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CHAPTER 9

Healthcare Professional Legal- Ethical Issues

Ethics is nothing else than reverence for life.

—Albert Schweitzer

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LEARNING OBJECTIVES

Upon completion of this chapter, the reader will be able to:

Identify a variety of ethical and legal issues that arise in selected healthcare professions (e.g., nursing, emergency services, laboratory, pharmacy, radiology). Explain how practicing one’s professional code of ethics can assist in resolving day-to-day issues that arise during patient care. Explain the difference between the certification and licensure of a healthcare professional. Identify helpful suggestions that help caregivers provide high- quality care.

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INTRODUCTION My life is my message.

—Mahatma Gandhi

This chapter presents an overview of how ethics and the law affect a variety of healthcare professions. The ethical codes for each profession demand a high level of integrity, honesty, and responsibility. Codes of ethics are designed to facilitate the resolution of common ethical dilemmas that arise in one’s profession.

The contents of codes of ethics vary depending on the risks associated with a particular profession. Ethical codes for psychologists, for example, define relationships with clients in greater depth because of the personal, one-to-one relationship psychologists have with their clients. Laboratory technicians and technologists, on the other hand, generally have little or no personal contact with patients but can have a significant impact on their care. Laboratory technologists, in their ethical code, pledge accuracy and reliability in the performance of tests. The importance of this pledge was borne out in a March 11, 2004, report by the Baltimore Sun, wherein state health officials discovered that a hospital’s laboratory personnel overrode testing equipment controls that indicated the HIV test results might contain errors and mailed the test results—which contained both false positives and false negatives—to patients anyway, leaving some patients ignorant of their positive status (preventing them from seeking treatment) and others devastated by the belief that they were HIV positive when they were not.

The various codes of ethics for each healthcare profession are accessible by profession on the Internet.

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PARAMEDICS AND FIRST RESPONDERS In the 2011 National EMS Assessment, “a national estimate of 36,698,670 EMS responses within the United States (excluding territories) was calculated. Nationally on average, there were 1,217 EMS responses per 10,000 population.” Many of these patients “have complicated medical or traumatic conditions that require considerable knowledge, skill, and judgment to be treated effectively in the out-of-hospital setting. The regulations that describe the scope of practice for emergency services personnel varies from state to state. The National EMS Model describes the various activities EMS personnel can legally perform as regulated by law through certification and licensure.” As of 2011, there were an estimated 826,111 EMS professionals licensed and credentialed within the United States.

The National EMS Scope of Practice Model identifies the psychomotor skills and knowledge necessary for the minimum competence of each nationally identified level of EMS provider. This model will be used to develop the National EMS Education Standards, national EMS certification exams, and national EMS educational program accreditation. Under this model, to be eligible for State licensure, EMS personnel must be verifiably competent in the minimum knowledge and skills needed to ensure safe and effective practice at that level. This competence is assured by completion of a nationally accredited educational program and national certification.

The scope of practice does not define every activity of a licensed individual, such as lifting and moving patients, blood pressure, or bleeding control. The scope of practice focuses on activities regulated by law (for example, starting an intravenous line, administering a medication).

The scope of practice for first responders is a continuing concern as the risks associated with their profession continue to change. The need for continuing education is therefore a high-priority concern in maintaining and improving their skills.

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First responders are always at risk when responding to those in need of emergency services. Illicit drugs and chemical hazards are often an issue in emergencies ranging from industry fires to routine roadside accidents. Carfentanil, for example, is another chemical substance on a long list of hazardous materials that was recently reported as presenting a hazard to all first responders as well as members of the general public. Carfentanil is a synthetic opioid approximately 10,000 times more potent than morphine and 100 times more potent than fentanyl. In those situations where there is a chemical hazard present, such as carfentanil, EMS and law enforcement personnel are required to follow safety protocols to avoid accidental exposure to themselves and the public.

The four more common levels of EMS personnel reviewed here are emergency medical responder, emergency medical technician, advanced emergency medical technician, and paramedic.

Emergency Medical Responder The primary focus of the Emergency Medical Responder is to initiate immediate, lifesaving care to critical patients who access the emergency medical system. This individual possesses the basic knowledge and skills necessary to provide lifesaving interventions while awaiting additional EMS response and to assist higher-level personnel at the scene and during transport. The minimum skill sets of an EMR include airway and breathing, insertion of airway adjuncts intended to go into the oropharynx, use of positive pressure ventilation devices such as the bag-valve-mask, suction of the upper airway, supplemental oxygen therapy, pharmacological interventions, such as use of unit-dose auto-injectors for the administration of lifesaving medications intended for self or peer rescue in hazardous materials situations, medical/cardiac care, use of an automated external defibrillator, trauma care, manual stabilization of suspected cervical spine injuries, and manual stabilization of extremity fractures, bleeding control, and emergency moves.

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Emergency Medical Technician The primary focus of the Emergency Medical Technician is to provide basic emergency medical care and transportation for critical and emergent patients who access the emergency medical system. This individual possesses the basic knowledge and skills necessary to provide patient care and transportation.

The minimum skill sets of an EMT include: airway and breathing (e.g., insertion of airway adjuncts intended to go into the oropharynx or nasopharynx); use of positive-pressure ventilation devices such as manually triggered ventilators and automatic transport ventilators; pharmacological interventions by assisting patients in taking their own prescribed medications; administration of over-the-counter medications with appropriate medical oversight, such as oral glucose for suspected hypoglycemia, aspirin for chest pain of suspected ischemic origin, and trauma care, and application and inflation of the pneumatic anti-shock garment (PASG) for fracture stabilization.

Advanced Emergency Medical Technician The primary focus of the Advanced Emergency Medical Technician is to provide basic and limited advanced emergency medical care and transportation for critical and emergent patients who access the emergency medical system.

The minimum skill sets of an AEMT include: airway and breathing, such as insertion of airways that are not intended to be placed into the trachea, tracheobronchial suctioning of an already intubated patient, patient assessment, pharmacological interventions such as establishing and maintaining peripheral intravenous access, establishing and maintaining intraosseous access in a pediatric patient, administration of (nonmedicated) intravenous fluid therapy, administration of sublingual nitroglycerine to a patient experiencing chest pain of suspected ischemic origin, administration of subcutaneous or intramuscular epinephrine to a patient in anaphylaxis, administration of glucagon to a hypoglycemic patient, administration of intravenous D50 to a hypoglycemic patient, administration of inhaled beta agonists to a patient experiencing difficulty breathing and wheezing, the administration of a narcotic antagonist to a patient suspected of narcotic overdose, and administration of nitrous oxide for pain relief.

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Paramedic A paramedic is a healthcare professional, predominantly in the pre-hospital and out-of-hospital environment, and working mainly as part of Emergency Medical Services (EMS), such as on an ambulance. A paramedic is an allied health professional whose primary focus is to provide advanced emergency medical care for critical and emergent patients who access the emergency medical system. This individual possesses the complex knowledge and skills necessary to provide patient care and transportation. The minimum skill sets of a paramedic include: airway and breathing, performance of endotracheal intubation, performance of percutaneous cricothyrotomy, decompression of the pleural space, performance of gastric decompression, pharmacological interventions, insertion of an intraosseous cannula, enteral and parenteral administration of approved prescription medications, accessing indwelling catheters and implanted central IV ports for fluid and medication administration, administration of medications by IV infusion, maintaining an infusion of blood or blood products, percutaneous means to access via needle-puncture, medical/cardiac care including performance of cardioversion, manual defibrillation, and transcutaneous pacing.

Many states have enacted legislation that provides civil immunity to paramedics who render emergency lifesaving services. The Pennsylvania Supreme Court, for example, in Morena v. South Hills Health Systems, held that paramedics were not negligent in transporting a victim of a shooting to the nearest available hospital, rather than to another hospital located 5 or 6 miles farther away where a thoracic surgeon was present. The paramedics were not capable, in a medical sense, of accurately diagnosing the extent of the decedent’s injury. Except for the children’s center and the burn center, no emergency trauma centers are specifically designated for the treatment of particular injuries. It should be noted that immunity to liability does not, however, extend to negligent acts. The plaintiff, for example, in Riffe v. Vereb Ambulance Service, Inc., alleged that, while responding to an emergency call an emergency medical technician began administering lidocaine to the patient, as ordered over the telephone by the medical command physician at the defendant hospital. While en route to the hospital, the patient was administered 44 times the normal dosage of lidocaine. Consequently, normal heart function was not restored, and the patient was pronounced dead at the hospital shortly thereafter. At trial, the superior court held that the liability of medical technicians could not be imputed to the hospital. The court noted the practical

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impossibility of the hospital carrying ultimate responsibility for the quality of care and treatment given patients by emergency medical services.

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NURSES: ETHICS AND LEGAL ISSUES The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person.

—To Be a Nurse: Swedish Hospital, Seattle, Washington

In memory of all those patients that have enriched my life and blessed me with their spirit of living—while they are dying. Nursing is the honor and privilege of caring for the needs of individuals in their time of need. The responsibility is one of growth to develop the mind, soul, and physical well-being of oneself as well as the one cared for. Excellence is about who we are, what we believe in, what we do with every day of our lives. And in some ways, we are a sum total of those who have loved us and those who we have given ourselves to. I have been with a number of people/patients when they die and have stood in awe. Nursing encompasses the sublime and the dreaded. We are regularly expected to do the impossible. I feel honored to be in this profession. To get well, I knew I had to accept the care and love that were given to me—when I did, healing washed over me like water. Through all of this I was never alone. In the caring for one another both are forever changed. A friend takes your hand and touches your heart. To all of you whose names were blurred by the pain and the drugs. Don’t ever underestimate your role in getting patients back on their feet. Will I lose my dignity? Will someone care? Will I wake tomorrow from this nightmare? You exist as women living between heaven and hell. Inside a machine that demands absolute vigilance. I hated every minute of my stay with you; however, I totally realize the value of your efforts. Please accept my heartiest thank you.

—Unknown Authors in Hospital Lobby

The nurse is generally the one medical professional the patient sees more than any other. Consequently, the nurse is in a

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position to monitor the patient’s illness, response to medication, display of pain and discomfort, and general condition. This section provides an overview of the ethical responsibilities and legal issues of nursing practice. Although nurses traditionally have followed the instructions of attending physicians, physicians realistically have long relied on nurses to exercise independent judgment in many situations. Patients in hospitals, nursing homes, or at home learning to manage a chronic condition are often at their most vulnerable moments. Nurses are the healthcare providers they are most likely to encounter; spend the greatest amount of time with; and often depend on for care. Research is now beginning to document what physicians, patients, other healthcare providers, and nurses themselves have long known: how well we are cared for by nurses affects our health and sometimes can be a matter of life or death.

The more than a decade old nursing shortage continues to require hospitals to search for foreign-trained registered nurses. New immigration laws have complicated the hiring and immigration process. Many countries are facing similar shortages, thus raising ethical dilemmas when recruiting foreign nurses from countries with shortages of their own.

Higher salaries and incentives have done little to resolve the nursing shortage. The unemployment rate would be expected to provide some incentive for students to enter the nursing profession, but the shortage persists. The Secretary of Health and Human Services (HHS), Kathleen Sebelius, announced in 2013 that $55.5 million in funding was awarded in FY 2013 to strengthen training for health professionals and increase the size of the nation’s healthcare workforce. Since that time the shortage of nurses continues to negatively impact healthcare services, and it is only getting worse, as nursing schools are unable to meet the needs of would-be students due to lack of staff and facilities. As one report noted, “There are currently about three million nurses in the United States. The country will need to produce more than one million new registered nurses by 2022 to fulfill its health care needs, according to the American Nurses Association estimates.”

Short on Staff: Nursing Crisis Strains U.S. Hospitals

To keep its operations intact, Charleston Medical is spending this year $12 million on visiting or “travel” nurses, twice as

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much as three years ago. It had no need for travel nurses a decade ago.

“I’ve been a nurse 40 years, and the shortage is the worst I’ve ever seen it,” said Ron Moore, who retired in October from his position as vice president and chief nursing officer for the center.

—Jilian Mincer, Health News, October 20, 2017

Hospitals are caught between the proverbial rock and a hard place. The shortage of nurses continues, as one office of government strives to alleviate the shortage while at the same time the Conditions for Participation (COP) for Medicare and Medicaid reimbursement requires that hospitals provide adequate nurse staffing in the present in order to qualify for reimbursement. More specifically, COP regulations provide:

(b) Standard: Delivery of Care: The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient.

Such regulations at best are ambiguous and difficult to enforce except in those instances where state laws, rules, and regulations set specific standards for nurse–patient ratios, such as those that apply in nursing homes and on hospital intensive care units. As noted in an abstract of an article entitled “Enforcement of Hospital Nurse Staffing Regulations Across the United States: Progress or Stalemate?” its authors describe how:

Nurse staffing regulations were enacted to ensure that adequate numbers of nurses were available to provide high-quality and safe care. Although these regulations represent progress toward addressing staffing inadequacies, enforcement language is absent or weak and compliance data are either not collected or difficult to access. Explicit and funded enforcement measures need to be included in staffing regulations. Additionally, compliance monitoring and reporting are necessary to evaluate these types of staffing

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regulations and to determine if they actually achieve the goal of appropriate nurse staffing.

Registered Nurse A registered nurse is one who has passed a state registration examination and has been licensed to practice nursing. The scope of practice of a registered professional nurse includes patient assessment, analyzing laboratory reports, patient teaching, health counseling, executing medical regimens, and operating medical equipment as prescribed by a physician, dentist, or other licensed healthcare provider. The nursing profession “is in a period of rapid and progressive change in response to the advances in technology, changes in patterns of demand for health services, and the evolution of professional relationships among nurses, physicians and other health professions.” Although most states have similar definitions of nursing, differences generally revolve around the scope of practice permitted.

Advanced Practice Nurse An advanced practice registered nurse (APRN) is a registered nurse having education beyond that of a registered nurse. APRNs include nurse practitioners, clinical nurse specialists, nurse anesthetists, and nurse midwives. They often play a critical role as primary care providers for patients who live in remote areas or have difficulty obtaining a primary care physician. APRNs are certified by a nationally recognized professional organization in their nursing specialty or meet other criteria established by a board of nursing that sets education, training, and experience requirements.

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Nurse Practitioner

The Role of Nurses Extends Beyond the Hospital Ward

Nurse practitioners … Studies have found that their ability to diagnose illnesses, order and interpret tests, and treat patients is equivalent to that of primary-care physicians. They also tend to spend more time with patients during routine office visits than physicians, and they are more likely to discuss preventative health measures.

—Consumers Union of United States Inc., The Washington Post, May 30, 2011

Nurse practitioners (NPs) are RNs who have completed the necessary education to engage in primary healthcare decision making. A nurse practitioner is a registered nurse working in an expanded nursing role, usually with a focus on meeting primary healthcare needs. NPs conduct physical examinations, interpret laboratory results, select plans of treatment, identify medication requirements, and perform certain medical management activities for selected health conditions. During the course of their studies, they engage in clinical work and select specialties such as cardiology or geriatric care. Moreover, the NP is trained in the delivery of primary health care and the assessment of psychosocial and physical health problems such as the performance of routine examinations and the ordering of routine diagnostic tests. A physician may not delegate a task to an NP when regulations specify that the physician must perform it personally or when the delegation is prohibited under state law or by an organization’s own policies.

The potential risks of liability for the NP are as real as the risks for any other nurse. The standard of care required most likely will be set by statute. If not, the courts will determine the standard based on the reasonable-person doctrine (i.e., what would a reasonably prudent NP do under the same or similar circumstances). The standard would be established through the use of expert testimony of other NPs in the field. Because of potential liability problems and pressure from physicians, hospitals and physicians’ office practices have been historically reluctant to use NPs to the full extent of their training. Such

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reluctance has been diminishing as the competency of NPs has been continuing to be well demonstrated in practice. Several cases involving NPs are presented here.

NP Negligence Imputed to Physician As described in Adams v. Krueger, the negligence of an NP can be imputed to a physician if the physician is the employer of the nurse. The plaintiff here went to her physician’s office for diagnosis and treatment. A NP who was employed by the physician performed her assessment and diagnosed the plaintiff as having genital herpes. The physician prescribed an ointment to help relieve the patient’s symptoms. The plaintiff eventually consulted with another physician who advised her that she had a yeast infection, not genital herpes. The plaintiff and her husband filed an action against the initial treating physician and his NP for their failure to correctly diagnose and treat her condition. The action against the physician was based on his failure to review the NP’s diagnosis and treatment plan. The trial court found in favor of the plaintiff and the defendants appealed. The court of appeals affirmed, and further appeal was made. The Idaho Supreme Court held that the negligence of the nurse was properly imputed to the physician. The physician and NP stood in a master-servant relationship and the nurse acted within the scope of her employment. Consequently, her negligence was properly charged, or attributed to Krueger in applying the comparative negligence statute. Even though a physician can be at risk as a defendant in a lawsuit against the negligent acts of a nurse practitioner, the risk is minimal as compared to physicians.

Nurse practitioners (NPs), like any clinicians, are at risk for being sued for malpractice. If a physician is associated with an NP (through employment, independent contracting, state-mandated collaboration, consultation, or supervision) who is sued, the physician bears some risk of being sued as well.

Physicians thinking about hiring or otherwise collaborating with NPs should understand that lawsuits involving NPs don’t even total 1% of all medical malpractice closed claims.

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Telephone Medicine There are circumstances which prevent a patient from going to the hospital or directly to a physician’s office. When that occurs, the physician or a nurse practitioner may give medical advice over the telephone, which can open them to more scrutiny since the provider would not be examining the patient in person. As noted in the case presented here, a 9-year-old boy died shortly following an after-hours phone call to a physician’s office for advice. An on-call NP had responded to the call and rendered her advice to the boy’s father, who then described his 9-year-old son’s flu-like symptoms, after which the NP had given care instructions to the father. Unaware that his son had diabetes mellitus, the boy died later that evening of ketoacidosis. The parents sued the nurse practitioner, alleging wrongful death of their son due to negligence in diagnosis and treatment of diabetic ketoacidosis. The case was settled against the NP. The key lessons in this case are clear:

Many illnesses can mimic others, and noting any subtle differences can be very difficult without actually seeing the patient or obtaining diagnostic tests. Clinicians triaging patients over the phone should err on the side of either bringing the patient into the office to be seen or, if the office is closed, sending them to the ED for evaluation. Clinical staff should carefully and accurately document telephone encounters with patients.

It should be noted that “If a physician is associated with an NP (through employment, independent contracting, state- mandated collaboration, consultation, or supervision) who is sued, the physician bears some risk of being sued as well. Physicians thinking about hiring or otherwise collaborating with NPs should understand that lawsuits involving NPs don’t even total 1% of all medical malpractice closed claims.”

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Clinical Nurse Specialist The clinical nurse specialist (CNS) is a professional registered nurse with an advanced academic degree, experience, and expertise in a clinical specialty (e.g., obstetrics, pediatrics). The clinical nurse specialist functions in a leadership capacity as a clinical role model, assisting the nursing staff to continuously evaluate patient care. The CNS acts as a resource for the management of patients with complex needs and conditions, participates in staff development activities related to his or her clinical specialty, and makes recommendations for establishing standards of care for patients. The CNS functions as a change agent by influencing attitudes, modifying behavior, and introducing new approaches to nursing practice, and collaborates with other members of the healthcare team to develop and implement the therapeutic plan of care for patients.

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. The major risks for nurse anesthetists include improper placement of an airway, failure to recognize significant changes in a patient’s condition, and the improper use of anesthetics (e.g., wrong anesthetic, wrong dose, wrong route).

Nurse Midwife Nurse midwives provide comprehensive prenatal care, including delivery for patients who are at low risk for complications. For the most part, they 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 health issues from puberty to postmenopause.

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Special Duty Nurse A special duty nurse is a nurse employed by a patient or patient’s family to perform nursing care for the patient. An organization is generally not liable for the negligence of a special duty nurse unless a master–servant relationship can be determined to exist between the organization and the special duty nurse. If a master–servant relationship exists between the organization and the special duty nurse, the doctrine of respondeat superior may be applied to impose liability on the organization for the nurse’s negligent acts. Although the patient employs the special duty nurse and the organization has no authority to hire or fire the nurse, the organization does have the responsibility to protect the patient from incompetent or unqualified special duty nurses.

Float Nurse Float nurses are designated as such because they are rotated from unit to unit based on staffing needs. They often cover nursing units with unusually burdensome workloads that often involve complex patients. Float nurses can present a liability to the organization if they are assigned to work in an area where they are not qualified and competent to perform the assigned duties. Failure to match skills with work assignments can be risky business for both the patient and the healthcare professional. Behavioral health nurses, for example, usually do not have the skills or competencies to cover for surgical nurses in the operating room. Failure to make assignments based on a nurse’s skills presents a legal risk if a patient is injured as the result of a nurse’s negligent act. The standard of care required in order to establish negligence would be based on the skills and competencies required of the assigned task. In addition to legal implications, it is clear that assignment of a professional to a task he or she is not competent to perform is ethically and morally wrong. The New York State Nurses Association, in a position statement on float nurses, states, in part:

Adequate staffing (appropriate number, mix and competency of nursing staff) is critical to ensure quality patient care.

The nursing profession has an obligation to evaluate and monitor patient assignments to ensure the delivery of safe, quality care.

The state has a responsibility to hold healthcare employers accountable for the provision of appropriate and timely orientation and training for staff expected to float to unfamiliar units.

The optimum solution to emergency staffing, such as in a sudden fluctuation in census or unexpected increase in absenteeism, is the establishment of an internal pool of competent personnel whose credentials have been reviewed and who have been oriented to the facility’s units and current policies.

All professional nurses must continually assess their own knowledge, ability, and experience and access appropriate resources when needed.

RNs have the right and responsibility to express their concerns and protest an assignment if placed in a potentially unsafe practice situation.

Joint Commission standards require that “Those who work in the hospital are competent to complete their assigned

tasks.” It is the responsibility of the hospital’s leadership to ensure that nurses are competent to perform the duties and responsibilities to which they are assigned. Not only is the employee responsible for a negligent act, the hospital can be found liable for assigning an employee to a duty that he or she is not competent to perform. This applies not strictly to float nurses but to all staff members.

Agency Personnel Healthcare organizations are at risk for the negligent conduct of agency personnel. Because of this risk, it is important to ensure that agency workers have the necessary skills and competencies to carry out the duties and responsibilities assigned by the organization.

Nursing Assistants A nursing assistant is an aide who has been certified and trained to assist patients with activities of daily living. The nursing assistant provides basic nursing care to non-acutely ill patients and assists in the maintenance of a safe and clean environment under the direction and supervision of a registered nurse or licensed practical nurse. The nursing assistant helps with positioning, turning, and lifting patients and performs a variety of tests and treatments. The nursing assistant establishes and maintains interpersonal relationships with patients and other hospital personnel while ensuring confidentiality of patient information. Common areas of negligence for nursing assistants include failure to follow or improperly performing procedures; failure to assist patients and prevent falls; unsafe placement or positioning of equipment; failure to maintain equipment properly; failure to observe a patient and take vital signs at appropriate intervals; failure to chart pertinent information regarding a patient’s changing condition (e.g., vital signs); and failure to respond to a patient’s call for help (e.g., call bells).

Student Nurses Student nurses are entrusted with the responsibility of providing nursing care to patients. When liability is being assessed, a student nurse serving at a healthcare facility is considered an agent of the facility. Student nurses are personally liable for their own negligent acts, and the facility is liable for their acts on the basis of respondeat superior.

A student nurse is held to the standard of a competent professional nurse when performing nursing duties. The courts have taken the position that anyone who performs duties customarily performed by a professional nurse is held to the standard of care required of a professional nurse. Every patient has the right to expect competent nursing services even if students provide the care as part of their clinical training.

Negligent Acts in Nursing The following cases illustrate some of the acts or omissions constituting negligence that all nurses should be aware of. They are by no means exhaustive and merely represent the wide range of potential legal pitfalls in which nurses might find themselves.

Nurse Assessments and Diagnoses Valid The defendant physicians in Cignetti v. Camel ignored a nurse’s assessment of a patient’s diagnosis, which contributed to a delay in treatment and injury to the patient. The nurse had testified that she told the physician that the patient’s signs and symptoms were not those associated with indigestion. The defendant physician objected to this testimony, indicating that such a statement constituted a medical diagnosis by a nurse. The trial court permitted the testimony to be entered into evidence. Section 335.01(8) of the Missouri Revised Statutes (1975) authorizes a registered nurse to make an assessment of persons who are ill and to render a nursing diagnosis. On appeal, the Missouri Court of Appeals affirmed the lower court’s ruling, holding that evidence of negligence presented by a hospital employee, for which an obstetrician was not responsible, was admissible to show the events that occurred during the patient’s hospital stay.

Ambiguous Medication Order A nurse is responsible for making an appropriate inquiry if there is uncertainty about the accuracy of a physician’s medication order in a patient’s record. The medication order in Norton v. Argonaut Insurance Co., as entered in the medical record, was incomplete and subject to misinterpretation. Believing the order to be incorrect because of the dosage, the nurse asked two physicians present on the patient care unit whether the medication should be given as ordered. The two physicians did not interpret the order as the nurse did and therefore did not share the same concern. They advised the nurse that the attending physician’s instructions did not appear out of line. The nurse did not contact the attending physician but instead administered the misinterpreted dosage of medication. As a result, the patient died due to a fatal overdose of the medication.

The nurse was negligent by failing to consult with the attending physician before administering the medication. The nurse was held liable, as was the physician who wrote the ambiguous order that led to the fatal dose. In discussing the standard of care expected of a nurse who encounters an apparently erroneous order, the court stated that not only was the nurse unfamiliar with the medication in question, but she also violated the rule generally followed by members of the nursing profession in the community, which requires that the prescribing physician be called when there is doubt about an order. The court noted that it is the duty of a nurse to make absolutely certain what the physician intended regarding both dosage and route.

Wrong Dosage of a Medication

State Cites Safety Drug Lapses at Cedars-Sinai

Cedars-Sinai Medical Center’s handling of high-risk drugs placed its pediatric patients in immediate jeopardy of harm, the state said Wednesday in its response to an overdose involving the newborn twins of actor Dennis Quaid.

In a 20-page report, the California Department of Public Health said the prestigious Los Angeles hospital gave the twins and another child 1,000 times the intended dosage of the blood thinner heparin Nov. 18.

“This violation involved multiple failures by the facility to adhere to established policies and procedures for safe medication use,” state inspectors wrote.

—Charles Ornstein, Los Angeles Times, January 10, 2008

More Heparin Overdoses, this Time in Texas

Add at least 17 Texas infants to the number of children mistakenly given overdoses of heparin in the hospital. At least one of those infants died, and an autopsy is planned to determine whether the blood thinner played a role. Another is still in critical condition.

—Tami Dennis, Los Angeles Times, July 9, 2008

The nurse in Harrison v. Axelrod administered the wrong dosage of haloperidol to the patient on seven occasions while employed at a nursing facility. The patient’s physician had prescribed a 0.5-mg dosage of haloperidol. The patient’s medication record indicated that the nurse had been administering doses of 5 mg, which were being sent to the patient care unit by the pharmacy. The nurse had admitted that she administered the wrong dosage and that she was aware of

the facility’s medication administration policy, which she breached by failing to check the dosage supplied by the pharmacy against the dosage ordered by the patient’s physician. The commissioner of the Department of Health made a determination that the administration of the wrong dosage of haloperidol on seven occasions constituted patient neglect.

Medicating the Wrong Patient A patient’s identification bracelet must be checked before administering any medication. To ensure that the patient’s identity corresponds to the name on the patient’s bracelet, the nurse should address the patient by name when approaching the