whether or not the patient is injured. The attending physician must be notified at the time of the fall. Itís his responsibility to decide whether the patient has ìno apparent injury,î or to order any tests he feels necessary.

In effect, I have found this to be a cultural phenomenon. By that I mean the culture of the particular health care facility. Physicians donít like to be called in the middle of the night, so nurses have historically accommodated them. This process must be re-thought because nurses donít, and absolutely should not, practice medicine.

September 2007

Horizontal Violence In The Workplace ‚ Nurses Rights To Report These Acts

Constance Watkins RN CLNC

Horizontal violence is the term used to describe aggression involving inter-group on peer conflict. A common term for this is bullying.

This type of violence can take many forms: hostility, blaming, bickering, verbal abuse, humiliating and even physical abuse. It also seems that the most common aggressors are nurse managers and supervisors.

Why does this happen? New nurses may feel inferior and allow the senior nurse to abuse her thinking this is the way she gains experience; thus allowing the senior nurse to think she has the right to dominate the new nurse. The new nurse then may think this is the norm and they themselves lash out at others. Nurses whether new or not, may have a low self esteem and just allow this to happen.

How can horizontal violence be stopped? The organization or hospital must have policies that identify and control circumstances where this type of abuse may occur and allow managers to take action.

What can you do if you are a victim?

Read the policies and procedures set forth on harassment
Talk with an advisor or counselor
Keep detailed written records of the incidents to include names, where it happened and any witnesses
Confront your aggressor and make it clear that this behavior must stop
Make a formal complaint in writing and submit to the proper department per your place of work guidelines
Take your complaint to an attorney and follow OSHA regulations

You have the right to work in a safe and secure environment. For more information on bullying, please visit: www.bullyonline.org

Suggested reading:

Ending Nurse-to-Nurse Hostility: Why Nurses Eat Their
Young and Each Other by Kathleen Bartholomew

August 2007
RN fined - wrong site procedure!
Rene' Jackson RN BSN MS LHRM

In June of 2006, a 66 year-old female patient entered an acute care hospital for left knee arthroscopy. The circulating RN during the procedure, according to hospital policy, was responsible for verifying the site with the patient, physician order, consent and site marking. However, the arthroscopy was performed on the patient's right knee.

The error was discovered after surgery, and though the hospital and the surgeon disclosed the error to the patient and her spouse, performed the surgery on the correct knee at no charge to the patient, the patient, after refusing an offer of an undisclosed monetary amount, retained an attorney and sued the hospital and physician. The error, according to regulations set forth by Florida's Agency for Health Care Administration (AHCA), was considered a Code 15, an adverse patient event that is reportable to the state within 15 days of its occurrence.

Section 456.072 of the Florida Statutes provides that performing or attempting to perform health care services on the wrong patient, a wrong-site procedure, or an unauthorized or medically unnecessary procedure, or procedure otherwise unrelated to the patient's diagnosis, constitutes grounds for disciplinary action by the Board of Nursing. The circulating RN was found in violation of this regulation.

The Board of Nursing requested one or more of the following penalties: permanent revocation or suspension of the nurse's license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, placement of the nurse on probation, corrective action, remedial action, payment of fees, or whatever else the Board deemed appropriate.

In order to expedite consideration and resolution of the action by the Florida Board of Nursing, the RN waived the right to a determination of probable cause and admitted that probable cause existed for this violation. In addition, he also waived the statutory privilege of confidentiality. However, he neither admitted nor denied the factual allegations contained in the original complaint.

In February, 2007, the Board approved a settlement agreement that imposed an administrative fine of $250.00, and costs of more than $2,000.00, to be paid within six months. The RN also had to successfully complete an education course on Legal Aspects of Nursing and Patient Assessment, and waived his right to appeal or further review of this case.

Though the hospital's attorneys guided the RN through the disciplinary process, the RN is responsible for ensuring compliance with the discipline ruling under the Final Order and Settlement Agreement.

July 2007
Electronic Medical Records (EMR)
Shelley Cohen RN BS CEN

The electronic medical or health record is already here for some of you and for those who have not yet experienced it, you will soon enough. Although it has many benefits, one of which is clearly legibility, as with any documentation process it can have risk if staff are not trained in the proper way to use the system. A variety of software programs exist for electronic medical records and some of them are even specialty specific. Minimize your risk with these documentation processes tips;

Assure you understand the process of your EMR
Incorrect spelling may be perceived as lack of professionalism
All check off columns without narrative will not always "tell the picture" about your patient
Always check the time of each note entry to assure the time aligns with the time you performed the action or made the assessment
Determine in writing the areas of the EMR that are mandatory for staff to complete
Charting must reflect critical thinking on the part of the nurse
Be alert when "clicking on" pre-printed phrases to assure the phrase correctly represents the information you want to communicate about the patient

Finally, remember filling in the vital signs does not imply you took any action in response to them!

June 2007

Nurses Giving Telephone Advice

Constance Watkins RN CLNC

This topic is of special interest to me because I actually worked for over four years as a telephone triage nurse.

Should registered nurses give advice over the telephone? Yes, but they must possess the necessary knowledge, skills and judgment to do so.

Physician orders or "standing orders" must be in place to prevent potential liability issues. Policies and procedures must be in place and staff held accountable to practice these safely and ethically.

Not only can nurses triage over the telephone, they can actually provide teaching and counseling, facilitate access to health care services by directing the caller to an appropriate hospital, clinic or physician that will meet their needs.

Because there is liability potential and a duty to provide care, policies must be in place and documentation of the advice given is crucial. The nurse must stress that if the caller's symptoms persist or get worse, they need to seek care at the nearest emergency room or with their private physician.

Benefits and services of nurses giving telephone advice:

Proper utilization of the emergency room or urgent care center
Referrals to community health education programs and services
Redirecting the uninsured and under insured to the most appropriate setting

When properly set up and supported, nursing telephone advice offers another method of delivering health care and nursing services to the public.

April 2007

Why apologize right away?

Constance Watkins RN CLNC

When an error is made, why is it so important to apologize right away?

Errors are unavoidable because we are all human, but we must take responsibility for our actions. When we make an error, we must take the time to acknowledge the mistake and then move on to the next step: Tell the person you have erred that you are wrong and that you did not mean to commit the mistake; be sincere. Apologizing right away could solve the problem and prevent the situation from growing even bigger, or even a lawsuit!

Litigation? No one likes to hear the words litigation or lawsuit. One way to prevent the mistake from growing is to follow the rules. Know your facilityís policies and procedures and how to access them. Be sure that the information you give, or disclose, is in compliance with workplace rules, policies and procedures. Such disclosure can be voluntary or involuntary, verbal or written.

Regret for your error? Show it! The other person needs to know that you take the mistake seriously and that you/your actions caused the problem and will do the best you can to remedy the error.

Timing: An apology must be honest and thoughtful. Donít wait one or two days to apologize. Itís about admitting the error; correcting the error and making the patient feel valued and important.

Apologize right away? Yes!

For more information please visit:

Institute For Safe Medication Practices at: http://www.ismp.org/

30 Safe Practices for Better Health Care at: www.ahrq.gov

March 2007
Patient/Family Threats To Sue

Rene'Jackson RN BSN MS LHRM

When a patient or family member says, "I am going to sue you and this hospital," the first thing you need to do is not get defensive. Express sympathy, even apologize, but do not acknowledge blame. Find out what the concern is first. Was the patient injured? Did the course of treatment not go as planned? There may have been a bad outcome, but no real medical error. If you are a staff nurse, try to correct the problem, within your scope of practice. If you need assistance, advise the charge nurse, supervisor, and/or the risk manager. You should document in the medical record only facts, not opinions or judgments.

If a family member says, "That doctor never returns my phone calls and my mother is in there suffering and you need to do something about it," first find out about the patient. If you are the patient's nurse, you will already know. What is the diagnosis, the treatment plan, is the patient's pain adequately controlled? Don't just tell the family that the doctor only comes in after office hours or has already made rounds, but make an attempt to put the physician and family member in touch with each other. Try to ascertain the real concern and make a concerted effort to resolve it. Don't make promises you can't keep. Always chart your attempts and the results in the medical record. Write an incident or event report only if the concern could not be addressed immediately and the issue turns into a grievance. Many times family members just want to know someone is advocating for their loved one and a situation should be diffused before it becomes volatile. Whatever you do, follow-up to make sure the concern is resolved to everyone's satisfaction, to the extent that it can be.

February 2007
Patients Who Don't Speak English

Constance Watkins RN

Poor communication can become a barrier to good health care and sometimes produces medical errors. In some cases, understanding the patient can make the difference between life and death.Whose responsibility is it to assure that these patients understand their medical care? It is both the nurses' and doctors' responsibility to make sure non-English speaking patients understand them and understand the treatment being provided.What can we do to better understand the patient?Can we rely on bilingual family members to translate? Studies have indicated that family members are not a good choice for the following reasons:

Prone to inject their opinion into the interpretation
Decide not to pass on pertinent information that they believe is embarrassing or confidential
May not fully understand what is said either

What is the solution? Use an interpreter to translate for the patient either in person or by telephone translation services. There is no excuse for nurses' or doctors' failure to take advantage of help that is readily available. The standard of care should include providing language assistance as this makes patients safer and decreases the chance of mistakes and/or malpractice. Reference: www.healthlaw.org Language Services Resource Guide

January 2007
Documentation
Rene' Jackson RN BSN MS

Do's

Do chart legibly. Poor handwriting leads to misunderstandings and miscommunications between caregivers.
Do read and comply with your facility's policies and procedures regarding documentation.Do document facts, observations, patient's condition and complications.Do correct errors by drawing one line through an error, initial it, and then write the correct statement or word. However, you should be familiar with and follow your facility's policy for correcting errors in a chart as it may differ.
Do date and time the entry and sign your name with your professional signature.

Don't

Don't use non-specific language, for example, "ate well" and "feels better".Don't add to the record after an adverse outcome or patient complaint. Especially not after a request for records. Even if your intentions are good, it could be misconstrued as an attempt to cover something up.Don't chart your opinions or make subjective statements, unless it is what the patient said (in quotes).Don't erase an entry or use correction fluid.Don't refer to incident reports in the patient's record.
Don't chart hearsay as if it were fact.