Constance Watkins, RN, CLNC is in her fifth year partnering with HRU to bring you insight that helps manage the risk of your professional responsibilities.Her topics and content help thousands of nurses address the timely issues we all face in our daily practices.
The Patient Protection and Affordable Care Act (ObamaCare) has sparked a lot of uncertainty among health care professionals. The new law requires employers with 50 or more workers to provide health coverage by 2014, or face a $2000.00 per employee penalty.
As more patients enroll in health coverage, there will be a need for more advanced practice nurses to play a front row role as the patient’s primary care provider. Part of the need for more nurse practitioners is largely due to physicians choosing not to go into primary care; thus, the need for nurses to deliver primary care to these beneficiaries. The Bureau of Labor Statistics projects that more than 581,000 new RN positions will be created by the year 2018. Who will educate these nurses? Nursing schools are already turning away qualified applicants because there are not enough faculty, schools, preceptors and funds.
So, is there a down side of The Patient Protection and Affordable Care Act for the nursing profession? The answer remains to be seen. Nurses must continue to support the growth and elevated role of their profession by taking part in the following;
· Participate in political decision-making.
· Consider teaching as part or full time faculty at a school of nursing
· Support colleagues who elect to advance their nursing practice
· Explore opportunities for yourself to advance in your role as a nurse
The American Association of Colleges of Nursing (AACN). (2010). Patient protection and affordable care act: PL 111-148 nursing education provisions.
Professional competency expectations are at an all-time high as patient and caregiver expectations of the health care system continue to rise. The spotlight is not only on empathetic caregivers, but also on the quality and competency of the care being delivered. As professionals, nurses are bound by the privilege of their license sanctioned through their board of nursing. Do not take this responsibility lightly - in the eyes and mind of any jury, your obligations to your license are paramount!
Review your current nurse practice act and your job description, and then answer these questions;
1. How can you validate that you are qualified to perform your job?
2. How recent is your continuing education and how relevant is it to your current role?
3. Do you have a working knowledge of current evidence based practices related to your nursing specialty?
4. Do you belong to a professional organization and use their reference tools to frame your daily practice?
5. Is your documentation "solid"- does it reflect your assessments, interventions, and patient outcomes?
The first time you consider any of these questions should not be in preparing for a deposition- be proactive. It is never too late to improve your level of practice and professionalism.
Patient Abandonment: Patient Abandonment refers to withdrawal from treatment of a patient without giving reasonable notice or providing a competent replacement.
Constance Watkins, RN, CLNC
The nurse-patient relationship begins when the nurse accepts responsibility for providing nursing care based upon a written or oral report of the patient needs. It ends when that responsibility has been transferred to another nurse along with communication detailing the patient’s needs. Once a nursing assignment has been accepted, it is the duty of the nurse to fulfill the patient care assignment or transfer responsibility for that care to another qualified person. In the absence of an established relationship, there usually is no duty to treat.
The following are examples of patient abandonment:
1. The nurse must have begun developed a nurse-patient relationship then severed the nurse-patient relationship without giving reasonable notice to the appropriate person so that nursing continuity of care would continue; the nurse withdraws from the nurse-patient contractual relationship and fails to provide sufficient notice to the patient:
Jane is assigned to 6 patients on the med-surg floor and has finished taking report from the night shift. 4 hours into her shift she receives a call that one of her children is ill and must be picked up. Jane talks to her charge nurse and they are unable to find a replacement for her. Jane tells the charge nurse that she will still have to leave regardless of whether or not a replacement is found. The charge nurse refuses to take report and Jane leaves the hospital.
2. The patient must be in need of immediate professional care and without this care his/her medical condition would be seriously impaired; the nurse leaves the facility without transferring patient care to another qualified individual:
Mary Lou, RN, leaves the operating room during a surgical case without transferring the care to another qualified individual, when this would seriously impair the delivery of professional care
The nurse may terminate care for specific reasons only after providing formal notice and providing the patient reasonable continuity of care. To evaluate charges of abandonment and unprofessional conduct, the following questions may be helpful: Did the nurse accept the patient assignment, establishing a nurse-patient relationship? Did the nurse provide reasonable notice when severing the nurse-patient relationship? Could reasonable arrangements have been made for continuation of nursing care by others when proper notification was given?
The patient; however, may terminate his care at any time. If this happens, the nurse should document what is said, who was notified, and the patient’s demeanor, behavior, and mental status.
Needleman J, Buerhaus P, Mattke S, et al. (2002). Nurse-staffing levels and the quality of care in hospitals. New England Journal of Medicine
You may also refer to your state’s nurse practice act as it relates to patient abandonment.
Patient Abandonment: Patient Abandonment refers to withdrawal from treatment of a patient without giving reasonable notice or providing a competent replacement.
Constance Watkins, RN, CLNC
The Nurse Whistleblower
What is a whistleblower? A whistleblower is a person who reports misconduct in the workplace, or a nurse who identifies an incompetent, unethical or illegal situation in the workplace and reports it to someone who may have the power to stop it; either inside the organization or outside.
Whistleblowers used to be seen as troublemakers but are actually now seen as brave individuals who take a stand against the practices of an organization’s unethical behaviors.
When a nurse contemplates whistleblowing, there are several questions they must ask of themselves:
What values are involved?
Do I have the courage to stand up for what is right?
Is this decision one which an informed moral person would make?
Can I live with my decision?
Are there laws that will protect my decision?
Some states have specific laws to protect nurses who are whistleblowers. These laws are intended to prevent employers from taking retaliatory action against nurses such as suspension, demotion, harassment or termination for reporting improper patient care or business practices. As part of the American Nurses Association’s (ANA) Nationwide State Legislative Agenda, ANA and State Nurses Associations are promoting strong whistleblower laws on the state level that provide protection for nurses advocating for patients without the fear of reprisal. Joining your state’s ANA and/or other specialty nurse association provides support for the lobbying efforts necessary to enact such laws.
Recently in the news there was a case in Texas in which the whistleblower nurse was actually acquitted. The story is too long to include in this article but I am attaching a link to the NY Times for your further reading:
Texas Nurse to Stand Trial for Reporting Doctor - NYTimes.com
American Nurses Association (ANA), (2001). Code for ethic for nurses with interpretative statements. Silver Spring, MD: AmericanNurses Publishing.
The professional consequences of whistleblowing by nurses. McDonald S, Ahern K. Source: Neurology Department, Royal Perth Hospital, Perth, Western Australia. firstname.lastname@example.org
Constance Watkins, RN, CLNC is in her fourth year partnering with HRU to bring you insight that helps manage the risk of your professional responsibilities.Her topics and content help thousands of nurses address the timely issues we all face in our daily practices.
Patients' hospital experiences and how they perceive their care are based on many situations such as:Communication with nurses and doctors, responsiveness of hospital staff, cleanliness and quietness of the hospital environment, pain management, communication about medicines and treatments, as well as other information and discharge instructions. But what if a mistake or adverse event happens? What changes with these perceptions? How should these scenarios be handled and who should address them?
Staff members must be taught how to approach saying ‘I’m sorry,’ and say it the right way. It is not just a nice thing to do; it’s a strategic business tactic that pays off in tangible ways. Such training helps employees do their jobs more effectively and gain more satisfaction from their work. This results in higher productivity, less turnover and of course, it results in happier patients who feel genuinely respected and cared for.
Nurses, doctors and other staff must understand their roles in disclosure if a mistake should occur. “I’m sorry” should be provided as soon as possible after an adverse event, however never admit fault until after a full investigation has been performed. Admission of fault should only occur after an investigation has proven a mistake has occurred and the error has causation to the injury or death.
When the investigation reveals an error has been made, schedule an appointment with the patient/family and legal representative if applicable to explain what happened and to admit fault. If no error has been made, empathize, answer questions and make medical records available for review. Offer other services such as transportation, meals and accommodations. All of these measures should take place with oversight from your organization’s administrative and legal counsel team.
It is okay to say “I’m Sorry”. Words are more powerful than most people realize. An empathetic apology takes only a few seconds and costs nothing, yet it can completely change a patient’s perception of care and that’s no small matter.
www.TheStuder Group.com “It’s a Patient Perception of Care—Not a Number” by Quint Studer
“I’m Sorry to Hear that…” Real-Life Responses to Patients’ 101 Most Common Complains About Health Care by Susan Keane Baker and Leslie Bank
Hospital Discharge Challenge # 3- Patient/family insist on unsafe discharge
Discharge planning should include the development of an ethically and morally appropriate safe plan that best meets the need of the patient. However, scenarios may occur where the patient and/or family insist on an unsafe discharge that can place the patient at risk.
The patient's right to autonomy prevails over the hospital's desire to achieve a beneficial patient outcome. Verifying that the patient has the capacity to make this decision, they have the legal right to accept or decline the discharge plan.
A sound discharge plan and a well documented medical record place the organization on more solid legal and ethical ground. Involuntarily holding a patient in this situation could result in strong legal ramifications for the staff and the organization.
Hospital Discharge Challenge # 2- Patients who refuse to leave the hospital
Numerous legal issues arise in discharge planning for the patient who refuses to leave the hospital. In some scenarios it is a matter of a family unwilling to assist or facilitate this process. Situations occur where family members are unable to assume responsibility for the patient for a variety of reasons. A dysfunctional family element may be present or the family may not have the physical capacity to care for their loved one.
Regardless of the circumstance, there is no requirement for a patient to consent to their discharge as this is a provider decision. A hospital may elect to actually evict a patient who will not leave – this is accomplished through activating state statute such as criminal trespass laws. The organization must assure that the patient is medically stable and proven competent prior to taking any such actions.
Although evicting patients may be a more common scenario in the long term care or rehab setting, the acute care environment is not exempt from the possibility of this occurrence. Consideration for the public relations fall out should the hospital need to move forward with an eviction is a must. Negotiating options for the patient and organization with the services of a mediator may prove helpful, especially if the patient involved is a Medicare/Medicaid patient.
Legal Eye Newsletter (2002). Patient Refuses To Leave The Hospital: Court Orders Him
Moved To An Adult Home. http://www.nursinglaw.com/refusal.pdf
Hospital Discharge Challenge # 1- Victims of Violence
A young woman whose boyfriend abused her requires admission to your hospital, yet she refuses stating she can take care of herself. When domestic violence is identified, health care providers should collaborate with the victim in evaluating their ability to access recommended treatments/ follow-up care, and should modify these when necessary for the best interest of the victim. It is unrealistic to expect these patients to comply with medical regimens that require them to do things that directly or indirectly endanger them or possibly their children. Health care providers engaged in discharge planning should ensure that any patient who is an identified victim of domestic violence has a safe place to go and the patient should be provided both written \and verbal information about local domestic violence services. No victim should be discharged if the patient states it is unsafe for them to return home and they have no alternative safe place to stay. Hospitals must collaborate with authorities and local support services and work with the victim to identify a safe and appropriate discharge option. The patient should retain the right to determine what options will meet their safety-related needs. In addition, health care providers should keep accurate medical record documentation of a victim's statements, injuries, symptoms, treatments, and referrals.
Case management and coordination is key to developing and implementing effective safety plans.
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.
If you are interested in submitting risk management tips to the website, please email Shelley Cohen directly @ email@example.com.
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.
Nursing Law’s Regan Report (2009). ER exam table gave way under 450 pound patient. 50 (7).
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.
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 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;
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.
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)
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!
Constance Watkins RN, CLNC
False imprisonment is a term you likely think of when watching a television episode involving innocent people in jail or prison. Did you know that nurses and other healthcare professionals could be guilty of committing false imprisonment against patients?
The following constitutes false imprisonment:
Restraining or restricting a person's movement without the legal authority to do so. The person may be physically restrained (tied up or locked up), restrained by drugs, or restrained by threats. The person does not need to try to escape.
The act of carrying out this purpose; the resulting detainment of the individual against their will
Verbal threats or the intentional illusion of authority, making the person being held believe that he or she is not free to go; emotional restraints
No means of escape: To be considered false imprisonment, a person must lack a reasonable means to safely escape the confinement.
The person confined must also be aware of the confinement
The person committing the act must not have legal authority to do
The act of false imprisonment is considered an intentional Tort. A tort is an area of civil law and is a wrongful act that is committed by someone or an entity that causes injury to another person or property.
What can you do to prevent accusations of false imprisonment? The nurse has a duty to notify the provider and nursing supervisors of the patient’s intent to leave “against medical advice”. Many hospitals or agencies request that a patient sign an “Against Medical Advice” (AMA) form when they intend to leave despite the absence of a discharge order.
Not all detainments constitute false imprisonment; it is based heavily on the context of the situation. There are cases where detaining a patient who is disoriented or mentally incompetent to take care of themselves is not considered false imprisonment. All states have a legal procedure to obtain authorization to detain some categories of persons who are mentally ill, engage in substance abuse, or are infected with a contagious disease.
When patients are oriented, competent and not legally committed, staff should avoid detaining them unless authorized by institutional policy or by an institutional administrator. Refer to your institution’s policies and procedures and your state’s statute regarding involuntary holds. You may also refer to the Nurse Practice Act in your state.
Please be familiar with your rights and responsibilities and your institution’s rules for patient care. Your patient has rights and you and your organization have responsibilities to those rights. Protect yourself and your license; be familiar with applicable law, rules, and policies.
American Medical Association: Code of medical ethics, Chicago, 2000-2001, AMA
Admitting Medical Errors
Constance Watkins RN, CLNC
Admitting medical errors may actually serve to reduce the number of errors themselves. Can this be true? When doctors and nurses do not feel compelled to honor the “code of silence” they are more likely to report dangerous medical situations and mistakes so that the situations can be corrected. This, in turn, prevents further problems by correcting the adverse incidents.
Though many doctors and other healthcare personnel worry that admitting errors will open them up to litigation, honesty may actually help to contain medical malpractice lawsuits. Accountability could go a long way in helping ease the pain of a medical mistake. President Truman felt so strongly about taking accountability that he placed a sign on his desk that read “The buck stops here”.
What can nurses do to reduce adverse events and help prevent a medical malpractice lawsuit?
Fill out an incident report
Admit the mistake to the patient and offer a straightforward explanation of what went wrong
Offer a heartfelt apology for the damage incurred; be sincere
Always abide by your facility policies and procedures when reporting an incident
The human spirit has a huge capacity for forgiveness and compassion and most people understand that doctors and nurses are human. Openness and compassion may satisfy patients for whom filing a lawsuit was formerly their only alternative.
Additional Reading: Aug. 17 issue of the Annals of Internal Medicine.
Wojcieszak, Doug, et al (2007). Sorry Works!. Indiana: Author House
Nurses, Negligence, and Malpractice
Constance Watkins RN, CLNC
In 2000, the Institute of Medicine issued the report To Err is Human revealing the staggering figures of between 44,000 and 98,000 people dying in a hospital every year as a result of a medical error. Many of these deaths were the result of healthcare workers’ negligence.
The nursing shortage and hospital downsizing have contributed to greater workloads and longer hours for nurses; thus, increasing the likelihood of error.
Failure to follow standards of care
Failure to use equipment in a responsible manner
Failure to communicate
Failure to document
Failure to assess and monitor
Failure to act as a patient advocate
Malpractice lawsuits are both professionally and emotionally devastating which should encourage nurses
Expand your knowledge and technical skills.
Know legal principles and incorporate them into everyday practice.
Practice within the bounds of professional licensure.
Acknowledge your strengths and weaknesses and never accept a clinical assignment you don't feel competent to perform.
The Institute of Medicine of the National Academy of Sciences (1999). To Err Is Human.