1. How common are these errors reviewed on the previous slides 1-47 in this week's lecture presentation? What are the top sentinel events in the hospital setting? Research Joint Commission (joint commission.org)and Institute for Healthcare Improvement (IHI.org)
2. What are some factors contributing to these errors?
3. What outcomes do they lead to (ex: what types of adverse events, mortality rate, cost, etc.)?
4. How should this problem be addressed (ex: best practices)?
Medical Staff Liability
Medical Staff Organization
Committees
Executive Committee
Bylaws Committee
Blood and Transfusion Committee
Credentials Committee
Infection Control Committee
Medical Records Committee
Pharmacy and Therapeutics Committee
Quality Improvement Council
Tissue Committee
Utilization Review Committee
Executive Committee
Recommends medical staff structure
Develops a process for reviewing credentials
Recommends appointments to the medical staff
Develops processes for delineating clinical privileges
Executive Committee
Performance improvement activities
Peer review
Fair hearing process
Reviews and acts on reports of medical staff departmental chairpersons and medical staff committees
Bylaws
Organization of the medical staff is described in its bylaws, rules, and regulations
Bylaws must be approved by the governing body
Bylaws must be kept current and the governing body must approve recommended changes
Bylaws describe various membership categories of the medical staff (e.g., active, courtesy, consultative)
Blood and Transfusion
Develops blood usage policies and procedures
Monitors transfusion services
Monitors
Indications for transfusions
Blood ordering practices
Each transfusion episode
Transfusion reactions
Credentials
Oversees application process for medical staff applicants, requests for clinical privileges, and reappointments to the medical staff
Makes its recommendations to the medical executive committee
Infection Control
Generally responsible for the development of policies and procedures for investigating, controlling, and preventing infections
Medical Records
Develops policies and procedures, including:
Release, security, and storage
Determining the format of medical records
Monitoring records for accuracy
Completeness, legibility, and timely completion, and clinical pertinence
Ensures records reflect condition and progress of the patient, including results of all tests and therapy given and makes recommendations for disciplinary action as necessary
Pharmacy and Therapeutics
Policies and procedures (e.g., selection; procurement; distribution; handling, use, and safe administration of drugs, biologicals, and diagnostic testing material)
Oversees development and maintenance of formulary
Evaluates and approves protocols for the use of investigational or experimental drugs
Pharmacy and Therapeutics
Oversees:
Tracking of medication errors
Adverse drug reactions
Management, control, and effective and safe use of medications through monitoring and evaluation
Monitoring of problem-prone, high-risk, and high-volume medications
Quality Improvement Council
Functions as a patient-care assessment and improvement committee
Tissue
Provides surgical case reviews, including:
Justification and indications for surgical procedures
Utilization Review
Monitors and evaluates utilization issues such as medical necessity and appropriateness of admission and continued stay, as well as delay in the provision of diagnostic, therapeutic, and supportive services
Ensures each patient is treated at the appropriate level of care
Utilization Review
Objectives of the committee include
Transfer of patients requiring alternate levels of care
Promotion of efficient and effective use of resources
Adherence to quality utilization standards of third-party payers
Maintenance of high-quality, cost-effective care
Identification of opportunities for improvement
Medical Director
Serves as a liaison between medical staff and organization’s governing body and management
Responsibilities include enforcing the bylaws of the governing body and medical staff and monitoring the quality of medical care in the organization
Medical Staff
Credentialing: Screening and evaluating qualifications
Appointment: becoming a member of the medical staff
Privileges: identifying the specific procedures and patient care services a physician will be able to provide at certain sites
Medical Staff Privileges
Screening process
Application
Medical staff bylaws
Physical and mental status
Consent for release of information
Certificate of insurance
State licensure
National practitioner data bank
References
Interview process
Medical Staff Privileges
Delineation of clinical privileges
Limitations on privileges requested
Practicing outside field of competency
Governing body responsibility
Misrepresentation of credentials
Appeal process
Must exhaust all remedies provided in a hospital’s bylaws before seeking legal action
Reappointments
Should be reviewed every 2 years
Common Medical Errors
Patient assessment
Diagnosis
Treatment
Discharge
Follow-up care
Patient Assessments
Involve the systematic collection and analysis of patient-specific data necessary to determine a patient’s care and treatment plan
A patient’s plan of care is dependent on the quality of assessments conducted by practitioners of various disciplines (e.g., physicians, nurses, dietitians)
Patient Assessments Examples
Unsatisfactory History and Physical Exam
Assessment of Unconscious Patient
Any physician should reasonably anticipate head injuries when car strikes a person
Failure to Obtain a Second Opinion when Requested
Assessments Sometimes Require Referral to a Specialist
Aggravation of Patient’s Condition
Liability only imposed for aggravation
Diagnosis
Refers to the process of identifying a possible disease or disease process, thus providing the physician with treatment options
A wrong diagnosis will not in and of itself support a claim of negligence
Patient must be examined adequately (physician must use ordinary care)
Diagnosis
Failure to order diagnostic tests
Plaintiff needs to show:
It is standard practice to use a certain diagnostic test under the circumstances of the case
The physician failed to use the test and therefore failed to diagnose the patient’s illness
The patient suffered injury as a result
Diagnosis Examples
Efficacy of test questioned
Is failure to order test a substantial factor in causing patient’s injury or death?
Failure to promptly review test results
Timely diagnosis (reducing chance of survival)
Failure to Read X-Ray Report
Failure to Monitor Patient
Diagnosis – Imaging Studies
Imaging studies
Failure to Order Appropriate Imaging Studies
Image Misinterpretation Leads to Death
Failure to Consult with Radiologist
Failure to Read Images
Delay in Conveying Imaging Results
Failure to Communicate Imaging Results
Diagnosis
Most frequently cited injury event in malpractice suits against physicians
Medicine is not an exact science and linking a patient’s symptoms to a specific ailment is complicated at best
Sometimes things go wrong despite all the advances of modern medicine
Diagnoses based on false test results
Can lead to harmful treatments
Accident Victim: Misdiagnosis
The police department physician examined an unconscious man who had been struck by an automobile.
The physician concluded the patient’s confusion was due to intoxication and he was placed in jail instead of a hospital.
The man remained semiconscious for several days and was finally taken to a hospital at the insistence of family; he subsequently died.
The autopsy revealed massive skull fractures.
Did the physician commit malpractice?
Accident Victim: Misdiagnosis
Yes!
A patient is entitled to a thorough examination as his or her condition and attending circumstances warrant.
This did not happen
Treatment
The attempt to restore the patient to health following a diagnosis
Involves the application of various remedies and medical techniques, including surgery and medications
Forms of Treatment
Active treatment is directed immediately to the cure of the disease or injury
Causal treatment is directed against the cause of a disease
Conservative treatment is designed to avoid radical medical therapeutic measures
Palliative treatment is designed to relieve pain and distress with no attempt to cure
Forms of Treatment
Preventive/prophylactic treatment is aimed at the prevention of disease and illness
Supportive treatment is directed mainly to sustaining the strength of the patient
Symptomatic treatment is meant to relieve symptoms without effecting a cure
Treatment: Choice of Treatment
Two schools of thought doctrine:
Applicable in medical malpractice cases in which there is more than one method of accepted treatment.
Under this doctrine, a physician will not be liable for medical malpractice if he or she follows a course of treatment supported by reputable, respected, and reasonable medical experts.
Use of unprecedented procedures that create an untoward result may cause a physician to be found negligent.
Treatment Examples
Selecting the wrong treatment
Failure of attending physician to recognize recommendations of consulting physicians
Delay in treatment
Failure to treat known condition
Failure to treat evolving emergency
Failure to respond to emergency calls
Treatment: Medication Errors
Limited and judicial use
Documentation of use and continuation
Medication errors
Wrong Dosage
Negligent drug overdose
Abuse in Prescribing Medications
Wrongful Supply of Medications
Medication Errors
Medication errors
Failure to administer drugs
Failure to document drug wastage
Administering drugs without a prescription
Administering wrong medication
Failure to clarify orders
Medication Errors
Administering by the wrong route
Failure to discontinue medication
Failure to identify correct patient
Failure to note order change
Treatment: Surgery
Surgery
Wrong Patient Surgery
Correct Surgery: Wrong Site
Foreign Objects Left in Patients
Procedure Improper
Endotracheal tube removed too soon after surgery
Improper Positioning of Arm
Preventing Surgical Mishaps
Require second opinions
Qualified credentialed physician for proposed procedure
Patient informed as to risks, benefits, and alternatives
Consent forms executed
Equipment, supplies, and staff prepared for procedure
Preventing Surgical Mishaps
History and physical exams completed
Pre-anesthesia assessment conducted
Correlation of pathologic and diagnostic findings
Vital signs and surgical site assessments continuously monitored
Discharge and Follow-Up Care
The premature discharge of a patient is risky business
The intent of discharging patients more expeditiously is often a result of a need to reduce costs
Discharge instructions must be clear and complete
Discharge and Follow-Up Care: Examples
Untimely Discharge
Failure to Provide Follow-Up Care
Failure to Follow-Up on Test Results
Abandonment: unilateral termination of a physician patient relationship by the physician without notice to the patient
Abandonment
Elements necessary to recover damages:
Medical care unreasonably discontinued
Discontinuance against patient’s will
Failure to assure follow-up care for patient
Foresight: Failure could result in patient injury
Actual harm was suffered by patient
Infections
Hospital acquired infections are a big problem
Nearly 2 million a year with 90,000 deaths
Fact that a patient contracted an infection will not in of itself cause a surgeon to be liable
Failure to effectively manage infection
Poor infection-control technique
Cross-contamination
Improper sterilization
Preventing spread of infection
Psychiatry
Commitment
Electroshock
Duty to warn
Suicide
Psychiatry
Commitment
Patient due process rights
Perform appropriate assessment prior to commitment
Two physicians to certify the need for commitment (separately)
Substantial danger of injuring oneself or third persons
Prove by clear and convincing evidence
Psychiatry
Duty to warn: when a therapist determines or reasonably should determine that a patient poses a serious danger to others, there is a duty to exercise reasonable care to warn and protect foreseeable victims
Suicide: duty to exercise reasonable care to protect suicidal patients from foreseeable harm
Fail to check on patient every 15 minutes as required
Restrained inadequately
Patient not examined daily as required by psychiatrist
Individual Exercise 1-Patient Safety
How common are these errors reviewed on the previous slides? What are the top sentinel events in the hospital setting? Research Joint Commission (joint commission.org)and Institute for Healthcare Improvement (IHI.org)
What are some factors contributing to these errors?
What outcomes do they lead to (ex: what types of adverse events, mortality rate, cost, etc.)?
How should this problem be addressed (ex: best practices)?
Principles of Medical Ethics: Code of Medical Ethics
Principles adopted by the American Medical Association are not laws, but rather standards of conduct that define the essentials of honorable behavior for the physician
A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.
A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.
Principles of Medical Ethics: Code of Medical Ethics
A physician shall respect the law and also recognize a responsibility to seek changes in those requirements that are contrary to the best interests of the patient.
A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.
A physician shall continue to study, apply, and advance scientific knowledge; maintain a commitment to medical education; make relevant information available to patients, colleagues, and the public; obtain consultation; and use the talents of other health professionals when indicated.
Principles of Medical Ethics: Code of Medical Ethics
A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.
A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.
A physician shall, while caring for a patient, regard responsibility to the patient as paramount.
A physician shall support access to medical care for all people.
Physician–Patient Relationship
Personalize treatment
Conduct a thorough assessment
Develop a problems list and comprehensive treatment plan
Provide sufficient time and care to each patient
Request consultations when indicated and refer if necessary
Physician–Patient Relationship
Closely monitor patient progress
Make adjustments to treatment plan as the patient’s condition warrants
Maintain timely, legible, complete, and accurate records
Do not make erasures
Do not guarantee treatment outcomes
Provide for cross-coverage during days off
Physician–Patient Relationship
Do not over-extend your practice
Avoid prescribing over the telephone
Do not become careless because you know the patient
Seek the advice of counsel should you suspect the possibility of a malpractice claim
Maintain the patient’s privacy rights
Physician–Patient Relationship
Relationship ends when:
Mutual consent of the parties
Patient’s dismissal of the physician
Physician’s withdrawal from the case
Agreement that physician’s services are no longer required
How does this relationship work?
https://www.youtube.com/watch?v=lBcMYGdrTMU
Discussion – what can patients do to enhance the physician-patient relationship?
Nursing and the Law
Scope of Practice
Permissible boundaries of practice for healthcare professionals
Statutes define the actions, duties, and limits of nurses
Role of nurses expand
Shortage of primary care physicians
Ever-increasing specialization
Improved technology
Public demand
Expectations within the profession itself
Nursing Diagnosis: States Recognition
Various states recognize that nurses can render a nursing diagnosis.
Nursing Diagnosis: Case
Cignetti v. Camel
Physicians ignored nurse’s assessment (diagnosis)
Contributed to delay in treatment and injury
Nurse testified physician told patient’s signs and symptoms
Were not associated with indigestion
Physician objected to nurse’s testimony
Physician stated: Statement constituted a medical diagnosis
Argument against nursing assessment
What was the court’s decision?
Nursing Diagnosis: Case
Missouri Revised Statutes (1975) authorizes an RN to make an assessment of persons who are ill and to render a nursing diagnosis. The Trial Court decision was affirmed
Nurse Licensure: Requirements for Licensure
Reciprocity
The nurse licensing board in one state recognizes licensees of another state
Endorsement
Boards determine if nurses’ qualifications are equivalent to their own state requirements at the time of initial licensure
Waiver
Nurses with equivalent qualifications can be waived in as licensed nurses
Examination
Some states make examination mandatory
Nurse Licensure: Suspension and Revocation
Violations may include
Procurement of a license by fraud
Unprofessional, dishonorable, immoral, or illegal conduct
Performance of specific actions prohibited by statute
Malpractice
Practicing without a License
Healthcare organizations are required to verify that each nurse’s license is current
The mere fact that an unlicensed practitioner is hired will not generally in and of itself impose additional liability unless a patient suffered harm as a result of an unlicensed nurse’s negligence
Nursing Careers
Registered nurse
Traveling nurse
Licensed practical nurse
Nurse manager
Certified nursing assistant
Float nurse
Agency nurse
Special duty nurse
Student nurse
Registered Nurse
A nurse who has graduated from an accredited nursing program, has passed a state registration examination, and is licensed to practice nursing
Traveling Nurse
A nurse who travels to work in temporary nursing positions in different cities and states
Licensed Practical Nurse
A licensed practical nurse (LPN), as well as a licensed vocational nurse (LVN), provides routine nursing care (e.g., vital signs, injections, assisting patients with personal hygiene needs, and wound dressings).
Under the direction of a registered nurse or physician
Nurse Manager
Chief nursing officer has responsibility for:
Maintaining standards of practice
Maintaining current policies and procedures
Recommending staffing levels
Coordinating and integrating nursing services with other patient care services
Selecting nursing staff
Developing orientation and training programs
Failure to supervise
Can lead to disciplinary action
Certified Nursing Assistant
A certified nursing assistant (CNA) is certified and trained to assist patients with activities of daily living.
The CNA assists with positioning, turning, lifting, and performing a variety of tests and treatments.
Cases
Failure to Follow Policy
Patient Fall
Patient Transfer
Leaving Patient Unattended
Float Nurse
Rotates from unit to unit based on staffing needs
“Floaters” can benefit an understaffed unit, but they also may present a liability if they are assigned to work in an area outside their expertise
If a patient is injured because of a floater’s negligence, the standard of care required of the floater will be that required of a nurse on the assigned patient care unit
Agency Nurse
Hospitals are at risk for negligent conduct of agency staff
It is important that the organization be sure that agency workers have necessary skills and competencies to carry out duties and responsibilities assigned by the organization
Special-Duty Nurse
A healthcare professional employed by a patient or patient’s family to perform nursing care for the patient
If a master–servant relationship exists between the organization and special-duty nurse, the doctrine of respondeat superior may be applied to impose liability on the organization for a nurse’s negligent acts.
Student Nurses
Entrusted with the responsibility of providing nursing care to patients
Students are personally liable for their own negligent acts, and the facility is liable for their acts on the basis of respondeat superior
Student nurse are held to the standard of a competent professional nurse when performing nursing duties
Advance Practice Nurses
Nurse practitioner
Clinical nurse specialist
Certified registered nurse anesthetist
Certified nurse midwife
Nurse Practitioner
Nurse practitioners (NPs) are registered nurses (RNs) who have completed the necessary education to engage in primary healthcare decision making
They are trained in delivery of primary health care and assessment of psychosocial and physical health problems such as the performance of routine examinations and ordering of routine diagnostic tests
Physician may not delegate task to NP if prohibited by regulations or organization’s policies
NPs’ negligence is imputed to the physician under respondeat superior (Adams v. Krueger )
Clinical Nurse Specialist
A clinical nurse specialist (CNS) is a professional RN with an advanced academic degree, experience, and expertise in a clinical specialty (e.g., obstetrics, pediatrics, psychiatry)
The CNS acts as a resource for the management of patients with complex needs and conditions
The CNS participates in staff development activities related to his or her clinical specialty and makes recommendations to establish standards of care for those patients
Clinical Nurse Specialist
The CNS functions as a change agent by influencing attitudes, modifying behavior, and introducing new approaches to nursing practice
The CNS collaborates with other members of the healthcare team in developing and implementing the therapeutic plan of care for patients’ standard of care
Certified Nurse Anesthetist
Administration of anesthesia by a nurse anesthetist requires special training and certification
Nurse-administered anesthesia was the first expanded role for nurses requiring certification
Oversight and availability of an anesthesiologist are required by most organizations
Certified Nurse Anesthetist
Major risks for nurse anesthetists include:
Improper placement of an airway
Failure to recognize significant changes in a patient’s condition
Improper use of anesthetics
Nurse anesthetist: Medical supervision required
Certified Nurse Midwife
Nurse midwives provide comprehensive prenatal care, including delivery for patients who are at low risk for complications
They often manage normal prenatal, intrapartum, and postpartum care
Provided that there are no complications, normal newborns are also cared for by a nurse midwife
Nurse midwives often provide primary care for women’s issues from puberty to postmenopause
LEGAL RISKS OF NURSES
Dilemma: Two Standards of Care
Restrictive standard
Less-restrictive standard
Adopting less-restrictive standard is risky
Risk of patient injury
Organization’s increased exposure to lawsuits
Patient Misidentification
Proper identification prior to performing a procedure
Meena v. Wilburn
Surgical staples removed from the wrong patient
Misidentifying infants
De Leon Lopez v. Corporacion Insular de Seguros
Hospital was negligent in delivering two babies to the wrong mothers
Patient Monitoring & Observation
Nurses responsibility for patient care
Report any pertinent findings to the attending physician
Eyoma v. Falco
Failure to note changes in patient’s condition
Nurse A assigned to monitor a postsurgical patient left patient & failed to recognize patient stopped breathing
Nurse A delegated that duty to Nurse B
Nurse A failed to verify the nurse accepted responsibility for the patient
Jury held nurse 100% liable for patient’s injuries
Patient Monitoring & Observation
Failure to monitor vital signs
Failure to repeat vital signs
Delay in fetal monitoring
Monitor alarm disconnected
Defective monitoring equipment
Failure to report defective equipment
Can cause a nurse to be held liable for negligence
If the failure to report is the proximate cause of a patient’s injuries
Defect must be known and not hidden from sight
Patient Monitoring & Observation
Delay in Reporting Patient’s Condition
Develop appropriate guidelines
When action or inaction jeopardizes patient safety
Goff v. Doctors General Hospital
Patient bleeding excessively
Failure to take prompt action
Utter v. United Hospital Center, Inc.
Amputation: Nurses failed to report patient’s deteriorating condition
Cuervo v. Mercy Hospital, Inc.
Compromised blood flow to leg, loss of pulse, and sensation
Nurses unable to reach physician for 6 hours
Failure to contact a back-up physician
Hiatt v. Grace
Failure to timely notify physician delivery child imminent
Delay in Reporting Patient’s Condition
Citizens Hospital Association v. Schoulin
Accident victim
Failing to inform the physician of patient’s symptoms
Leblanc v. Walsh
Nurse fails to notify physician of patient’s fluctuating heart rate
Delay in Reporting Patient’s Condition
Montgomery Health Care v. Ballard
Failure of nurses to follow adequate nursing procedures in treating pressure ulcers
Seriousness of such failure was driven home when the court allowed $2 million in punitive damages
Delay in Reporting Patient’s Condition
Delay in Treatment
Howerton v. Mary Immaculate Hospital, Inc.
Nurses delayed assessing & notifying physician of patient’s serious condition
Testimony that if the baby had been delivered sooner, she would have sustained no neurologic damage
Evidence sufficient to go to trial for nurses delay in notifying physician of patient’s condition
Failure to follow orders
Written orders
Verbal orders
Verify orders
Supervisor’s orders
Incorrectly Transcribing: Telephone Orders
There are periodic contradictions between what physicians claim they ordered and what nurses allege they ordered
Orders should be read back for verification purposes
Questionable orders must be verified with prescribing physician
Physicians must authenticate their verbal order(s) by signing the written order in the medical record
Nurses who disagree with a physician’s order should not carry out an obviously erroneous order
Report to the supervisor concerns with a particular order
Leaving Patient Unattended: Patient Suffered Injury
Vanhoy v. United States
Patient injured as a result of being left unattended
His endotracheal tube became dislodged
Likely extubated more than 21 minutes
Veteran suffered anoxic brain injury
Government required to pay $3,500,000
The delay in treatment resulted in the patient’s injury
Failure to Record Patient’s Care
Pellerin v. Humedicenters, Inc.
Nurse failed to record administration of medication
Failure to record falls below the standard of care for nursing
Patient Falls
Failure to follow policy
Failure to raise bed rails
Nurse followed safe procedures
Not every fall is a result of negligence
Fall from examination table
Duty to Question Discharge
Premature discharge
A nurse has a duty to question the discharge of a patient if he or she has reason to believe that such discharge could be injurious to the health of the patient
Koeniguer v. Eckrich
Duty to Report: Physician Negligence
Note changes in patient’s condition
Report changes in patient’s condition
Prompt notification required
Physician failure to respond
Need to report “all” patient symptoms
Failure to Question Discharge: Swollen beyond Recognition
The hospital’s negligence is based on acts of omission, by failing to have the patient examined by a physician and by discharging her in pain
Evidence presented a woman conscious of her last days on earth
Swollen beyond recognition, tubes exiting almost every orifice of her body, in severe pain, and deteriorated to the point where she could not verbally communicate with loved ones
NKC Hosps., Inc. v. Anthony
