Nurses @ Higher Risk 4 Lawsuits.

  1. I'm hoping to increase nsg awareness on the topic of defensive nursing.

    Most of you are aware of defensive charting practices. The practice of stating facts--not opinions.

    However, many nurses seem to throw caution to the wind when they accept nursing assingments.

    I have observed many nurses trying to handle dangerous heavy pt loads. Loads that are so high and unsafe that pt care is compromise. One example is nurse Jane Doe or John Doe comes into work and is assigned a dangerous asignment of 12 patients instead of his normal 8. Being a kind and thoughful person, he naturally decides not to let his co-workers down and accepts the assignment.

    However, his kindness can not effectively manage to do his job in a manner that is deemed safe. As a matter of fact, many of his patients do not receive prn meds in a timely manner; treatments are delayed; and numerous Now and Stat orders are on his charts wating to be noted. Furthermore, he is so swamped that he is not able to CHART AS THE SHIFT progresses; therefore, he forgets to chart defensively and accurately.
    As the shift progresses, the nurse is constantly besieged by his patients to come to their aid when they use the call light. As a result of this nurse being swamped, he cannot pass schd meds on time and is often very late passing prn pain meds. His patients are frustrated because they are not being waited on in a timely manner. And as a result, complaints are filed against this nurse. And to top it all off, he has a patient code which later died. He also had a confused patient crawl out of bed and as a result of confusion and overall general weakness, this patient is transferred to ICU for head trauma.

    As a consequence to the fall that one patient received, that patients family decides to sue nurse John Doe and the hospital that he was working at.

    Another family is also pursuing a claim of negligence d/t their beloved family member not receiving prn pain meds until a hour after requesting them.

    Keep in mind that John Doe is a excellent nurse but has bit off more than he can chew by accepting this assignment of 12 patients who are all over 65, have high co-morbidity factors, are all bedfast and need constant one on one supervision while they are using the restroom, who need patient teaching, need f/u on schd insulin, etc.

    John has been informed that he is named in a suit for negligence, For the patient who fell and later went to ICU and died.

    He is also named in another negligence suit d/t not giving prn meds w/in a resonable amount of time. The suit states that the patient suffered severe emotional distress as a direct result of not being medicated in a timely manner.

    John, was not trying to give less than quality care. As a matter of fact he is known for delivering exceptional nursing care. However, on this fateful shift, John was overwhelmed w/ stat and now orders. He also had to start IV's on several patients and was also monitoring a pt receiving 2 units of PRBC's. He was also overwhelemed by having to answer call light after call light.

    John had one aid and that aide had 16 pts to care for. John was unable to get assistance from his coworker, for they were overwhelmed as well.

    Johns charge nurse could rarely offer John any help for she was tied up with her duties.

    So to make a long story short, John did the best that he could with what he had. However, his best was not good enough for John could not keep pace with the problems that arose.

    QUESTION:

    Could John loose his license as a result of the events that transpired on his shift?

    Yes!

    Even though John did every thing that he could to keep pace w/ the mounting problems, he invariably was unable to monitor his patients--to access for changes in status--on a regular basis. Except for the quick focal assesment that he gave everyone on arrival to the floor, he was unable to give head to to assessments.

    Remeber John was responding to now and stat orders. And also monitoring blood, as well as answer call lights, etc.

    Do you think that John could possibly loose his license?

    Do you think that John could face criminal charges?

    Yes, to both above.

    No matter how kind and compassinate John is. John made the fateful error of accepting a pt load that he could not handle. Therefor, as a cosequence, a patient died, and another did not receive prn meds on time.

    Attorney's have won their settlement, John's
    nursing insurance paid the claim. However, the nursing board in John's state found him liable for negligence and providing inadequate nursing care and has revoked his license and to make matters worse criminal charges are pending for negligence.

    Is this fair?

    No.

    John should have made his charge nurse aware that he could not handle that many patients. But out of fear from termination and out of fear for letting his co-workers down and out of pity for his patients, John accepted the assignment.

    Accepting the assignment was John's undoing. He placed fear from termination and fear from not being their for his coworkers above the safety of his patients. And now John is facing jail time, and lost his license to practice.

    But John being naive, accepted the unacceptable. Afterall, he has seen countless other nurses do the same thing. And on several other occassions, John accepted more pts than he normally gets--and not once did anything major happen.

    But see that's the problem: no one comes to work ready and prepared for the worst case scenario.

    But nurses, I don't know about your state, but the state of Texas sends out quarterly newsbriefs on LVN nursing and in these briefs there are countless pages of people who have lost their license by putting themselves in a jam.

    I have seen instances where nurses lost their license d/t not giving a prn med on time or d/t a pt falling resulting in death.

    Your license is everything. You worked hard for it. Don't make the mistake that John did. He tried to be SUPERNURSE.

    Everyday hospitals are constantly asking nurses to accept higher and higher loads and nurses give in; however, it can be to their own undoing.

    This story is not a real story. Howver, it could very well happen. And I'm sure that countless nurses have lost their license by being suckered into accepting assignments that are too dangerous.

    It is your license...Think about it.
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  2. 23 Comments

  3. by   NCNocRN
    Last edit by NCNocRN on May 15, '04
  4. by   jp#1
    To Sub-Q: First of all, THANK YOU SO MUCH FOR VALIDATING EVERYTHING I'M FEELING RIGHT NOW! I agree with everything you said! Let me share a true story with you: I attended the Board hearing of a registered nurse in the early 1990's. She had been coerced by her supervisor to float to an area she did not want to go to, didn't feel comfortable in; they promised her (supervisor and charge nurse) they would help her and give her the lightest load. Well, unfortunately she gave in. She BELIEVED them. Something very bad happened that night and a pt. died. She wasn't this pt.'s primary nurse--she was involved in a secondary role. She pleaded with the Board, cried, promised them she would never work in a hospital setting again if they would just let her keep her license. Of course, her pleadings and promises fell on deaf ears. I remember her telling us.."Don't EVER ACCEPT AN ASSIGNMENT YOU DON'T FEEL COMFORTABLE WITH. DON'T EVER, EVER BELIEVE ANYBODY." I never forgot that. Although it's been many years since that happened, it is only now it's become something I can't and will not ignore anymore. I quit my job in the latter part of 2000 and I will not jeopardize my license and sanity any further just to pacify and obey the supervisors and management. They repeatedly leave the RN and CNA's hanging and do not darken the door to help. Of course, they are always around to critique and chastise you about your actions. Whenever they decide to clean it up, I'll return to nursing; I'm not holding my breath. Too often I feel guilty about giving pts. substandard care because there is no time and not enough staff, etc. They are getting short changed to say the least. Bottom line---I HAVE TO THINK ABOUT AND PRESERVE MY LICENSE. Thanks again, Sub-Q. I really appreciated and enjoyed your post. Now I don't feel like I am the only one.
  5. by   chili2641
    Subqu,

    Why dont you go to law school and study cival litigation. I also have an interest in the law. I just finished my Bachelors degree in criminaljustice. I am planning on attending law school. I hope to practice criminal and cival defense. I would also be interested in defending accussed nursing home employees. Negligence has four elements to it in cival cases I am sure you know these. Gross negligence is used in criminal cases. Remember a crime must be commited to be charged with a criminal offense. I take issue with how easily we throw around the terms neglect and abandonment. Those are serious accusations and the one accussing better know what they are talking about. No, I am not a lawyer but the basics we should all know.

    ------------------
    Nursing assistant
  6. by   canoehead
    Wait.

    What are the alternatives? He informs the charge nurse that he cannot accept this assignment, then what? There is no one available to take the overflow. So does he wait until they assign him fewer patients, but the most acute? That is even worse. If he says he can take these 8 but not these 4 do they need to agree, or is it his call? (I don't think so) If they say this is it, suck it up, does he go home, leaving everyone, and losing his job? Is there recourse if he is dismissed for insubordination? If he properly goes up the chain of command without results who outside the hospital is prepared, and has authority to make the changes. While he's doing this, and falling further behind what is happening to his patients? (abandonment) If he takes report has he "accepted the assignment" and now is abandoning them. If report is not given how can he say he can't handle the load?

    It takes balls of steel to take a stand against admin, and sometimes your coworkers. We need more information before jumping into this lava pit.
  7. by   Lynn Casey RN
    Great post!This topic has been swept under the rug long enough.It is unfortunate that nursing school does not prepare us for the bullying from all angles!I had to leave CCU,my favorite nursing field because of banging my head against the wall one too many times.Consistant short staffing,increased med errors,and major staff turn over(in 2 years avg experience has gone from 10 years to 1 year!)Management,physicians and nurses all aknowledged there is a problem there(the head nurse being the center of it)but no action.Anyways,I left.Now,if I find myself up against management I either demand help,go home sick or defenseively chart.I chart...Nursing supervisor"Joe BLow"notified re shortage of nurse this shift,writer working short until staff located,against writer's wishes.As well,we are fortunate to have professional practice forms to fill out.This form is signed by nurse manager,writer,and administration must reply with a recommended action and excuse(oops!)I meant explanation for the inability to locate help.It is my hope that nursing schools will start a course on professionalism standards, avoiding emotional abuse,and acceptable vs. unacceptable expectations.Thanks!
  8. by   SUBQ
    OK, I have what seems to be a logical argument from Canoehead. I have inculede Canoeheads post from below and will answer the questions that Canoehead posed:

    Canoehead Writes:

    canoehead Wait.


    What are the alternatives? He informs the charge nurse that he cannot accept this assignment, then what? There is no one available to take the overflow. So does he wait until they assign him fewer patients, but the most acute? That is even worse. If he says he can take these 8 but not these 4 do they need to agree, or is it his call? (I don't think so) If they say this is it, suck it up, does he go home, leaving everyone, and losing his job? Is there recourse if he is dismissed for insubordination? If he properly goes up the chain of command without results who outside the hospital is prepared, and has authority to make the changes. While he's doing this, and falling further behind what is happening to his patients? (abandonment) If he takes report has he "accepted the assignment" and now is abandoning them. If report is not given how can he say he can't handle the load?

    It takes balls of steel to take a stand against admin, and sometimes your coworkers. We need more information before jumping into this lava pit.


    Ok Canoehead,

    First of all the nurse is aware from expereince that 12 acute pts. is 4 too many. After all 8 is the normal load.

    This nurse should use good judgement and should NOT accepet this assingment. Therefore he is in no way falling under the term "ABANDONMENT".

    While he goes through the chain of command he informs his charge nurse and CEO of the facility that 12 is dangerous and unacceptable: quality nsg care WILL BE COPMROMISED! They balk and tell him "thats just the way it is" He is FUMED! However, he suggests that his hospital call in a PRN AGENCY NURSE to get them thru the crunch. Once again they balk. They state: "that's not how we do things here, it is not in our budget, and you'll have to suck it up and deal w/ it. the other nurses have been working short as well."

    This is usually the argument. And one that I have been thru personally.

    I walked out of an assignment just like the one described above. However, the one above is fictional and was used to illustrate a point that so many nurses cave in and accept these unacceptable assignments w/ little concern for what may possibly happen during a shift: Its what I like to view as the worst case scenario.

    Although not a pessimist, I am a realist and when I come into my facility and start to get report, I look for RED FLAGS! If I find that the pt acuity is TOO HIGH or I have received and overwhelming load, I ask that the schedule or assignment be changed.

    Unfortunately, the last time that I asked for a schedule change--when I was assigned 12 bedfast pts--all with high co-morbidity factors, I was denied.

    And I said the hell with it. Because I looked at the worst case scenario for this group of pts. and it did not look to good.
    There were too many negative factors that could have triggered a night of horrors!

    I also looked at the best case scenario. And I could not foresee anything positive happening for these pts this shift.

    All of them would have received less than adequate care.

    I did not go to school and graduate to give less than adequate care. I give EXCELLENT PATIENT CARE! Or I do not give care at all.

    Now, another argument is: what about my co-workers? I'm leaving them hanging by not accepting this assignment.

    True! However, I did not go to school to take care of healthy nurses. It is sad that they are left in this position; however, they could have walked as well.

    But they did not. They decided to stick it out--take up the slack and keep on trucking.

    They were lucky. No one coded. However, I know for a fact that every single pt suffered in that hospital that night. I know that they received less than adequate care.

    However, THE HOSPITAL IS RESPONSIBLE TO THE PATIENTS THAT THEY ADMIT. IT IS THEIR RESPONSIBILITY TO STAFF IT ADEQUATELY SO PATIENTS RECEIVE QUALITY CARE.

    However, many nurses cave in under pressure and continually accept dangerous pt loads.

    AND THAT MY FRIEND, CAN COMPROMISE SAFETY, LIVES AND YOUR LICENSE.

    I quit my last job due to a nightmare situation just like above. And guess what?
    I have had more than 5 offers to go work at other facilities. And all of them know that I quit my last job w/o a 2 week notice.

    As a matter of fact, everyone that I have spoken with has commended me for doing so.

    So if you are faced with a similar circumstance, I can't tell you what to do. However, I can tell you this:

    THAT YOU CAN LOSE YOUR LICENSE FOR BEING OVERBURDENED.

    AFTERALL, ITS YOU THAT ACCEPTED THE REPORT AND ACCEPTED THE ASSIGNMENT.

    Its your license...think about it
  9. by   Tiara
    When you have to think defensively all of the time and need a lawyer in your uniform pocket, it's time to take a stand. After all, you are the patient's advocate and if that conflicts with your hospital's idea of loyalty, then the problem is not with you. It's the system. If you cannot in good conscience be a good advocate within the system, maybe it's time to look elsewhere.
  10. by   OC_An Khe
    An interesting thread, I agree with SubQ that we have to take a stand and know when to say no. Then say it. At least in my facility, so far anyway, where RN's have refused unsafe assignments no one had to quit or where disciplined. Low and behold they were able to find a nurse only after the refusal of assignment. We must not forget that many administrators focus and goal is not patient care, its profit and their responsibility to the stock holders is paramount.
  11. by   Mijourney
    Hi. Timely topic. I am much intrigued with the previous posters' responses. What would have been optimal is for all the nurses to have walked out in unison on their assignment then the following shifts call in. If administration will not support safe assignments for the nurses and their patients, then the nursing staff should stick together even if you don't have a personal affection for one another. In my opinion, this may be one of the only ways to force administration to deal with the problem of unsafe staffing and working conditions. I never thought I would see myself writing this, but after reading all the posts expressing frustration on staffing from hospital-based nurses, what recourse do you have? Administration does not have enough respect for their "customers" to provide them with access to the best care possible.
  12. by   Totallyburned
    I am a nurse that has gone through an administrative trial for accusations of gross negligence, & won...however, the assistant attn'y general, that tried me, accused their very own administrative law judge of being biased, thus following up with an appeals via the bureau of health serivices and ignoring the ALJ's recommendation, proceeded via slapping me with an undeserved probation. I am, however, fighting their appeal against the ALJ's decision (complete exhoneration), despite the hospitals open and admitted altering of records and tampering; adding to information and leaving out critical portions of the chart...oh, there is more they were openly guilty of, such as perjury, but the state did not even chastise them, the state had exculpatory information...I just don't understand why me? Taking me to trial was more than likely cheaper than going after the hospital (there is after all political matters not clear to us all), the trial costed the state over 1 million and I paid out 100,000.00 in personal attn'y fees. But rather than go after the real offender, the hospital, it looks good to clean up the community and get rid of the nurse. About protection, as much as I know, there is no insurance against gross negligence claims, nor will there ever be is my guess and understandble seeing there would be so many claims. Just check out the site that shows nurses who have had their license pulled. I just won't go away though, I fight! I am awaiting for the appeals judges to docket this case for an oral argument. I am more than confident that I will win again, but here is the let down, if you think you have any protection, your wrong, because you can most definitely be used as an escape goat and although your innocent, your screwed! My story is quite entailed and I am so very wore out. I lost almost everything and I hold onto only the truth (God sees everything and he is my defender!). I refused to just let them lie and use me to cover-up for their mistake! We need fair and honest representation! No one would listen to me, the ANA never responded to my pleas for their help, and the MNA's 'Anita Szczepanski was the only one that would listen, she told me they are looking into it, but never heard a word back from her, even though I wrote her and called her numerous times. One person stepped in, only after I threatened to notify the Detroit Freepress journalist (I did anyways), that was the pre-elected now governor, Jennifer Granholm. She demanded that the asst. attn'y gen. provide a written detailed report and that the committee reconsider their decision...that is until after she was elected then they proceeded to fire away. The new attorney general, M. Cox wrote me a very unprofessional letter that stated I should have taken the first offer to go on probation---huh! The odds are against the nurse in all realms. You ought to go to the sites that list the nurses who are having their license pulled...it will shock you. But, who is standing on their behalf...NO ONE!!!!!!!!! Why should anyone want to be a nurse, we are unsupportive of one another. However, I am very supportive and have become as politically pro active as I can get. I have to add, I am the only nurse ever in the history of Michigan's that has to face an appeals board that has won an administrative law judge's decision, what that means that my case sets a precedence for other nurses and if I lose, it will hurt nurses in this state and they don't even know about it. If you want more details, just write me 'twilite345@yahoo.com' I will talk to you and share with you my painful journey and will keep you updated and if your in a situation like my own, I can extend my ears and offer you good advice. Honestly, it would behove nurses to demand fair representation, at least a trial before our peers. My guess is that I won only because I kept the original papers and my witnesses. Take care all...do write
  13. by   ceecel.dee
    Originally posted by Totallyburned
    I just won't go away though, I fight!

    I refused to just let them lie and use me to cover-up for their mistake!

    ...my case sets a precedence for other nurses and if I lose, it will hurt nurses in this state and they don't even know about it.
    I really admire your spirit to take a stand for what you feel is right "for the many".

    Good luck!:kiss
  14. by   mattsmom81
    We indeed walk a tightrope at work and yes,
    it is easy for administration to place the blame on the nurse.

    An assignment increase of 50% from 8 to 12 is pretty easy no for a nurse to make, IMO. The trouble comes in with the more subtle increases in load...such as the now nonexistent acuities systems used to show.

    I and my coworkers have used the Texas Safe Harbor provision several times in the past year in dangerous situations...and have made SOME headway with administration; but the battle is far from won.

    I agree it is better to refuse and lose your job than lose a license, but the system is setup to chastise nurses who are quit without notice and/or fired for insubordination....without a union there is not much support. The OP has not suffered as a result of quitting without notice, however this is not always the case in real life.

    No easy answers other than be careful, know your practice act and your protections (few as they are), carry malpractice insurance and choose your battles wisely.

    Totally burned, I am so sorry for what you are going through...I hope your nurses' association is behind you. I admire your resolve and your bravery. Thanks for sharing your story and my thoughts are with you.

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