Monthly Archives: November 2012

When the shoe is on the other appendage

A nurse under fire deserves our support whenever possible. But is it always possible, and would you feel like a Benedict Arnold if you testified against another nurse’s care?

Think of it this way: when a person is harmed by negligence, you are not attacking another nurse; you are defending a patient.

Consider this recent case: An elderly woman with Alzheimer’s disease was in hospice and had been minimally responsive for several months. But then her physician decreased her sedation and she began talking with family, responding to her environment, and eating solid food. Her children were delighted with this gift of quality time and even her physician documented the marked change in her behavior. He did not connect the dots that he had overmedicated her (but that is another issue).

One night, a float nurse placed a high dose fentanyl patch on this lady’s chest, who had no order for any type of narcotic and no complaints of pain. Exactly how did that happen?

  • Why did the nurse not look for an old patch before placing a new one?
  • On whose chart did she document having applied the patch?
  • What was the effect on the patient who missed her rightful dose?
  • What is this nurse’s work history?
  • Did the facility report this event to the State Board of Nursing or Medicare?
  • Could this have been an attempted mercy killing?
  • Did this act result in permanent damages?

The patch was applied at 9am. At 9:45pm the patient was noted to have fluid-filled lungs and was given atropine, but the patch was not found for another 13 hours. By then it was too late to save her.

I ask you, who monitors pulmonary congestion for 25 hours and doesn’t see a patient’s chest while listening to lungs? If any nurse had looked, she would have found the patch. This case had many unacceptable breaches in care, resulting in death 70 hours after the patch was applied.

What do you think? Is this a family complaint you could get behind? Do you think the nurse’s action resulted in damages that ended in her premature death?

Remember, your job would not be to opine on causation, but to simply and objectively state your understanding of the standard of care in medication administration. Tell the attorney/jury what would constitute good care, and why failure to do so constituted negligence.

You can do that.

Thoughts for the New Nurse

1. Lay hands on your patient as often as you can – not just for auscultation or checking an armband as you dispense meds; see them, and know they are probably afraid

2. Sometimes a back rub or a foot massage offers more relief than a Vicodin – warm the lotion first

3. Respect your nursing assistants and make sure they know how much you value their input – tell them your concerns about a patient so they know what to look for, and compare their observations to your own.

4. You will never have a clearer memory of what you learned in school than you do right now – but you will know more about life, and nursing, with every day that passes.

5. Keep reading, studying, learning, and subscribing to free email alerts from places like WebMD. Go to conferences and stay connected with positive people who love what they do.

6. Don’t believe everything you read from medical blogs. The chemical/food/ beverage that causes cancer one week will probably be its cure six months from now.

7. The nursing process is a great blueprint that you will always remember and follow, but make sure your care plans are more than canned entries. Of course we want to “prevent skin breakdown” – add that back rub and foot massage to your care plan!

8. Keep your eye on theI&0, know your patient’s normal appetite and bowel habits, be aware that a suddenly confused patient with a Foley may have a UTI, and that the patient who pulls off their oxygen usually needs it the most.

9. Never let a shift end without a narrative about your patient despite (or because of) electronic documentation.

10. Be proud of your degree, but
      a. do not let initials define you
      b. never minimize the nurse who has two years of schooling instead of four
      c. listen completely and respectfully to everyone, because their knowledge is not your knowledge…but it can be

This Could Be You

Part One: Yes, I am talking to YOU

Do you consider yourself a good nurse, or put another way, would you want your family taken care of by someone just like you? Do you feel comfortable teaching new nurses “how we do it” at your hospital, or on your infusion team, or in your home health care agency or nursing home? I am willing to bet that you can recognize deviations in care, and recognize good care when you see it, and yet, let’s be honest. 99.9% of “us” nurses get the willies when we think about testifying in court. A part of this fear is the belief that we might find ourselves being deposed or on the witness stand, defending our own actions. Talk about a knuckle-biter.

Well, take a step back from that ever-present awareness that you could err, and think about the nurse who already accused of making a mistake and causing harm to a patient. Doesn’t she need help?

Who is that nurse? Not necessarily someone in PACU or CCU, but the nurse on the floor – the one giving or supervising tube feedings, suctioning an ET tube, helping a patient to the bathroom or pushing meds in an IV. Does that sound like anyone you know? In this world of computerized documentation, meant to make our job straightforward (or someone’s job, at any rate), you know how easy it is to miss a check box even though work was done – your Risk Management department delivers this message like your job depends upon it. Oh.

If you were the nurse whose care was being questioned, who would you want on your side? Who else, but another nurse who works in the same environment you do, who understands the rapid pace and demands upon your time, the responsibility for supervising the actions of others and the potential consequences of being nothing more than “there” at the time an event occurred.

Your nursing experience is what makes you so valuable to the legal system and fellow nurses, because you do not live in a world of textbooks and online research.

If  asked to review the medical records of the patient harmed in the hospital or any other setting, would you know how to do that? Of course you would; you know what belongs in a chart and therefore you know what is missing when you (don’t) see it.  Chances are quite high that if someone asks you to serve as an expert witness, harm did occur, because attorneys are not in the business of spending upwards of 100k to try a case that has no injury. Injury and merit, however, are not synonymous.

The question you would be asked is not “did a bad outcome occur”, but “did the bad outcome arise as a direct result of this nurse’s (in) action”? Can the nurse’s care be rightfully defended, who else was in the chain of command, and most importantly, was the standard of care met? Remember that nurse experts are not being asked to diagnose a condition; they are being asked what a reasonable and prudent nurse in the same setting would have done.

Next time, Part Two: When the shoe is on the other appendage.

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