Lawsuits and Nursing Notes

caroladybelle, BSN, RN · Jul 1, 2006

It would be impossible to offer an opinion as we do not have all the facts of case nor the evidence for/against these healthcare practitioners.

As a general note, it would be difficult to give any medicine to a patient in the hospital without it having been ordered by an MD, and provided by a pharmacist.....both of which should have access to a patient's allergy list, other meds being given and knowledge of the patient's diagnosis. Depending on the nature of the "allergy" , they may order the med anyway.

And as a general rule, the MD is also the person that decides on the patient's location in a hospital - the floors or the ICU. While nurses can encourage a transfer as well as discourage ordering of some meds by giving the MD info, they still are the ones that write orders.

Daytonite, BSN, RN · Jul 1, 2006

i had an rn friend who took a job with a law firm. her job was to be one of several reviewers who went through the charts of patients the firm was considering in taking on their lawsuits against hospitals. she told me that the firm had a number of health care professionals reviewing these charts against standards of care and the particular hospital policies. in all the cases where a lawsuit would proceed, there was very clear evidence in the chart alone that hospital employees caring for the patient had made some serious mistakes. it all hinged on what was written or not written in the chart. even the stuff that they didn't find documented they would try to find evidence of being done since they were aware that so many nurses are very blasé about their charting. they would look at billing records for evidence of dressing materials and iv needles and tubings being charged to the patient to indicate that these things might have been done with the patient although never charted. she said many flat out mistakes, however, would stand out like sore thumbs. it never ceased to amaze her how (i'll use the word) ignorant some nurses were in charting the very ignorant things they did to patients that went against good nursing practice, against hospital policies and against doctor's orders. there had to be some very major mistakes made if a lawsuit has already been filed with as many errors cited as you have listed.

you protect yourself every day during your practice by following good nursing practice, the hospital policies and doctor's orders. that really isn't so hard to do. some nurses, however, don't take that extra few minutes to look for allergies before giving medications. do you know all the places in a chart that allergies might be listed? i've never changed a dose of a medication without getting a doctor's order first and writing it on the chart. don't know about you, but i learned that in nursing school--pretty basic rule. i also took extra time to make sure my charting was complete even if i had to clock out first and go back to finish up. i felt it was protecting me and my license. i've attended several one day seminars on nursing and the law over the years and the things that were always stressed was to (1) know your hospital policies and follow them (2) always go back to source documents--that means checking original doctor's orders and admission information, and, (3) chart, chart, chart what you have done for the patient and anything out of the norm that you observed about the patient and what you did about it.

caroladybelle, BSN, RN · Jul 1, 2006

Adding:

It is inappropriate to "cover things up". Changing charting is inappropriate, if it occurred, and destroying/"losing" records is also wrong.

Daytonite, BSN, RN · Jul 1, 2006

Very true. I'd also add that if it is done at the request of facility administrators I would refuse and then get the heck out of the employ of that facility since only bad is going to follow.

guest64485 · Jul 1, 2006

I am curious if this family will be having an autopsy done on the deceased? I'm sure that would answer some of their questions

Holly27 · Jul 1, 2006

They had a autopsy done and thats why there is a lawsuit after the doctors and nurses.All I know is that the nurses said that they called the doctor to have patient moved to ICU 3 days after the fact the family beg them to do something. This included the nurses and Dr. She was septic. The husband gave a list of meds to the admissions nurse. Well they gave one of the meds anyways and she got sick. So they gave something else to counteract it and it was double the recommend dose. After the husband complain that they gave her something she was allergic too. The nurse acted like she never received anything about allergies. A person at the law office said the nurses notes had been altered or totally redone after the fact.

I just wanted feedback about the statements I received back from the nurse I was telling this too.

I'm a new grad and was telling this to a 15 year nurse. Who stated " You have to do what you have to do if want to keep working" and also that "Sorry that the person died but I still need to feed my family"

Is this the norm? I don't plan on making life threatening mistakes or any for that matter but I know it happens. Is covering up just a part of it?

I know that I've been told to always protect yourself because no one else is protecting you. But is this a little too far?

Just wanted some opinions.

Editorial Team / Admin · Jul 1, 2006

Holly,

No need to repeat excerpts from your original post. I think you know now this is not the norm. No, nurses should not ever alter medical records in the name of deceit. Medical records can be added to after the fact, but must be done appropriately. Nurses should not ever destroy medical records.....period.

Nurses cover themselves as Daytonite pointed out, by practicing within their scope of practice and adhering to the standards of care for any given situation.

The comment from the "15-year" nurse was very very inappropriate and totally uncalled for. It is frightening to know someone would actually say this.

charlies · Jul 2, 2006

Most nurses have high ethical standards. While this post seems to have the flavor of a fishing expidition to it, i'll go ahead and bite. Don't judge our profession based on a few bad apples.

Holly27 · Jul 3, 2006

Fishing Expedition ? I'm not sure I'm understanding. Anyways,I just want to know the chances of me encountering someone like that and the proper say to respone. Yes I was in total shock when she made the statement. I've always hear ppl say cover your tail but never to that extreme. Heck she even told a story where she had charted checking level of pain after med and she said she did'nt really even check it. I'm nervous and freak out at the same time about starting a new job.I just have questions and no nurses to ask.

Editorial Team / Admin · Jul 3, 2006

Hello, Holly27,

You will come across all types in you career. But, hopefully, you will not see another like that "15 year" nurse to which you refer. If anything, you need to distance yourself from her. Hope you will not be associated with her for if you are, you are obligated to report her highly unethical and negligent behavior. Believe me, she is not the norm. And, this is NOT covering yourself. This is blatant lying and deceit.

As for being nervous, that is very common and expected. Just practice guided by your own ethical/moral compass, stay within your professional scope of practice, be familiar with and practice within your entity's policies/protocols, and stay here at allnurses.com. We are here to help you along the way.

Good luck with your new career and job.

tantarosa · Jul 3, 2006

I'd like to add my 2 cents worth. there are many very good nurses. in my career of 20 years I too have come across nurses that have respoded like you have experienced. My advice is, I know that I have high morales and a high expectation as a nurse. I feel all nurses should be like me,unfortunately in the real world there are plenty of bad nurses. I just left a job because my DON wanted me to turn a blind eye to some horrible nursing practices that were going on. I said I cannot do that and gave my notice. When I care for people I always think of them as my family member and how would I treat my own family, I treat my patients the same way. You need to get a good mentor or find a nurse you feel safe asking questions. Always follow your gut feeling.

Good luck