BillEDRN

There are essentially two types of involuntary holds. Those associated with psychiatric issues or those with temporary decisional incapacity, usually related to alcohol or other intoxicants. Either way, you are responsible for their safety. A physician or other independent licensed provider (NP or PA) is usually tasked with making a determination about their ability to leave AMA. If they cannot make an informed decision, or are considered a threat to themselves or others, then the hospital is responsible for keeping them safe. Restraints (both chemical and physical) can be used, but within the guidelines established by regulatory agencies (Joint Comm., CMS, State Dept. of Health). How much force and for how long you can keep them, even the criteria for determining danger to self or decisional capacity, is full of grey areas, so don't expect to see a lot of specific information about exactly what you can and cannot do. Check your state statues, but don't be surprised if the situation isn't specifically addressed. From a liability standpoint, it's best to have a physician make the determination and then make sure charting accurately reflects the patient's condition, behavior, and attitude, as well as all attempts to keep him if things look like they're heading towards restraint-ville.

I have worked in many areas, but mostly ED. Many of my collegues who work in other speciality areas feel the same way: they wouldn't want to work anywhere else. I think you have to experience the various areas to see what fits you best. The key is being willing to try different things. I personally think ICU gives a wonderful background that allows you maximum flexibility in changing positions/specialities. But, you still need to be willing to change if it isn't a good fit for you. As far as this self-admitted adrenalin junkie, I don't mind the precipitous deliveries. I've caught 'em in the back seat of a car, the waiting room, the BR, and even the elevator.:)

HIPAA allows limited release of PMI to law enforcement. Ususally it is limited to name and general condition, but may include more. See here for additional info: http://www.hhs.gov/hipaafaq/permitted/law/505.html

At the very least I would request a copy of the medical records to review and re-familarize yourself with the documentation. While reviewing your charting, you might consider doing so with the info previously provided (sorry I forget who made the post) about documenting the agreement of the patient, location and prep of the draw site, and chain of custody information as a "learning moment" for any future similar situation. If you really want to push the issue, you could ask to speak to Corporate Counsel if the Risk Manager seems to be dismissing your requests for help/assistence/guidence. First, like others have said, it is actually unlikely that you will have to testify at all, but even if so, it is unlikely that the Defense will treat you in that manner for several reasons. First, most Courts (I use this term to include the Judges and/or jury members) tend to look very favorably on nurses, and as such don't view attacks on them in a very good light. The defense knows this and won't want to risk alienating the court any more than absolutely necessary. Second, assuming you didn't do anything really negligent or unprofessional, minor mistakes you may have made in documentation or draw procedures are not likely to be viewed as anything but deminimus or inconsequential. So attacks on your testimony are again more than likley to leave a "bad taste in the mouths" of the Court. It is common to feel nervous or fear making a mistake during testimony, so don't feel bad. As I said earlier, familarize yourself with the documentation you made, make notes now about any information that may have been ommitted or that you feel may be important and discuss your concerns with an attorney. If for some reason the hospital legal staff aren't helping you, the suggestion to talk to the Prosecuting Attorney is a very good one. They have a vested interest to make sure your testimony is helpful to their case so I'm pretty sure they'll be helpful. You also might ask to what degree their case hinges on your testimony. If the blood draw only proves to be a minor piece of their strategy, it is even more unlikely that you'll even have to testify. And, if you do, equally unlikely the defense is going to be interested in making you look bad. If you get called to testify, try to relax on the stand. Don't feel you have to answer any question immediately and ask for clarification if you don't understand the question. If you need to review the documentation to answer a question, request the opportunity to do so. If you don't know the answer to a question, don't be afraid to say so. Just answer the question and don't try to provide any additional information or rationale unless specifically asked and the Prosecution doesn't object. As for the personal items brought to court, I think in general the issue was blown out of proportion to your situation. Certainly it would be unwise to bring things that may obviously discredit you to the court (a bottle of psychotropics, a fifth or alcohol, or an inflamatory book or magazine) but routine personal items are very unlikely to cause any problems. As to the examples given previously, I would still like to know the specifics of them. For example, was the person with the pill bottle the witness or the defendant? To wit, it makes a huge difference if he was the defendent on trial for driving under the influence and stated he was not taking any medications. In that case the fact that he was witnessed with medications on his person could possibly impune his prior testimony and thus be relevant to the proceedings. On the other hand, the fact that a witness takes, say thyroid medications, is not germaine to the proceedings and would not be asked about it during proceedings. There is a reason legal analysis of cases are so detail oriented and at the minimum identifies the key players in the defense and prosecution. That is because, as noted above, similar actions of, evidence against, or observations of, those parties affect the proceedings differently. What may be damaging to the defence may not have the same effect for the prosecution. Without that level of specificity it is very difficult to assess the influence of those varibles on the outcome of the trial. The other thing to remember is that it is likely that the guy you drew blood from is being represented by a public defender. That PD is unlikely to post spys at the metal detector in an attempt to spot questionable items carried by witnesses to his case. It just isn't cost effective. The same holds true even if the defense isn't a PD. Unless the guy you drew is some mega-wealthy big-shot who can afford a private investigator to stand by the entrace waiting for you to pass thru the metal detector, I really doubt anyone is going to be looking at your personal effects as a means to discredit your testimony. And finally, I apologize if any of my actions detracted from your attempts to seek information about this issue. It was not my intent and had honestly wanted the specifics for my future reference. In general I think most of the advice was accurate. I obviously have some disagreement about some of it, so you are of course welcome to evaluate the logic and rational of my thought as I have tried to presented them and come to the conclusion you feel is most appropriate for you. Good luck.

Ms. Kelly: I apologize if I have offended you with the inferrence of any profanity. I admit that maybe I was inartful in the choice of "that" word to describe the caustic and denigrating response I got from RN1989 to what I intended as a legitimate question on the vague advice given about carrying personal items to court. However, the unprofessional behavior and lack of self-respect clearly started with that reply. And I think that such an unprovoked attack is much more an indication of an anger management problem than my admittedly inartful prose and attempts at pithy comebacks. You are of course entitled to your own opinion, but I would be interested in your assessment of her response since you seem to feel mine was so inappropriate. Exactly what I was trying to do. I will even give RN1989 the benefit of the doubt and state that I am sure that was her intention as well. Unfortunately, her advice on the personal items she alluded to as being possibly problematic, obviously lacked any real value because of the vaugeness. Hence my request for some clarification. Correct. If you read my initial post, you will see I agreed with RN1989 and only supplemented it with some additional, specific advice I tend to provide to my clients. Interesting observation, thank you. The specifics of this example actually make it useful to others. This was what I was asking of RN1989 and instead got some mad drivel about, among other things, trying to take the thread in some other direction. Are you suggesting that some personal items, such as a wallet, purse, personal hygeine supplies, medications, none of which I have ever (nor any of the attorneys I work with and we have 50+ of them) specifically requested my witnesses bring to court, should be left at home? If not these items, are there others you feel are problematic? Do you have some list of suggested items to leave at home? I know I send our witnesses a print out with tips for preparing for a deposition, along with other printed materials because with think it's important to give them something they can take home and review because they so frequently suffer a little information overload in the office. I would think, based on your responses, that same concern exists for these yet undefined personal items. As such, maybe a printed list would be helpful. And finally, I tend to think that making vague statements such as "bring nothing to court that you are not asked to" is analogous to telling a client not to say anything on the stand that will get them into trouble: It may be true but, the vague nature of the statements does little to help someone unfamilar with the legal process prepare adequately. I tend to view my advice to witnesses much like I view discharge instructions. They need to be given in a manner that best suits the client, and with enough detail to be helpful for that individual's situation. I wouldn't tell the post-op chole patient to follow up with his PCP 'if things don't feel right," but rather specific signs and symptoms of possible obstruction, infection, dehiscence, and pancreatitis. Aloha

Wow. Are you always this helpful to those that ask for clarification of the advice you give, or are you in general just an *ss? I'm not sure what got you so riled up, but I can assure you that I was in good faith asking for clarification about your statement to the effect that personal effects may be used against you as a witness in court. As I mentioned, but maybe didn't make entirely clear, part of my job (I work for a law firm that helps defend malpractice suits) is to help prepare nurses for depositions and trial, hence my genuine concern that I wasn't aware of something important to pass on to those I am supposed to be helping. It was my hope that, based on your experiences, I might be able to help another nurse avoid going thru whatever this bad experience you allude to. I don't know where you thought I might disagree with you, after all, I don't know what happened or the significance of that experience, which is why I asked for clarification. As to taking this discussion down a "different road," I must admit I don't know what the heck you're talking about. Seems the only one willing to diverge from providing specific advice on how to handle a deposition subpoena, or go down that "different road" with unsubstantiated and unwarranted allegations of ulterior motives, is you. Since you list your location as the "nuthouse," you might want to up your medication dosage, your paranoia is showing. But maybe helping someone else by providing specifics is too much of a "passionate discussion" for you to become involved in. Oh well, after your little tirade, I suspect it wouldn't have been that useful any way.

I am unfamilar with the term "safe harbor" as it is not common here. But, I assume that it documents an unsafe staffing situation. If so, I agree that it should be filled out for each and every occurence like the one described by the original poster. In regards to the issue of "it doesn't do anything" I have to disagree. The fact that it does not appear to have any immediate effect on the current staffing issues does not make the documentation useless or unproductive. If an untold effect happened and a patient was harmed as a result of the staffing issue, that documentation could go a long way to protect the nurse assigned to the patient that was harmed in any subsequent legal action. Additionally, oversight and regulatory agencies (such as Joint Commission, CAMS, DoH) can use those types of reports for mandating corrective actions, especially if injuries or sentinal-type events happen. Think of it this way: Does the fact that you document the coumadin given to a patient prevent a stroke or DVT? No, of course not. But, does that same documentation protect you 3-4 years from now when that stroke or DVT patient tries to sue you and the hospital, claiming that if you had given him his meds he wouldn't have had the stroke/DVT? Yep, you bet.

RN 1989, I help prepare folks (nurses as well as others) for deposition and trial testimony and think much of what you say is very good advice. I would add that I would wait to respond to questions (and this should be worked out with your lawyer beforehand) while watching your lawyer. If it looks like he/she may try to object to a question, keep quiet until you're sure there is no objection raised. I do question your advice and would ask for clarification, based on your later comments, about personal objects "being shown to everyone." I would be most grateful if you could share the specifics of your experiences so I might better understand the circumstances and adjust any advice I provide accordingly. Thank you.

That's too bad. I have had to work with corporate counsel and risk managers on several occasions with multiple facilities as a staff nurse, and found that each time they were most helpful. I am sure that it was because they were interested in presenting the best possible legal position for the facility. As far as covering your shift, that's the facilities responsibility when you receive a subpoena. In my current position at a law firm, we advise all of our clients (hospitals) to assist any employee who receives a subpoena, as it's in their best interest to be in the best legal position possible for any legal proceeding.

I have worked in EDs for over 20 years and I can tell you that women can be every bit as "bad" as men when it comes to sexually explicit comments, inuendos, and behaviors. I suspect that some of the posters you are railing against were trying to be humorous or witty and are not necessarily the unprofessional weirdos you want to portray them as. And yes, I have had a female nurse make a comment about how placing a foley on a patient made her happy her guy was a little more "blessed" than the patient. I have had females make remarks about member size on occassions too numerous to count; I have been party to many a conversation about how hot the guy in room "x" is with the girls arguing over who would get to take care of them; I even had one woman tape tongue depresors togather to approximate the size of one well endowed patient she cared for so she could show the other girls on the unit. I could go on, but I would hope you get the point. The one thing I have come to appreciate is that most healthcare providers are caring and compassionate people who frequently try to find humor in the tragedy and misfortune they are routinely asked to deal with. If you, as a seasoned veteran have not been so inclined to participate in this type gallows humor or witisims, congratulations! However, I think most of us that have been around long enough realize it is a common means of blowing off steam, especially when discussing things with our coworkers, from a stress filled job. The sad part of this is that the posters thought that they could do so here, in the presence of collegues and peers who were understanding and that they would be safe from ridicule, scorn, and harsh judgements. Apparently the understanding, compassion, and non-judgemental attitude so frequently advocated by those like yourself does not extend to your collegues.

I suggest you speak to your risk manager and corporate counsel as they will be representing you. Assist them as well as you can and be honest. Depending on who subpoenaed you, the preparation may be a little different. If it was for someone who was for a blood draw (I assume the LEO thought the patient was drunk or under the influence of something) I suspect it was the Prosecution who wants to document your compliance with applicable standards for the legal drawing of evidence to be used in building the case against the guy.

I don't know about the state of nursing care in the UK, except to say that lots of your nurses are coming here to practice and not many US nurses are flocking to the UK. So, take that observation for what it's worth. However, to answer your question, my grandparents are deceased, but my elderly mother recently was diagnosed with breast CA and had to undergo multiple procedures and ultimately surgery. At one point, she had to have a male tech administer dye for for a radiology study. The dye was injected into her breast to map migration to her lymph nodes. Initially, she was hesitant to have this performed by a male. So, I talked to her about this concern. After a short time, she realized her fears were unfounded and that a male could be as caring, gentle (considering the procedure), empathetic, professional and competent as a female. Moreover, she made the realization that placing limitations on someone for reasons of sex is rarely, if ever justified. Just as she hoped that no such limitations would be arbitraily placed on her daughter's professional endeavours because of her gender, none should be placed on someone else's son. So, my response to irrational and unfounded fear/concern/modesty is one of education and logic. I know this may run counter to the current drivel espoused by many of the nurse educators, but I for one prefer to educate people as opposed to perpetuate unhealthy stereotypes, discrimination and fear.

I wouldn't "force" care on anyone at anytime...however, I have told patients that I was the only nurse available to do the procedure so they could decide to have me do it or not. I find it interesting that you tried to accomodate a black person's request for a black nurse. If the situation was reversed, a white person asked their assigned black nurse for another, white nurse, would that be OK?

As a former ER tech and ER nurse, I agree with the above....good luck

"I dont think I am missing the point." I hate to berate the point, but I think you are. The discussion was about why this form of discrimination is tolerated when other forms are so vehemently renounced. "I see this a different choice from saying you dont want a nurse because he/she is orange/green/has 3 arms etc. And I am only talking about personal care (ok double standard on my part in dividing care up!)." So you recognize that you are inconsistent in you arguments and that you do(or so it appears, as I assume you would have the same problems with a realistic class that may be subject to discrimination, such as blacks) have a problem with other forms of discrimination. "Patients who see me in my role as nurse practitioner have chosen to see me..." I am not sure what type of system you work for, but for many patients, and the nurses that care for them, such options are not always available or practical. Assuming you were the only nurse available, and a patient requested a male because of an STD, would you let him wander out into the healthcare maze and let him try to find a male to treat him? Or would you try to convince him that his health, as well as others he might have (or had) contact with, was in jeopardy and that as a professional you would treat him with the same understanding, dignity, and compassion as a male counter-part? "I would not support discrimination on any other grounds.." So at least you recognize it as discrimination, which only validates that we have a reasonable basis to question why this type of discrimination is OK, when others are not.

While you are entitled to your personal opinions and biases, you are incorrect about your discrimination. It does not matter an iota if your response is an "emotional" one or not...it is still discrimination. If a patient requested a white nurse 'even though they recognized that a black nurse was just as qualified' because it was an "emotional" issue for them, would you then say it wasn't discrimination? Of course not! And while I appreciate your discomfort, let's call it what it is. Like all forms of discrimination, the best way to address it is with open and honest discussions, not attempts to bury the true nature of it under the guise of a different name.

Karen, It seems you miss the point of the discussion regarding what is "acceptable" discrimination and what isn't. Why is it that female nurses are not so accepting if someone says they don't want a female nurse (i.e. a male patient asking for a male because of some problem "down there" - I know I have personally heard female nurses tell such a patient to "get over it...I've seen it all before") but want to make it a cultural issue if a female patient doesn't want a male nurse? Sure, we should accomodate a patient's requests if possible, but I do not think we need to perpetuate outdated stereotypes. As a student, I was excluded from most aspects of my OB/GYN rotation, but have delivered several babies. I was also told by my instructor that "men shouldn't be in nursing" so there is some legitimate concern that such regressive thinking needs to be addressed. Oh, and by the way, I have, on several occasions, had patients ask for a different nurse or a doctor based on race or ethnicity. We didn't accomodate those requests, and I am not sure we need to do so for gender either.

Besides treatment to prevent infection, it is extremely important to document ANY needle stick for purposes of any future claim that may arise out of a subsequent infection. What happens if you do get HIV or hepatitis? Do you think your facility is going to pay for the associated costs for treatment or care without something to document it happened at work? Not likely. Just think about how your facility handles your "routine" illnesses that are very likely from occupational exposures....

Anyway, I'm making like a duck with water running off its back: it doesn't affect me personally. No, thank Heavens, I've finally gotten past the fear of offending the great god Doctorus Medicus Ad Nauseam. I guess most nurses do, eventually. I just didn't know I had until today IMHO - you should take this incident to the administrators with your own claims of unprofessional behavior and also claim a hostile work environment. No one should be subjected to the treatment you got, especially for advocating for the patient, and especially in light of the legitimate issues of patient abandonment. If we collectively allow this type of behavior to continue unchecked, it is bound to continue. If there are no consequenses to the physicians and NP's poor behavior, it will seem to them as if it were OK. As you experienced with the "new" doc, issues can, and should be resolved in a professional manner. I had a similar incident many years ago, back when the radiologists had to come in to read the CT scans for our ED patients. I was sitting in a chair, in front of the window, in the CT room, so I could visually monitor a vented trauma patient. One of the hotshot radiologists came bounding into the room, looked around, and seeing no empty chairs, demanded that I get up and give him mine. I of course, remained seated, explained that I was busy with charting and monitoring my patient, and that if he wanted a chair, he should ask one of the many residents, or med students observing, to get up. This only made him more upset, and he threatened to "kick my a**" if I didn't get up. At that point, I did get up, and being 6 foot and used to fighting with drunks in the ED, got "in his face" and suggested that if he really wanted an altercation, he could have one, but that since I was bigger, and well schooled in self-defense, that he might want to reconsider. He thought about it for a second, and then asked the resident to give up his chair. The moral - Like children and bullies, tolerating bad behavior only causes that behavior to continue.

Actually, you are partially correct. As you correctly state, "at will" means an employer or employee may terminate the relationship at any time, without cause. The one caveat to that is that the employer may not terminate you based on any number of protected classes (sex, religious affiliation, marital status, or sexual orientation for example, there are others). However, if you believe you were fired illegally, it is not as easy to "prove" your case in court. First, you would have to make a claim to the Equal Employment Opportunity Commission (EEOC), who would make a determination about the merits of your case. If so determined, you could proceed to court, where after your claims of discrimination were made, the employer would have an opportunity to state why the fired you wasn't because of some protected status. And since you mentioned it, the possibility does exist that the employer could fire you for that tattoo. After the employer gets done explaining that he fired you because you were always late, had poor performance, or that you treated the customers badly, you would get an opportunity to refute those claims on the basis of any evidence you had. So, it really is not that hard for an employer to fire you, and no, they really don't have to worry about the headaches of a lawsuit, for the most part, as it is frequently difficult to have enough evidence to refute an employer's seemingly reasonable justification for firing you. A link to the EEOC is below if you need any additional information. http://www.eeoc.gov/ Abandonment would only be applicable if you walked off the job after starting your shift. Not showing up for work is not abandonment, and therefore not providing notice of your intent to quit wouldn't be abandonment either. Poor form, yes, but, not abandonment. Unless you have agreed to some additional terms of employment, an employee policy manual's "suggestions" for notice would not be binding on the employee wanting to quit. Again, it might be poor form, but not illegal.

My knees didn't give out, but I have a few scars and myalgias after 20 years in emergency medicine, including pre-hospital, flight nursing, and hyperbarics. I also did a few cases as an ER expert, so when I was offered a job in a law firm, I "eased into" it for 2 years on a per-diem basis, and then made the full-time jump the first of this year. Like you, I love it and agree with the respect, professionalism (more so at times then I ever felt at the hospital) and positive feed-back comments. I also do many of the same things you describe, and while I usually work the defense side (usually doctors, hospitals, or nurses) we do some personal injury stuff as well. I still consider myself an advocate, mostly for my professional colleagues working in a clinical setting, but for some "patients" as well. The flexibility has allowed me to pursue an advanced degree. A subsequent poster asks about "those courses" to work in the legal arena. I assume they meant the "legal nurse consultant" designation. In my admittedly limited experience to date, I find most attorneys don't know, or care much about these various and different certifications. A broad based clinical experience, as well as a willingness to research and learn about the many things you haven't been exposed to in the clinical setting, and the ability to communicate (that is, write well, and not the jargon laced short hand most clinicians use daily in charting) well, are much more important. However, the ability to read and "interpret" poor copies of barely legible handwriting on the medical records, is an extremely valuable asset as well.

Having family interpret is not, in and of itself a Healthcare Insurance Portability and Accountability Act (HIPAA) violation, and by the way, neither is giving basic medical information to family, unless the patient expressly states that you cannot. That being said, there is some liability exposure, as you correctly identified, in communication issues (the interpreter didn't interpret correctly, or did not understand your question), that result in problems. Unfortunately, most healthcare workers do not fully understand the HIPAA's regulations and very often unnecessarily restrict information. There is no doubt that the laws are sometimes confusing, but to date, there have been only two criminal cases prosecuted, and no civil cases. For a law that has been in existence this long, that is pretty significant. http://www.mtexpress.com/index2.php?ID=2005115979 http://www.medicalnewstoday.com/medicalnews.php?newsid=75936 http://www.medicalnewstoday.com/medicalnews.php?newsid=44585

My initial thoughts are in alignment with the other posters, in respect to the premise that your staff are probably too busy, and stretched too thin in regards to staffing. However, you must also look at other contributing factors, like do you make it convenient to create the requisite stickers before the nurse heads into the room to draw blood/start IVs? What happens when a patient arrives and the nurse immediately follows him/her into the room and is then required to draw blood/start IVs? Does someone else have the responsibility to make and deliver the required labels? In short, you need to look at the systems issues, both during the construction period, and afterwards to eliminate those processes that create difficulties in labeling the specimines at the bedside. For example, does each nurse have their own label maker (adressograph, or whatever your facility uses)? Are labels generated by lab personnel only after the order is entered? Whatever the cause, you need to identify it then make it "easy" for the nurses to comply. All too often, the "system" is set up in such a fashion that complying with stated goals is nearly impossible. Because of this, nurses often try to "work around" the difficulty, and in doing so, make mistakes.

Get everything in writing and request something from the Corporate Counsel (the facilities attorney) noting that he is aware of the requests from administration and the instructions to perform unnecessary testing to try an effect a transfer. I presume, but am not certain, that the actions requested by the administration to get her out and then not accept her back to your facility are illegal, and once the attorney is made aware of those requests, he will be forced to recommend against it or face possible malpractice charges and/or sactions from the state Bar Association.

I agree that as nurses, we should encourage our peers to stop being victims. Their participation in the healthcare/political arena would go a long ways towards that goal. Unfortunately, the system is what it is now, and it does create "victims." Much like a battered spouse, you don't just tell them to "stop being a victim" you offer support and don't blame them for the situation they are in.