Nurses Can Be Sued for Following Doctor’s Orders, NC Court Rules

subee, MSN, CRNA · Sep 4, 2022

8 hours ago, chare said:

Nurses Can Be Sued for Following Doctor’s Orders, NC Court Rules

Although the nurse involved in this case was a CRNA, based on the court's opinion I don't think it a stretch that this could be applied in a case involving a non-advanced practice nurse.

Very complex issue. I just read that North Carolina does not require supervision of CRNA's in ambulatory surgery settings. The details of the case are too sketchy to evaluate anything. But we have always been responsible for not following the standards of care which I don't know were followed in the above case.

subee, MSN, CRNA · Sep 4, 2022

I found out a little more online. It was obviously in a hospital and is sounds like child was not intubated soon enough during a stormy induction. I wish I knew more because I can't understand how this could happen unless someone failed to detect a difficult airway before the case started.

Editorial Team / Admin · Sep 4, 2022

2 minutes ago, subee said:

I found out a little more online. It was obviously in a hospital and is sounds like child was not intubated soon enough during a stormy induction. I wish I knew more because I can't understand how this could happen unless someone failed to detect a difficult airway before the case started.

My thoughts as well, @subee

chare · Sep 4, 2022

25 minutes ago, subee said:

Very complex issue. I just read that North Carolina does not require supervision of CRNA's in ambulatory surgery settings. ...

As I'm not a CRNA I'm unsure, however will take your statement as fact. Having said that, I don't think this applies here as the patient was undergoing a cardiac ablation at Carolinas Medical Center (CMC), not an ambulatory surgery center.

31 minutes ago, subee said:

I found out a little more online. It was obviously in a hospital and is sounds like child was not intubated soon enough during a stormy induction. ...

And you base this on what exactly? At my facility, anesthesia for all procedures in the pediatric cardiac catheterization center is provided by a pediatric cardiac anesthesiologist. While a CRNA might assist, he or she would never be the sole anesthesia provider. And, from what I know about CMC and their pediatric cardiac program I strongly suspect their procedures are similar.

38 minutes ago, subee said:

... I wish I knew more because I can't understand how this could happen unless someone failed to detect a difficult airway before the case started.

How familiar are you with pediatric cardiac and cardiothoracic patients? Again, I'm not CRNA, butt I have 15 years experience caring for pediatric cardiac and cardiothoracic patients. These patients are often severely compromised going into the induction, and when the code it is often a result of cardiovascular collapse and not a failed or difficult airway as you suggest. Our pediatric cardiac intensivists are quite good at both providing sedation and incubating and they routinely defer non-emergent intubations to pediatric cardiac anesthesiology. And, depending on the patient it isn't uncommon to have ECMO on standby

subee, MSN, CRNA · Sep 5, 2022

16 hours ago, chare said:

As I'm not a CRNA I'm unsure, however will take your statement as fact. Having said that, I don't think this applies here as the patient was undergoing a cardiac ablation at Carolinas Medical Center (CMC), not an ambulatory surgery center.

And you base this on what exactly? At my facility, anesthesia for all procedures in the pediatric cardiac catheterization center is provided by a pediatric cardiac anesthesiologist. While a CRNA might assist, he or she would never be the sole anesthesia provider. And, from what I know about CMC and their pediatric cardiac program I strongly suspect their procedures are similar.

How familiar are you with pediatric cardiac and cardiothoracic patients? Again, I'm not CRNA, butt I have 15 years experience caring for pediatric cardiac and cardiothoracic patients. These patients are often severely compromised going into the induction, and when the code it is often a result of cardiovascular collapse and not a failed or difficult airway as you suggest. Our pediatric cardiac intensivists are quite good at both providing sedation and incubating and they routinely defer non-emergent intubations to pediatric cardiac anesthesiology. And, depending on the patient it isn't uncommon to have ECMO on standby

Like I said, I don't know enough about the case. But I think airway compromise is more likely for this scenario in an ablation. One can oxygenate a dead body if need be for donation purposes...if the airway is secure.

subee, MSN, CRNA · Sep 5, 2022

5 hours ago, subee said:

Like I said, I don't know enough about the case. But I think airway compromise is more likely for this scenario in an ablation. One can oxygenate a dead body if need be for donation purposes...if the airway is secure.

I got the information re: independent practice from a Becker's January 18, 2017 Becker's ASC review but it will not allow me to save the article in a file. The BON of NC does not require that a CRNA work with an anesthesiologist; that is a hospital requirement. At any rate, I have NO idea why a CRNA would be working in this room. That would be unusual in a large medical center that has subspecialty anesthesia residencies. I can think of several cases I've done that required a 2nd anesthesia person in the room and that was the CRNA working with an anesthesiologist. But these are cases that involve a lot of physical work (liver transplants, ruptured aortic aneurysms, traumas). This would not be the case for an ablation. We would never the the sole provider for those cases but that is not by law; it's because it's the hospital policy. My point is that we have no information here to know what the dynamics were going on in the room at the time. Nor do I know if this situation portends anything for the bulk of RN's. What was your idea when you posted it?

chare · Sep 6, 2022

4 hours ago, subee said:

... Nor do I know if this situation portends anything for the bulk of RN's. What was your idea when you posted it?

As the nurse involved was an advanced practice provider, my initial thought was that this precedent would most likely pertain to advanced practice providers. However, and this is my lay opinion, I think the absence of the advance practice designation in Justice Morgan's opinion might be problematic. Those of us that post here that are nurses can easily understand the distinction. However, in a case that goes to trial, I'm not convinced that a jury will.

Quote

[...]

Justice Michael Morgan, for the majority 3-2 opinion, wrote, “Due to the evolution of the medical profession’s recognition of the increased specialization and independence of nurses in the treatment of patients over the course of the ensuing ninety years since this Court’s issuance of the Byrd opinion, we determine that it is timely and appropriate to overrule Byrd as it is applied to the facts of this case.”

[...]

Silver_Rik, ASN, RN · Sep 7, 2022

On 9/5/2022 at 9:27 PM, chare said:

As the nurse involved was an advanced practice provider, my initial thought was that this precedent would most likely pertain to advanced practice providers. However, and this is my lay opinion, I think the absence of the advance practice designation in Justice Morgan's opinion might be problematic. Those of us that post here that are nurses can easily understand the distinction. However, in a case that goes to trial, I'm not convinced that a jury will.

I’m not a lawyer, but I don’t think that’s an issue for a jury to decide. The judge or appellate court would make the determination of whether it applies to a non advanced practice nurse. I agree that this is a distinction that probably has to be further sorted out.

FallingInPlace, ADN, BSN, RN · Sep 7, 2022

As a North Carolina nurse, this does not give me comfort, although it sounds as if this decision was made about a case where a nurse veered far off from the standard of care. Time to consider other employment options.

MaxAttack, BSN, RN · Sep 7, 2022

I just finished reading through the opinion (https://appellate.nccourts.org/opinions/?c=1&pdf=41701) and it's pretty clear that they are referencing advanced practice nurses. They are recognizing that a nurse and CRNA are not the same (which should be a given) and therefore a precedent that applies to nurses should not apply to advanced practice nurses.

Quote

It is also apparent that the independent status, the professional stature, the individual medical determinations, and the shared responsibilities with a supervising physician have grown in significance and in official recognition since Byrd for a nurse such as a certified registered nurse anesthetist

I think this ruling reflects growing pains of the evolution of advanced practice nursing. Even in the dissenting opinion registered nurses and advanced practice nurses are lumped together at times. If anything that seems like the stretch here. I don't see anything that changes for bedside nurses. IMO the article is clickbait.

subee, MSN, CRNA · Sep 8, 2022

16 hours ago, MaxAttack said:

I just finished reading through the opinion (https://appellate.nccourts.org/opinions/?c=1&pdf=41701) and it's pretty clear that they are referencing advanced practice nurses. They are recognizing that a nurse and CRNA are not the same (which should be a given) and therefore a precedent that applies to nurses should not apply to advanced practice nurses.

I think this ruling reflects growing pains of the evolution of advanced practice nursing. Even in the dissenting opinion registered nurses and advanced practice nurses are lumped together at times. If anything that seems like the stretch here. I don't see anything that changes for bedside nurses. IMO the article is clickbait.

The nurse practice act for CRNA's in North Carolina does make reference to their liability for their actions:

21 NCAC 36 .0226 NURSE ANESTHESIA PRACTICE

(a) Only a registered nurse who completes a program accredited by the Council on Accreditation of Nurse Anesthesia Educational Programs, is credentialed as a certified registered nurse anesthetist by the Council on Certification of Nurse Anesthetists, and who maintains recertification through the Council on Recertification of Nurse Anesthetists, shall perform nurse anesthesia activities in collaboration with a physician, dentist, podiatrist, or other lawfully qualified health care provider. A nurse anesthetist shall not prescribe a medical treatment regimen or make a medical diagnosis except under the supervision of a licensed physician.

(b) For the purpose of this Rule, collaboration means a process by which the certified registered nurse anesthetist works with one or more qualified health care providers, each contributing his or her respective area of expertise consistent with the appropriate occupational licensure laws of the State and according to the established policies, procedures, practices, and channels of communication that lend support to nurse anesthesia services and that define the roles and responsibilities of the qualified nurse anesthetist within the practice setting. The individual nurse anesthetist shall be accountable for the outcome of his or her actions.

(c) Nurse Anesthesia activities and responsibilities that the appropriately qualified registered nurse anesthetist may safely accept shall depend upon the individual's knowledge, skills, and other variables in each practice setting as outlined in 21 NCAC 36 .0224(a), including:

I cannot find the same language in the non-CRNA version of the practice act in N.C. I'm still confused as to why judges are making this decision instead of the board of nursing since the language is clear that the CRNA is liable. All of us who work in the health care professions know that this is a very arcane subject even for us!