POLITICAL SCIENCE-Philipine Legal and Political Issues in Nursing

8/10/2019 POLITICAL SCIENCE-Philipine Legal and Political Issues in Nursing

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Legal and Political Issues in Nursing

and the Philippine Nursing Act of2002


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Introduction

During the course of an average workday, the typical oor nurse carries outnumerous treatments, passes out a large number of medications, performs frequentphysical assessments, and makes multiple decisions that aect the health and well-being of patients. Nurses rarely have the time to fully investigate and consider althe ethical and legal implications of their actions. hey often make critical decisionsabout patient care while in the midst of high-pressure situations that force them to

act quickly. !ometimes nurses make mistakes. "ortunately, only a small percentageof the mistakes made by nurses actually produce in#ury to patients. $f this smalnumber of in#ured patients, an even smaller percentage goes on to seekcompensation for damages through legal action. Nevertheless, the number olawsuits %led against nurses continues to increase. &any of these suits are welpublici'ed in the news media and give the impression that every action a nursetakes can leave that nurse open to a lawsuit. ( )iken,*++

he elements of professional negligence therefore are ( e/istence of a dutyon the part of the person charged to use due care under circumstances, (* failureto meet the standard of due care, ( the foreseeability of harm resulting fromfailure to meet the standard, and (0 the fact that the breach of this standard

resulted in an in#ury to the plainti.

Concept of Law

1aw is a rule of conduct, #ust, obligatory, laid by legitimate power for commonobservance and bene%t. 2t is a sciences of moral laws founded on the rationanature of man which regulates free activity for the reali'ation of his individual andsocial ends under the aspect of mutual demandable independence.

Classication of Law

. 3rimininal 1aw-2t de%nes crimes, treats of their nature, provides for their

punishment

*.2nternational law- 2t regulates the intercourse of nations.

.4olitical law - 2t treats of the science of organi'ation and administration ogovernment.

a 3onstitutional 1aw- 2t treats of constitution, their establishment, construction and construction, and interpretation, and of the validity of legal enactmentsas tested by the criterion of conformity to the fundamental law.

b )dministrative 1aw 5 2t %/es the organi'ation and determines the competence

of the authorities which e/ecute the law, and indicate to the individual theremedies for the violations of his rights.

0. 4rivate 1aw 5 2t indicates a statute which relates to private matters that do notconcern the public at large.


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a 3ivil 1aw 52t determines or regulates assistance, authority and obediencebetween members of a family, and those that e/ist between members of asociety for the protection of private interest.

b 3ommercial 1aw- 2t relates to the rights of property and the relations ofpersons engaged in commerce.

c 6emedial 1aw - 2t deals with the rules concerning pleadings, practice andprocedure in all courts of the 4hilippines.

Legal denition of nursing

he Nurses )ssociation of New 7runswick (889 de%ned Nurses Act to bethe practice of nursing :and includes the nursing assessment and treatment ofhuman responses to actual or potential health problems and the nursing supervisionthereof.; he practice of nursing progresses and develops over time. heassociation e/pounds the concept of holism is germane to nursing. his is evident inthe nursing view of the individual, the concept of health and the practice onursing (bthere is reasonable necessity for the means employed by the persondefending himselfMherself to prevent such aggression> and (c there is lack ofsuIcient provocation on the part of the person defending himself.* Chen heMshe acts in defense of the person of the rights of hisMher spouseascendant, descendants, or legitimate or natural or adopted brothers osisters, or relatives bu aInity in the same degree, provided that the %rst andsecond requisites presented in the ne/t preceding circumstances are presentand further requisite, in the case of provocation was given by the personattacked, that one making defense had not part therein..Chen he or she acts in defense of the person or rights of stranger providedthat the %rst and second requisites mentioned in the %rst circumstance and

that the person defending is not induced by revenge ,resentment or other evimotives.0. Chen any person who in order to avoid an evil or in#ury, does an act whichcauses damage to another provided that the evil sought to be avoidedactually e/ists, the in#ury feared is greater than that done to avoid it andthere is no other practical and less harmful means to prevent it.K. Chen heMshe acts in the ful%llment of a duty or lawful e/ercise of a right oroIce.

1."3e)pting Circu)stances


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hese are certain circumstances under which the law e/empt a person fromcriminal liability for the commission of a crime. he following persons under thecircumstances stated are e/pressly e/empted by law from criminal liability for thecrime they may have committed who was at fault for attaching the hysteroscopeincorrectly was disputed. Gvidence presented at trial revealed that the two nurses

assigned to the surgical procedure had neither hospital training nor e/perience inthe hysteroscope=s use. Gvidence also showed that the supervising nurse who madethe assignments was unaware of the nursesA lack of e/perience. No e/pert opinionon the standard of care was presented at trial.

)t the end of the trial, the #udge instructed #ury members to use thei:common knowledge; to decide if the nurses deviated from their duty in caring for&s. 3hin. (he common-knowledge standard applies when the facts of a case aresuch that a layperson=s common knowledge and e/perience would enable a #uror toconclude, without hearing e/pert testimony, that a duty of care has been breached.

he #udge also informed the #ury that because &s. 3hin was unconscious at the time


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of the procedure, she was blameless in her own death and at least one of thedefendants clearly was at faultTshifting the entire burden of proof from the plaintito the defendants (that is, each defendant had to prove that he or she was not atfault.

he #ury awarded the plainti E*,+++,+++ in damages and found thedefendants liable in the following proportions< the physician, *+S> the e/periencedcirculating nurse, *KS> the ine/perienced circulating nurse, *+S> and the hospitalKS. he scrub nurse and the manufacturer were cleared of all liability.

2mmediately after the verdict, the trial #udge ruled in favor of the hospital=smotion that questioned the validity of applying the common-knowledge standard inthis case> the #udge reapportioned liability solely to the physician. 2n granting thehospital=s motion, the #udge said the application of the common-knowledgestandard had been an error. 7ut in the physician=s appeal, the appellate courtreversed the trial court=s decision and essentially restored the original #ury verdict,saying that each defendant had not entirely established the lack of fault in &s.3hin=s death and that the trial court had not erred in applying the common-knowledge standard.

3.Failure to assess and monitor and failure to communicate.

3hanges in the health status of a patient can be gradual or sudden andnurses are usually the %rst to see the changes and take action. ) nurse=s accuracyin assessing and monitoring and her timely reporting of changes in health status toa physician can often mean the dierence between life and death. Qital aspects ofcommunication besides timeliness in reporting the change include persistence innotifying the physician of the change, and accuracy in communicating the natureand degree of the change.

2n 7usta v. 3olumbus @ospital 3orporation (889, the &ontana !upreme3ourt aIrmed the #udgment and orders of the District 3ourt of the Gighth Hudicia

District.

Chile he was a postoperative patient at 3olumbus @ospital in Lreat "alls, &r7usta died from in#uries sustained in a fall from his third-oor window> apparently hehad tried to climb down on an improvised rope. )t trial, the nurse assigned to carefor &r. 7usta testi%ed that during her last evening visit with him, he hade/perienced an episode of tachycardia and hypertension. @e had also behavedatypically, desiring isolation and refusing all nursing care and his prescribedmedication, known to have adverse eects, including confusion, an/iety, andpsychosis. he nurse did not report the symptoms and the change in behavior tothe physician. !he also testi%ed that when she observed the patient at midnight, heappeared to be sleeping> she did not reassess his vital signs.

&r. 7usta=s surgeon testi%ed that, because of the mind-altering adverseeects of the patient=s medication, he would have reassessed his patient if he hadbeen noti%ed of the changing signs and symptoms. G/pert testimony opined thatthe nurse was negligent in failing to adequately monitor &r. 7usta on the eveningand night before he died, and in failing to report the constellation of signs andsymptoms to the surgeon> and that the hospital was negligent in failing to maintaina safe environment (evidence presented at trial showed that the hospital had notacted on a H3)@$ directive to restrict the opening of windows in patientsA rooms.


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he #ury found that the negligence of 3olumbus @ospital combined with thepatient=s contributory negligence caused the patient=s in#uries and death> the #uryapportioned +S of the liability to the hospital and +S to &r. 7usta. he #ury foundthat &r. 7usta and his estate were damaged in the amount of EK,+++ and his heirsEP++,+++. 7ased on the #ury=s apportioned liability, the district court entered a

#udgment in favor of &r. 7usta=s estate in the amount of E,K++ and in favor of hisheirs, of EK9+,+++.

4. Failure to document.

DocumentationTthe purpose of which is primarily to communicate patientinformation among providersTmust accurately reect the nursing process, showingevidence of nursing assessment and diagnosis, planning for nursing intervention,implementation and evaluation of planned interventions, and patient response.

he 3ourt of )ppeals of 1ouisiana, "ourth 3ircuit, aIrmed the trial court=sverdict in 4ellerin v. @umedicenters, a case concerning a failure to documennursing procedures. he plainti had alleged that an GD nurse administered anin#ection of meperidine (Demerol and hydro/y'ine pamoate (Qistaril in asubstandard manner, causing a lump at the in#ection site and continuous pain

which was later diagnosed by a neurologist as cutaneous gluteal neuropathy. @owthe in#ury actually occurred could not be proven at trial. &edical e/perts gaveconicting testimony regarding the cause of the patient=s nerve in#ury (either thehydro/y'ine pamoate or the needle could have caused it. Nurse e/perts opinedthat the failure to document the site and mode of in#ection fell short of the standardof care. )t trial, the defendant testi%ed that her customary practice was giving anintramuscular in#ection and that this practice met the standard of care. he #uryfound in favor of the plainti and awarded more than E8+,+++ in damages.

$n appeal, the defendants (the hospital and the nurse argued that evidencepresented at trial demonstrated that the nurse=s breach of the standard of carecould not have caused the patient=s in#ury. he appellate court disagreed, stating

that the nurse e/pertsA testimonyTinsuIcient by itself to support the #ury=sdecisionTdid support that decision when combined with the other evidencepresented at trial.

5.Failure to act as a patient advocate.

1egal and ethical issues often become entwined in health care settings, andnurses must be knowledgeable in both. *he )N)=s 3ode of Gthics for Nurses with2nterpretive !tatements provides nurses with a framework for ethical decisionmaking and de%nes the role of the nurse as patient advocate.

)ccording to $=Weefe in Nursing &alpractice and the 1aw, :4atient rights arethe hallmark for advocacy of nursing care. Nurses are compelled to strive fore/cellent care of patients and the inclusion of their rights in today=s health caresystem.;2t=s important to note that, as patient advocates, nurses may berequired to care for patients whose health care decisions conict with the nurse=sethical beliefs.

2n Woeniquer v. Gckrich (8PP, the !upreme 3ourt of !outh Dakota reversedand remanded for trial an order of summary #udgment in favor of Dakota &idland@ospital by the 3ircuit 3ourt of the "ifth Hudicial 3ircuit. Phe case involved thedeath of a patient, Cinnifred !coblic, as a result of sepsis, which was alleged to
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have developed when she was discharged with a fever some days after urinarytract surgery. he plainti, &s. Woeniquer, representing her mother=s estateinitiated a medical malpractice suit against two physicians and Dakota &idland@ospital, alleging deviation from the appropriate standards of care for a patient inpostoperative urology.

&s. !coblic=s surgery was performed on Hanuary K, 8P. @er temperatureuctuated during her postoperative hospital stay and was recorded as ++.*X" on

Hanuary 9 at P


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d 2f you found yourself in a comparable situation and weredirectly responsible for the patientAs care,how would you actJ

e 2f you were the nurse manager on duty, how would yourespondJ

Case (# Nurse>s negligence was grossl- apparent.

2n this case the plainti had #ust undergone some back surgery. he nursetaking care of the plainti had mistakenly reduced the amount of pain medicationadministered by the plaintiAs pain pump. 3onsequently the plainti e/perienced avery restless and disturbed night. he ne/t day, despite the plaintiAs adamantrequest to stay in bed because she needed to rest, and despite the physicianAsorders that the patient get up out of bed only if she could tolerate it, the nurseinsisted the plainti get up. he plainti pleaded with the nurse to let her stay inbed. @owever, the nurse told the plainti that she had to get up because the bedneeded to be made. he nurse then pulled the plainti by her arm into an uprightposition. he plainti continued to protest and started to cry that she wase/periencing tremendous pain and feeling faint. hereupon the nurse shoved theplainti into a straight backed chair.

he court found that the nurseAs actions in taking the plainti out of bedagainst her will despite the plaintiAs protestations of pain and fatigue, and contraryto the physicians written orders prohibiting such behavior, were so grossly negligentthat such conduct was a matter within the #udgment and comprehension olaypersons. his meant the court decided that the #urors would not need theassistance of an e/pert witness to reach the conclusion that the nurse had breachedthe standard of care because the nurseAs conduct was so egregious.

Case *# Negligence can ,e pre)ised upon a failure to act.

his was a malpractice case from !outh Dakota based on the negligence ofthe hospitalAs nursing sta. 2n this case the patient, who was suering fromincontinence, entered the hospital for corrective surgery. he patient remained inthe hospital for appro/imately si/ weeks following the operation. During hehospitali'ation the patient e/perienced a uctuating temperature. $n the morningof the day of her discharge her temperature was ++.* degrees "ahrenheit@owever, despite her high temperature, the patient was discharged.

he patient was readmitted to the hospital four days later complaining ofsevere abdominal pain and fever. !he was diagnosed at that time with sepsis, andtransferred to a Bniversity hospital. wo weeks after her transfer the patient died

he personal representative of the deceased patientAs estate initiated a malpracticesuit against the hospital.

2n court the e/pert witness testi%ed that in her opinion the hospitalAs nursing

sta failed to meet acceptable standards of nursing care for post-operativeurological patients by and0 "ailing to document that the condition of and drainage from the patientAsincision was reported to the physician.

2n her deposition the Director of Nursing con%rmed the e/pertAs assertion thatthe nurse has a duty to question the physicianAs order when there has been a


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signi%cant change in the patients condition. he court agreed that nurses shouldindependently evaluate a patientAs condition prior to release from hospital and alsoattempt to delay a patientAs release if their condition warrants continuedhospitali'ation. "urthermore, nurses should discuss their concerns with thephysician.

his case points out that nurses can not rest assured that following thephysicianAs orders will protect them from liability. oday, nurses are e/pected to usetheir #udgment based on their education, skill and e/perience and to communicatetheir concerns regarding patient welfare to the physician. he case also illustratesthe importance of documenting communications with the physicianF

Case 2# Failure to o,serve and co))unicate )a- ,e negligence.

2n this pivotal case, the plainti was a young male who broke his leg whileplaying in a college football game. @e was transported to the hospital emergencyroom where traction was applied and his leg was placed in a plaster cast.

he nurses had a duty to check the plaintiAs toes for changes in colortemperature, movement, sensitivity and circulation every ten to twenty minutes@owever the nurses did not check for circulation nearly as frequently as needed andin fact only performed these checks a few times a day. !hortly after the cast wasapplied the plainti complained of severe pain. @is toes became visibly swollen anddark in color.

Gventually his toes turned cold and became insensitive to the touch. 2f theplaintiAs toes had been checked for circulation as frequently as required theconditions that indicated a dangerous impairment of circulation would have beenrecogni'ed. "urthermore, the nurse should have known that time was of theessence because the condition would become irreversible within a matter of hours

he nurses had a duty not only to recogni'e the dangerous condition but also topromptly inform the physician so that medical attention could be obtained.

he plaintiAs cast was split open three days after it had been applied. $newitness in the room testi%ed there was a stench in the room that was worse thanany unpleasant smell he had e/perienced since Corld Car 22. 2t was medicallyimpossible to save the plaintis leg, and ultimately his leg had to be amputatedeight inches above the knee. he nurses failed in their duty to recogni'e andpromptly communicate dangerous conditions to the physician so that medical carecould have been obtained. he hospital was found liable for failing to have anadequate number of nurses specially trained to recogni'e the patientAs dangerouscondition and to communicate with the medical sta.

Case 4# +ut- to notif- ph-sician of i)portant changes in patient>scondition.

2n this case the plainti had a .cut-down. procedure into her right leg topermit intravenous infusion. "rom


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) nurse e/pert testi%ed that a nurse who observes swelling or other dangersigns in the area of a .cut-down. has a duty to notify the doctor in charge. )s aresult of this massive in%ltration the plainti suered necrosis of certain tissues inher leg. his necrosis would not have occurred if the plaintiAs leg had beencarefully observed after .cut-down. he hospital nurses failed in their duty toobserve the condition of the plaintiAs leg and promptly report all adversesymptoms to the attending physician.

Case ?# Incorrect ad)inistration of in@ection in@ures patient.

he plainti was admitted to the hospital for delivery of her second child.During laborand delivery the plainti was given several in#ections into her right buttock by thenurses. hree days after discharge the plainti started to complain of severe pain inher right hip. he pain was so severe that she was unable to walk. he plainti wasreadmitted to the hospital that day. $n admission her temperature was + degrees"ahrenheit. @er right buttock had a marked in duration and was tender to the touch

he plaintiAs fever responded to antibiotics and she was discharged once again@er discharge diagnosis was .acute peripheral neuritis, probably secondary toin#ections that she received in the right buttock during labor and postpartum..

he plainti continued to receive treatment after her discharge from thehospital. ) treating radiologist, orthopedist and neurosurgeon agreed the plaintiwas suering from spinal osteomyelitis due to an infection originating in the tissueof the right buttock and spreading to the bone and probable involvement of thesciatic nerve. he treating physicians further agreed that the in#ections given to theplainti by the nurses in the hospital most likely caused the infection and resultanosteomyelitis. he plainti %led a lawsuit and the physicians. %ndings werecon%rmed by e/pert opinion.

Case # Nurses have a dut- to protect their patient fro) danger.

2n this case the plainti sued to recover for personal in#uries he sustainedwhen his hospital bed caught on %re. he plainti who was paraly'ed was admittedto the hospital two days before the %re occurred. he plainti was a pipe smokerand his pipe and matches were in his room on a table near his bed. he nurse onduty was aware that the plainti was paraly'ed and that he could not remove thepipe from his mouth. Despite this knowledge and awareness, the nurse left theplainti unattended in the room with a K lit pipe in his mouth. he pipe fell fromthe plaintiAs mouth and started a %re in his bed.

)s a result the plainti was burned. Nurses have a duty to protect andsafeguard their patients from any known or reasonably apprehended danger. henurse in this case was found negligent for failing to protect her paraly'ed patientfrom the reasonably foreseeable %re ha'ard of a lit pipe.

Case B# Misuse of euip)ent results in nurse ,eing found negligent.

he plainti in this case was a seventy eight year old woman who washospitali'ed for pneumonia and vertigo. 7ecause of her weakened condition theplainti was restricted to bed e/cept for use of the bathroom. ) steam vapori'erwas left by the nurse in a location the plainti needed to pass in order to reach the


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bathroom. )s the plainti was returning to her bed after visiting the bathroom sheplaced her hand on the side of the bed to stabili'e herself. he side of her bed washot and burned her and this caused her to fall onto the vapori'er. he vapori'etoppled over and the plainti sustained further burns.

he nurse was found negligent for failing to safeguard and protect her patienfrom the foreseeable danger of the vapori'er. )s a result of negligence the elderlyplainti was badly burned.

Case D# +ut- to infor) ph-sician of change for the worse in patient>scondition

his case involved a patient who fell from his hospital bed following surgery$n the day of the incident a nurse heard a thump coming from the plaintiAs roomand found the plainti on the oor ne/t to his bed. he plainti stated he had triedto get out of bed and that he fell as he tried to get out through the foot of the bed.

he side rails of the bed were raised at the time of the fall. he plainti sustained afractured hip and required e/tensive hospitali'ation and convalescent care. )s aresult of the in#ury the plaintiAs ability to walk is limited.

he evening nurse had entered in the nursing record that the plainti hadbecome increasingly confused and had related her concerns to the night nurse@owever, the attending physician was not informed of the deterioration in thepatientAs condition. he nurse was found negligent for failing to advise theattending physician of a change for the worse in the patientAs condition, and that ifsuch noti%cation had been given further supervision would have prevented theplainti from falling out of bed.

Case E# !he nurse>s failure to act was negligence.

he plainti was admitted to the hospital to give birth to her third child. )appro/imately p.m. the plainti was taken to the delivery room where her childwas born. 4rior to the birth of her child the physician performed an episiotomy. hephysician did not suture the episiotomy but pelvic packs were inserted to controthe bleeding. 4rior to 8


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of nurses. he nurse was aware that the plainti was bleeding yet failed to observethe plaintiAs vital signs. "urthermore, the nurse did not notify the physician at+


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headache and inability to void. he nurse took a blood pressure reading again at


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Nursing & Healtcare !irectories on" #eNursefriendl$Nursing %alpractice ase 'tudies ($ !ate) 1**5+2,,1-

(. Ph-sician +is)isses Nursing Assess)ents PatientAl)ost Loses Li),.owe v. /isters of Pallottine Missionar-/ociet- *==( $L (?D?4?2 /.".*e $;

'ummar$: The patient was involved in a motorcycle accident in which his bike fellonto and injured his left leg. hen the nurses assessing the patient could not detecta pulse in that leg! an ominous sign of circulatory failure. The physician whennoti"ed chose to dismiss this fact and discharge the patient. The patient wouldreturn soon after with worsening symptoms that would require emergency surgery.

#hould the nurses have initially pressed for further action! treatmentJhttp


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) primary concern at that point to a nurse or physician should have beenimpaired circulation to the leg. 3ompromised circulation in any part of the body is amedical emergency which can lead to severe damage and the loss of a limb. henurses appropriately brought this to the attention of the physician who would alsoe/amine the patient.

2n the physicianAs e/amination, he noted the pain, swelling and tenderness inthe knee also noted by the nurses. @owever, he would document that he did %nd apulse in the leg, though with diIculty.

Chen questioned by the Nursing sta on why, even with the aid of theDoppler Bltrasound, they were unable to detect a pulse, no e/planation was oeredby the physician.

)s far as he was concerned, a pulse was present, the pain was due to a:severe sprain; and the patient could be discharged. @is instructions to the patientwere to go home, rest, elevate the leg, apply ice to keep the swelling down and tofollow-up with an $rthopedic 4hysician in a few days.

2t should be noted that the physician also reviewed an /-ray of the knee

which showed bone :fragments; in the knee area representing acute in#ury. Despitethis %nding, the patient was still discharged.

he Nursing sta made the patient aware that they had been unable todetect a pulse in the leg and e/plained that it :possibly; could be due to theswelling from the in#ury. hey instructed the patient to call or return to the hospitaif the pain got worse or did not begin to subside.

hat evening, the pain intensi%ed and the swelling got worse throughout thenight. he patient then contacted another physician who agreed to take a look athis leg. he patient would present in the morning to a dierent GmergencyDepartment.

$n e/amination at this hospital, a working diagnosis of a dislocated knee andlacerated popliteal artery was made. he severity of the damage to the patientAs legwas enough to prompt the physician to consider amputation. he patient wasfortunate in that there were e/perienced surgeons on hand to perform emergentsurgery and save his leg.

he patient would spend a total of thirty-%ve days in the hospital followingthe surgery and never fully regain function of his leg. @e would sue the hospitawhere he was initially treated and the physician who originally sent him homefollowing his in#ury

$n review of the case, the physicianAs side would settle out of court for a sumof E*K,+++. he lawsuit against the hospitalAs Nursing sta proceeded to court.

2t was claimed that the nurses, even though they picked up signsMsymptomsof a medical emergency in their assessments, did not do enough to see that thoseconcerns were addressed by the physician on duty. hey would argue that had thematter been pursued further, the patientAs true in#uries could have been diagnosedand treated earlier. Garlier treatment could have prevented the permanent damageand in#uries the patient would sustain due to a delay in treatment.


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he #ury trial would award the plainti EPP+,+++ due to the negligence of thehospitalAs Nursing sta. he hospital would appeal.

$uestions to be answered.

%. &id the Nursing sta' have a duty to accurately assess and detect the patient(sinjuries within their scope of practice.

). &id the Nursing sta' do enough to see that the signs*symptoms of the patient(spotential injuries were properly evaluated.

+. hen the physician dismissed their concerns! should they have gone over hishead,

here is no question that Gmergency Department nurses have a duty to fullyassess and accurately evaluate the condition and potential in#uries of patients intheir care. 2n this case, the lack of a pulse both by palpation and by DopplerBltrasound following a knee in#ury, should have been a ma#or :red ag; for vascularimpairment and cause for further evaluation.

he Nursing sta acted appropriately in that they e/tensively documentedwhat they found and reported it to the physician treating the patient. $n review ofthe medical chart, it is clear that the patient had a potentially emergent situationdeveloping. Chat is also clear, is that the physician chose not to address thesymptoms present, and that the nurses left the situation at that.

2t was clearly stated in the hospital policiesMprocedures that if a nursebelieved appropriate care was not being given to a patient, a hospital supervisormust be noti%ed. 2f on noti%cation the situation was not resolved, the ne/t in the:chain of command; must be made aware until the situation was resolved.

2n the same fashion, that a nurse has a duty to question an inappropriate

medication order, a nurse also has a duty to a patient to question a potential missedor incorrect diagnosis. here is a duty also to inquire as to why treatments andfurther evaluations may or may not be performed.

he lack of a pulse in an in#ured e/tremity is clearly a potential signMsymptomof vascular impairment and cause for alarm. Yet after the physician stated he :got apulse; the nurses left the decision to evaluate further in his hands, even though hecould not e/plain why they were not able to detect a pulse in their assessments.

2t can be argued that the ultimate course of action when treating any patientis up to the physician in charge to decide. 2f this had occurred in a clinic, doctor=soIce, or any other setting that argument might have been made successfully and agreater responsibility apportioned to the physician

@owever, the hospital Gmergency Department that the patient initiallypresented to had speci%c procedures that were to be initiated in cases like this. 7ynot following those policiesMprocedures, the nurses opened themselves and thefacility to liability in this case.


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*. "3travasation Follows Che)otherap- Ad)inistration.Potential Co)plication or Nursing Negligence#Iacano v. /t.Peters Medical Center 224 N. @. /uper. ?4B N8 &*==='

#ummary: -ntravenous therapy has inherent risks and potential complications.hen you introduce chemotherapeutic drugs and known vesicants! those risksincrease dramatically. -n this case! a known risk! etravasation! occurred followingadministration. The question arises! could the nurses have acted sooner to preventthe etravasation and resulting tissuedamage.http:**www.lope/%.com*lope/*clinical.cases*010%+0.htm

he patient was an $ncology patient being treated as an outpatient for non@odgkinAs lymphoma, a cancer of the lymphatic system. $n a regular basis (everythird "riday, she would come in for her treatments. @er 3hemotherapeutic regimenconsisted of four dierent drugs, three of them given intravenously. he 2Q drugswere 3ytoto/an, $ncovin, and )driamycin.

$ncovin and )driamycin are known vesicants (chemicals which can causetissue damage and destruction if they leak into surrounding tissues and typicallyadministered via :2Q 4ush; meaning they are in#ected directly into the bloodstreamthrough an 2Q access device. 2t is critical that the patient be monitored fosignsMsymptoms of adverse reactions or complications during and after this type ofadministration.

:G/travasation of chemotherapeutic vesicant agents can result in signi%canttissue damage, alteration in limb function, and pain. Ruality of life for long-termsurvivors can be severely impacted by negative sequelae from vesicante/travasation. 3urrently, there is no known preventive therapy. Garly detection and

intervention are paramount to halt tissue damage and reduce the chance opermanent disability or dis%gurement.;*

$n this day, the patient was accompanied by a friend who witnessed hetreatment. !he would attest to the patientAs account of administration of themedications and complaints of discomfort soon afterwards. !he would state that thenurses on duty had been informed of this discomfort not once but twice but didnothing. 6eports of a red, swollen and puy hand appearance were allegedly madeto the nurse with no action taken.

he patient was initially given 3ytoto/an (not a vesicant through a periphera2Q line in her right hand. !hortly after the infusion began, the patient would begin

her complaints of discomfort in that hand.

he patient would state that even after describing her hand discomfort, thenurse in#ected the vesicant medications into the right hand 2Q site.

he nurse would later state that she got :good blood return; from the siteand did not recall any complaints of pain by the patient. No nurseAs notes wereavailable to collaborate her testimony.

!oon after administration of the vesicants, there were further complaints ofpain, and new complaints of :burning.; )n e/travasation was then reported to the
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physician. $rders were obtained to discontinue the 2Q in that hand and treat thee/travasation with cold compresses. )pparently, it was not until the patienreported a :burning; sensation that the nurse took notice and took action on thepatientAs concerns.

:Chat is G/travasationJ he leakage of intravenous drugs from the vein intothe surrounding tissue.( G/travasation in#ury usually refers to the damage causedby leakage of solutions from the vein to the surrounding tissue spaces duringintravenous administration. $nce an e/travasation has occurred, damage cancontinue for months and involve nerves, tendons and #oints. 2f treatment is delayedsurgical debridement, skin grafting, and even amputation may be the unfortunateconsequences.;

2t is important to note that despite the patientAs complaints of pain, andwitness reports, despite the documented report of an e/travasation and resultingphysician orders to deal with it, despite the restarting of the 2Q to continue therapyno mention of these events was available in the nursing portion of the chart when itwas reviewed after the fact.

he patient would need an $rthopedic consult to deal with the e/tensive

damage caused by the e/travasation. Debridement and tissue repair would leavepermanent scarring and irreversible damage.

he patient sued the Nursing sta on duty that day for negligence. he courtsreturned an award of .K &illion dollars. his would later be ruled e/cessive andreduced to +.K &illion dollars.

he defense appealed for a new trial based on the e/cessive award initially granted.


%. ho was responsible for monitoring the patient for potential complications! and

was this monitoring carried out within acceptable standards of care,

). #pecial precautions*monitoring must be in place when administering vesicantmedications. ere the nurses negligent in their duty to monitor for complications ofchemotherapy,

+. as the patient in fact having pain and discomfort well before the administrationof the vesicants, -f so! was the nurse in error! to administer the medication despitethe patients concerns and complaints,

1. as there appropriate documentation to support either the nurses or thepatient(s account of the situation.

2. 3ould the etravasation and resulting tissue damage have been prevented,

4. &id the jury in the initial trial award an ecessive amount based on 5awedinformation in the initial trial.

he two nurses on duty were clearly responsible for monitoring this patien(and all the other patients in the oIce as well. 2t is recogni'ed that the greatestresponsibility would fall on the nurse who was administering the vesicant-typemedications. 7efore administering any medication into an 2Q site, it must beassessed for signsMsymptoms of irritation, patency and proper placement.


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2t would seem incredible, that a patientAs complaints of %rst discomfort, painand then burning would not be investigated by the nurses on duty. hese areobvious signsMsymptoms of potential vesicant complications. Due to the lack odocumentation, this is what we must assume happened.

$f the two nurses on duty, at least one of them would have been made awareand had the responsibility to notify both the other nurse and the physician whenappropriate. 2n light of the fact that an e/travasation did occur and resulted in tissuedamage, a case for negligence in the monitoring of this patient is established.

2t can be argued that the :prudent nurse; when made aware of a patientAsdiscomfort, would have either slowed or stopped the intravenous infusion andchecked the site before proceeding. Cith the patientAs companion echoingcomplaints of both pain and a :puy, red; appearance, that 2Q site should havebeen discontinued immediately.

2t is unfortunate that no nurses notes were available to give the nursesA sideof the story. 2t can only be assumed that there was in fact a problem with the site(based on the later reported e/travasation and tissue in#ury.

?Gach state has enacted a nurse practice act that authori'es an individual topractice as a registered nurse if the applicant meets speci%c criteria. 1aws oradministrative rules in each state further outline documentation issues, such ashandling of records, falsi%cation of records and con%dentiality.9 6egardless of yourwork setting or nursing specialty, you must document care based upon therequirements of your stateAs nurse practice act. "or information on your stateAsnurse practice act, contact the National 3ouncil of !tate 7oards of Nursing atwww.ncsbn.org.;0

here is an inherent duty which a nurse (like a physician owes to a patienwhich is to do no harm, and protect them from foreseeable complications. 2n thiscase, when the nurse in#ected the vesicants into an 2Q site that had already been

reported as :causing discomfort,; that duty was clearly not adhered to. @ertestimony later that she had :good blood return; from the site was clearly aninadequate assessment.

he presence or absent of :blood return; is not a reliable indicator of anintravenous lineAs proper placement or appropriate location.

)gain, it would seem incredible that a nurse would in#ect vesicants, chemicalsknown to damage tissue and cause signi%cant complications, into an alreadyproblematic intravenous site. Due to the lack of documentation in the medicarecord, we must assume this is what took place based on the end results.

2f in fact the patient was complaining of discomfort from the site, then thevesicants should never have been in#ected. 2t is dictated by standards of care thatthe e/isting site be discontinued and treatment initiated if warranted by nursing

#udgment or physicianAs orders, another intravenous site be initiated and themedications placed in an alternate location. 2f no other location was available, oraccessible a call would need to be placed to the physician for further orders.

#ummary: -n the end! the appeals court would "nd that even though theinitial award was ecessive! it was not based on an error or misinterpretation offact. The request for a new trial was denied and the 6200!000 award for thenegligence on the part of the nurses was upheld.


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2. Patient Falls $hile A),ulating Post0op Negligence orMedical Malpractice# Mc1ee v. HCA Health /ervices of!ennessee Inc. *=== $L (?22=== /o.*d !N

#ummary: 7ne of the most important interventions post8operatively is to get apatient up and walking. -t minimi/es chances of complications such as &9T!neumonia! ulmonary ;mboli and &ecubitus


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the two is in the severity of alleged negligence, potential for damages and theburden of proof. his makes the distinction critical.

he nurse would testify in her depositions, and the medical records in thechart would show, that she had assessed the patient prior to getting her up. o thebest of her knowledge, she saw no reason not to ambulate the patient. !he hadmade the attempt to carry out the doctor=s orders following the applicablestandards of care.

2n preparing the case, the family would argue that because the case was %ledfor :simple negligence; and not :medical malpractice,; the testimony of an e/pertwitness was not required to prove their case.

7ecause of how the suit was %led, the hospital %led for summary #udgment tohave the case dismissed. he hospital argued that their was, based on the facts andcircumstances, no convincing argument of :simple negligence to be made. hecourt agreed and dismissed the actionedical>alpractice@ suit! vs @#imple Negligence!@ it may in fact have proceeded to court.The plainti' could have found an epert witness to testify that some applicablestandards of care ?not obvious to a layperson@ may not have been followed.


4. Clinical Nursing Malpractice Case Studies, January 29, 2002Coleman v. East Jefferson eneral !osp., "4" So.2d #044$ %&'#999(

anuary )=! )00): Nurse #ued Bor CToo >any #ticksC Dow >any Attempts -s Too>any,:C#tarting -ntravenous Eines and erforming 9enipunctures are basic nursingskills in the Acute 3are or Dospital settings. -n this case! a female patient wouldaccuse a male nurse of negligence and causing a resulting injury when he neededthree attempts to successfully start an intravenous catheter.

?http


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) male nurse was assigned to the patient when the 2ntravenous 3atheter wasto be placed. he nurse was having diIculty %nding veins in the womanAs arms. @ethen attempted twice to start a line in her hand and was successful on the thirdattempt.

2t was the policy of the hospital at that time, that a nurse may attempt anintravenous catheter insertion no more than two times before calling for assistance.

"or the remainder of the patientAs treatment at the hospital, it would bedocumented that the patient complained of discomfort at the 2Q site and tolerated itpoorly.

4ain or discomfort at the site of an 2Q insertion should present a :red ag; toan e/perienced nurse.

Chen combined with redness, swelling, puss or e/udates at an 2Q site, paincan signal one of many potential complications of 2ntravenous herapy includinge/travasation of 2Q uidsMmedication, infection of the site or a dislodging of thecatheter.

Chen pain or potential complications are reported, the site should bethoroughly evaluated for signs of a problem. 2f symptoms persist, the placement ofanother line at an alternate site should be oered for continued 2ntravenous

herapy.

here was no indication in the hospital record, that other signsMsymptoms of acomplication e/isted other than the painMdiscomfort. his may have been positionadue to the location of the 2Q site in the patientAs hand.

here was no indication that placement of another line was either oered toor refused by the patient.

:Chen an 2.Q. lawsuit is argued in court, top-notch 2.Q. skills don=t mean muchunless they=re backed up by appropriate, accurate, and concise documentationBnfortunately, documentation is where many nurses fall short.;

"ollowing her discharge, the patient would %le a suit alleging negligence onthe part of the nurse and hospital. !peci%cally, she claimed a poorly performedcatheter insertion caused her to develop 6ee/ !ympathetic Dystrophy in her righthand.

:Chat is 6ee/ !ympathetic Dystrophy !yndromeJ

6ee/ sympathetic dystrophy syndrome (6!D! is a chronic conditioncharacteri'ed by severe burning pain, pathological changes in bone and skine/cessive sweating, tissue swelling, and e/treme sensitivity to touch. he syndromeis a nerve disorder that occurs at the site of an in#ury (most often to the arms orlegs. 2t occurs especially after in#uries from high-velocity impacts such as thosefrom bullets or shrapnel. @owever, it may occur without apparent in#ury.;

!ummary #udgment was entered for the hospital %nding that no negligencewas evident.

he patient appealed.


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$uestions to be answered:

%. as the nurse negligent in his catheter insertion technique, ere certi"cationsand hospital policies*procedures adhered to,

). ere standards of care! speci"c to -ntravenous 3atheter -nsertions adhered to.

+. as it plausible! that the patient(s ?Re5e #ympathetic &ystrophy@ may have

resulted from the multiple catheter insertion attempts that day,

$n review of the chart and following e/pert testimony, no de%ciencies intechnique could be found in the placement of the catheter. 7y his employmentrecord and training, he was fully quali%ed to place intravenous catheters as a part ofhis scope of practice as a licensed nurse.

2t was noted that the hospitalAs standards, allowed for a ma/imum of twoattempts before calling for assistance. he nurse in question, attempted threetimes.

$n further review, the :community; standards, which was the measure used

for this case, allowed four insertion attempts. 7y this standard of care, the nursewas within reasonable limits by trying three times.

G/pert estimony addressed the issue of :causation; of the patientAs :6ee/!ympathetic Dystrophy.;

2n statements made, no direct causative link could be established betweenthe starting of an intravenous catheter, and a diagnosis of 6ee/ !ympatheticDystrophy.

)t best, the plaintiAs e/pert stated that it was a slim possibility, that a linkcould be made. he physician oered no support to the claim that the plaintiAsalleged in#uries were caused by the catheter insertion.

The appeals court aFrmed the judgment of the lower court.

-t should be noted that -ntravenous Therapy! while a basic part of nursing practice!is etremely prone to complications and resulting malpractice G negligence actions.


?.Pathologic Fracture or Patient In@ured in Fall$oodha) v. "l-ria Me)orial Hospital *==( $L B?2*DN.".*d 5hio/epte),er 4 *==( Pathologic Fracture orPatient In@ured in Fall


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#ummary: The patient in this case had an etensive 7ncologic history includingmultiple metastases and a predisposition to pathological fractures. hen the

patient fell while transferring a wheelchair! the cause of the broken hip found afterthe fall was put intoquestion.http


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he nurse on duty that day was assisting the patient from her bed to awheelchair for her discharge from the hospital. Chen the patient got up withassistance the nurse brought her to a standing position. Chile the nurse reachedover to lock the wheelchair, the patient fell to the ground.

$n e/amination following the patient=s fall, a fractured hip would bediscovered. $n review of the radiological evidence and the clinical presentation ofthe patient, it was unclear if the fall caused the fracture, or a pathological fracturecaused the fall.

he patient would soon die from her disease. @er estate administrator choseto sue for damages related to the fall.

he court would rule that there was no clear evidence that the fractured hipwas caused by the fall. ) directed verdict was given in favor of the nurse andhospital.

he estate administrator would appeal.

$uestions to be answered:

%. 3ould it be clearly determined that either the fall caused the fracture! or that thefractured caused the fall.

). as the Nurse or her actions*inactions the proimate cause of the patientHs fall orthe hip fracture.

+. as the lower court in error in itHs directed verdict.

G/pert testimony would opine that it was impossible to tell whether thefracture was caused by the fall or if the hip had fractured spontaneously andprecipitated the fall. he orthopedic surgeon giving the testimony clearly stated thatpatients at risk for pathologic fracture are notoriously diIcult to identify.

?1ytic bone metastases must be greater than cm and have destroyed +-K+S of the bone density in order to be seen by /-ray. 2t is also diIcult to distinguishbetween metastases and benign lesions such as 4aget=s disease or osteoporosis onplain %lm. $n bone scan, radiolabeled bisphosphonates are taken up by in areas ofbone formation but not by the tumor cells. 3 is more speci%c than bone scan andcan distinguish between osteolytic and osteoblastic lesions. &62 is the mostsensitive method of detection bone metastases because cells can spotted beforelocal bone reaction has occurred.?

he role of the nurse was closely e/amined to determine if a case could bemade for a ruling under 6espondeat !uperior. Bnder this doctrine, an employer isresponsible for the negligent acts of its employees.

o make this case, the plainti would have had to prove via e/pert witnesstestimony that the nurse was e/plicitly the cause of the patient=s in#uries.


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!ince the true cause of the fracture was never clearly identi%ed, the nurse=srole in the situation was not a pivotal factor.

$n appeal, the evidence oered was re-e/amined. 2t was clear to the appealscourt that the burden of proof was clearly insuIcient to make a case for theplainti.

Bor the plainti'Hs case to be successful! it would have needed to be proven

conclusively! that the nurse caused the patientHs injuries. The best the plainti'Hsepert testimony could o'er was a ?maybe@ that the nurse was responsible.

This was not enough to sway the appeals court. The verdict was aFrmed.


.!rau)a Patient In /hoc And In +ecline " Ph-sician+oes Not !ransfer5cto,er ** *===#

#ummary: hen a patient from a trauma scene arrives at the hospital! initialassessments and evaluations are critical. -n this case! a patient involved in a >otor9ehicle Accident was brought in with symptoms indicative of #hock. 7n evaluationthe decision was made to treat the patient on site. The patient then would die soonafter admission. #hould the ;R physician have transferred her,

http:**www.lope/%.com*lope/*clinical.cases*)000*%0))00.htm

he female patient was transported to the hospital via ambulance following amotor vehicle accident.

?&otor vehicles accidents account for more deaths than all natural disasterscombined. 2n fact in the Bnited !tates your chances of being in#ured in an motovehicle accident is better than one in a thousand, in any one year. 2f you are a malethan you are twice as likely to die in a motor vehicle accident than if you are afemale. Yet, if you are a female you are slightly more likely to be in#ured. he agesof 9 and *0 are the most dangerous for both se/es.?*

he facility she was brought to was a 6ural @ospital and not well equipped todeal with trauma emergencies. he attending G6 physician was a second yea4ediatric resident, perhaps not the most desirable candidate to handle this type ofpatient.

@er initial physical symptoms of coldMclammy skin and falling blood pressure8KMKK on arrival were later opined to be highly indicative of shock.

?!hock is caused by any condition that dangerously reduces blood owincluding heart problems (such as acute &2 or heart failure , changes in bloodvessels, changes in blood volume, and in#uries. 6elated factors include bleeding vomiting , diarrhea , inadequate uid intake ( uid imbalance , and kidneydisorders. ypes of shock include anaphylactic shock (caused by allergic reaction
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bacteremia or septic shock (associated with infections, cardiogenic shock(associated with heart disorders, diabetic shock ( diabetic hyperglycemichyperosmolar coma , electric shock , hypovolemic shock (caused by inadequateblood volume, and neurogenic shock (caused by damage to the nervous system.

!hock is a life-threatening condition that requires immediate medicatreatment. !ome degree of shock can accompany any medical emergency. !hockcan get worse very rapidly. 7e prepared to begin rescue breathing or 346 asneeded.?

he attending physician ordered intravenous uids at a rate of *++Mcc pehour, [-rays were ordered and performed and attempts to stabili'e the patientinitiated.

Despite the eorts of the G6 4hysician and Nursing !ta, the patient wouldcode three hours following her admission, attempts to resuscitate the patient werenot successful.

)n autopsy on the patientAs body identi%ed ?reatable !hock? as the mostlikely cause of death. he family would bring suit against the driver of the other

vehicle involved, the G6 physician and the @ospitalMNursing !ta.

he court found for the plainti and ruled that the attending physician wasnot, in fact quali%ed to treat a patient in the condition the patient had been in.

) ruling was handed down and responsibility assigned at +S to thephysician and 8+S to the @ospitalMNursing !ta. )n award of E8++,+++ was reducedto EK++,+++ pursuant to a statutory cap.

he hospital would appeal.


%. as the initial assessment of the patient accurate and was the testingperformed adequate to identify the patient(s condition, Iased on thepresentation of the patient were adequate measures initiated by the ;Rhysician.

). as the attending ;R physician! a second year ediatric Resident! medicallyquali"ed to assess and treat a patient in the condition of the young womanwho presented that day.

+. as the facility adequately sta'ed and equipped to handle a Trauma;mergency on site! or should arrangements have been made to transfer to amore suitable facility for that purpose.

1. as there another facility within a reasonable distance to for the patient tobe transferred to,

2. as the patient stable enough to be transferred had another facility beenwithin a reasonable distance.

4. as the treatment the patient received delivered in a timely and responsiblefashion, ere there delays or negligence on the part of the Dospital*Nursing#ta'.


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G/pert witnesess testifying at the trial would e/amine the documentationincluding initial assessments by both the &edicalMNursing sta and the test resultsfrom the labsM/-ray performed.

hey stated that the initial presentation of the woman was strongly indicative ofshock and would require treatment that the 6ural facility simply was not equippedto oer. Bpon completion of the initial assessments, immediate arrangements fortransfer to a rauma 3enter would have been #usti%ed and prudent.

he evidence to #ustify the patientAs transfer was overwhelming when e/aminedby an Gmergency &edicine 4hysicianMG/pert Citness.

2t was then revealed that the hospital had no policies or procedures in place fortransfers to larger facilities.

rauma patients such as the young woman in question were not frequentcommon or e/pected at this facility.

he decision to transfer the patient would have been based on the patientAspresentation which was strongly indicative of a trauma case the physicianMfacility

could not safely handle.

he decision to transfer the patient was laid squarely in the lap of the attendingphysician who did not give the order.

estimony and documentation from the chart would reveal that the nursing stadiscussed transferring the patient with the physician at the time. he nursing stain addition to the symptomatology indicating shock, told the physician the patienhad active vaginal bleeding of unknown origin.

he e/pert testimony both NursingM4hysician indicated that the decision totransfer was for the physician to make.

2t should be noted here that a healthcare or medical professional owes a clearlyde%ned duty to the patients they accept into their responsibility. !tandards of 3aredictate the level of services that will be provided.

his is clearly de%ned in Nurse 4ractice )cts and &edical 1icensure guidelines.

2f, as in this case, safe and competent care cannot be given, that duty mandatesthat care of the patient be transferred to a more quali%ed practitioner or facility thatcan give adequate care.

2f this is not done, the applicable standards of care are then breached andpossible claims of negligence may result.

2f the physician in this situation would not arrange for the transfer of the patientit was the responsibility of the @ospitalMNursing !ta to inform the on dutysupervisors and administrators of the situation.

@ad this been done, and had the record shown that the)dministrativeMNursingM@ospital sta were aware and recommended that the patien


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be transferred, the assignment of responsibility would have shifted from the hospitato the individual physician.

Iased on the testimony of the Nursing sta' documenting the need for transferand it(s discussion of same with the physician! the appeals court shiftedresponsibility from =0J of hospital to K2J and increased the physician(s liabilityfrom %0J to )2J based on the evidence.


$ctober K, *+++< 4hysician 6estraint $rders Bnclear $n ransfer, Do You )pply 2nhe 2nterimJ!ummary< he use of &echanical or 4hysical 6estraints on confused patients ishighly controversial. Due to substantial Death 2n#ury attributed to their use theyare considered a last resort measure in providing for the safety of a patient. 2n thiscase, orders specifying what restraints and when they were to be used wereunclear. 2n a patient that was clearly at high risk for in#ury, should they have beenapplied till the physician could have been contactedJ

ousignant v. !t. 1ouis 3ounty, 9+* N.C.*d PP* - &N (888http


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a new graduate might be e/pected to work in. $nce in the %eld, it is e/pected thatadditional and speci%c training to a Department or !pecialty will be obtained. 2n thiscase, the 4sychiatric nurses did not pick up on a festering infection in a patient thathad tried to commit suicide. Cas the fact that they were 4sychiatric nurses a valide/cuseJ1atshaw v. &. 3armel @ospital, K ". !upp. W1 - (888http


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)lt v. Hohn Bmstead hospital 08 !.G. *d P++http


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)ugust K, 888< Qiolent 4sychiatric 4atient )ttacks Nurse,No 1egal 6ecourse )gainst "acility or 4sychiatristJ3harleston v. 1arson, 989 N.G. *d 8 5 21 88P!ummary< 2t would seem absurd, that if a physician admits and facility assigns anurse to care for a known violent patient, that it has no legal obligation to protectthat nurse against violence. 2n this case, a psychiatric patientsought admission tofacility. $n admission, he threatened to attack a nurse. Chen the patient wouldfollow through on his threat, the nurse was denied legal recourse against thepsychiatrist who could have taken precautions against the attackhttp


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Huly P, 888< Lood !amaritan 1aws )cts. Do hey 3over Nurses QolunteeringNursing 3are Chen ) 3iti'en Loes )naphylactic.?$-duty? healthcare professionals renderingGmergency aid are in most cases?covered? by the Lood !amaritan )cts. hese are laws enacted in each state thaprovide some degree of immunity from liability for good faith eorts in givingemergency care. 2n this case, a nurse and physician were sued for providingassistance in a volunteer function at a ?%rst-aid? station. Lood !amaritan?immunity? was not recogni'ed by the courts7occasile v. 3a#un &usic 1td. 980 ) *d 9P9 - 62 (88http


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child=s corneas had been harvested and it was too late.)ndrews v. )labama Gye 7ank, * !. *d 9* 5)1 (888http


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Rules of the Board of Regents, Part 29, Unprofessional Conduct,Effective November 23, 2! ,'ince 1*1/ te (oard of 0egents andte New or 'tate ducation !epartment ave overseen te

preparation/ licensure/ and practice of te professions.

*8.* Leneral provisions for health professions.

a. Bnprofessional conduct shall also include, in the professions of< acupuncture

athletic training, audiology, certi%ed dental assisting, chiropractic, dentahygiene, dentistry, dieteticsMnutrition, licensed practical nursing, massagetherapy, medicine, midwifery, occupational therapy, ophthalmic dispensingoptometry, pharmacy, physical therapist assistant, physical therapyphysician assistant, podiatry, psychology, registered professional nursingrespiratory therapy, respiratory therapy technician, social work, specialistassistant, occupational therapy assistant, speech-language pathology, e/cepfor cases involving those professions licensed, certi%ed or registered pursuantto the provisions of )rticle or -7 of the Gducation 1aw in which astatement of charges of professional misconduct was not served on or before

Huly *9, 88, the eective date of 3hapter 9+9 of the 1aws of 88

*. willfully harassing, abusing or intimidating a patient either physically overbally>

. failing to maintain a record for each patient which accurately reectsthe evaluation and treatment of the patient. Bnless otherwise providedby law, all patient records must be retained for at least si/ years$bstetrical records and records of minor patients must be retained for

at least si/ years, and until one year after the minor patient reachesthe age of * years>

0. using the word ?Doctor? in oering to perform professional serviceswithout also indicating the profession in which the licensee holds adoctorate>

K. failing to e/ercise appropriate supervision over persons who areauthori'ed to practice only under the supervision of the licensedprofessional>

9. guaranteeing that satisfaction or a cure will result from theperformance of professional services>

. ordering of e/cessive tests, treatment, or use of treatment facilities notwarranted by the condition of the patient>

P. claiming or using any secret or special method of treatment which thelicensee refuses to divulge to the !tate 7oard for the profession>

8. failing to wear an identifying badge, which shall be conspicuouslydisplayed and legible, indicating the practitioner=s name andprofessional title authori'ed pursuant to the Gducation 1aw, whilepracticing as an employee or operator of a hospital, clinic, grouppractice or multiprofessional facility, registered pharmacy, or at acommercial establishment oering health services to the public>

+.entering into an arrangement or agreement with a pharmacy for thecompounding andMor dispensing of coded or specially markedprescriptions>


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.with respect to all professional practices conducted under an assumedname, other than facilities licensed pursuant to )rticle *P of the 4ublic@ealth 1aw or )rticle of the &ental @ygiene 1aw, failing to postconspicuously at the site of such practice the names and the licensure%eld of all of the principal professional licensees engaged in practice atthat site (i.e., principal partners, oIcers or principal shareholders>

*.issuing prescriptions for drugs and devices which do not contain thefollowing information< the date written, the prescriber=s name, addresstelephone number, profession and registration number, the patient=sname, address and age, the name, strength and quantity of theprescribed drug or device, as well as the directions for use by thepatient. 2n addition, all prescriptions for controlled substances shalmeet the requirements of )rticle of the 4ublic @ealth 1aw> and

.failing to use scienti%cally accepted infection prevention techniquesappropriate to each profession for the cleaning and sterili'ation odisinfection of instruments, devices, materials and work surfacesutili'ation of protective garb, use of covers for contamination-proneequipment and the handling of sharp instruments. !uch techniquesshall include but not be limited to

ii. discarding gloves used following treatment of a patient andchanging to new gloves if torn or damaged during treatment of apatient> washing hands and donning new gloves prior toperforming services for another patient> and washing hands andother skin surfaces immediately if contaminated with blood orother body uids>

iii. wearing of appropriate masks, gowns or aprons, and protectiveeyewear or chin-length plastic face shields whenever splashingor spattering of blood or other body uids is likely to occur>

iv. sterili'ing equipment and devices that enter the patient=svascular system or other normally sterile areas of the body>

v. sterili'ing equipment and devices that touch intact mucousmembranes but do not penetrate the patient=s body or usinghigh-level disinfection for equipment and devices which cannobe sterili'ed prior to use for a patient>

vi. using appropriate agents, including but not limited to detergentsfor cleaning all equipment and devices prior a sterili'ation ordisinfection>

vii. cleaning, by the use of appropriate agents, including but nolimited to detergents, equipment and devices which do no

touch the patient or that only touch the intact skin of thepatient>viii. maintaining equipment and devices used for sterili'ation

according to the manufacturer=s instructions>i/. adequately monitoring the performance of all personnel

licensed or unlicensed, for whom the licensee is responsibleregarding infection control techniques>

/. placing disposable used syringes, needles, scalpel blades, andother sharp instruments in appropriate puncture-resistancontainers for disposal> and placing reusable needles, scalpeblades, and other sharp instruments in appropriate punctureresistant containers until appropriately cleaned and sterili'ed>


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PHILIPPIN" N7/ING LA$

"P71LIC AC! N5. E(B2

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Ie it enacted by the #enate and house of representative of the hilippines in3ongress assembled.

A!ICL" I!I!L"

!ection . Title.5 his )ct shall be known as the :4hilippine Nursing )ct of *++*;

A!ICL" II+"CLAA!I5N 5F P5LIC

!ec. * &eclaration of olicy.5 2t is hereby declared the policy of !tate to assumeresponsibility for the protection and improvement of the nursing profession byinstituting measures that will result in relevant nursing education, humane workingcondition, better career prospects and digni%ed e/istence for our nurses. he !tate


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hereby guarantees the delivery of quality basic health services through an adequatenursing personnel system throughout the country.

A!ICL" III5GANIJA!I5N 5F !H" 15A+ 5F N7/ING

!ec. &eclaration and 3omposition of the board. 5 here shall be created a4rofessional 6egulatory 7oard of Nursing, hereinafter referred to as the 7oard, to be

composed of a 3hairperson and si/ (9 members. hey shall be appointed by the4resident of the 6epublic of the 4hilippines from among two (* recommendees, pervacancy, of the 4rofessional 6egulation 3ommission, chosen and ranked from a listof three ( nominees, per vacancy, of the accredited professional organi'ation ofnurses in the 4hilippines who possess the quali%cation prescribed in !ection 0 othis )ct.

!ec. 0 $uali"cation of the 3hairperson and >embers of the Ioard.5 hechairperson and &embers of the board shall, at the time of their appointment,possess the following quali%cation

. 7e a registered nurses and holder of a masterAs degree in nursing, educationor other allied medical profession conferred by a college or university dulyrecogni'ed by the Lovernment 4rovided, hat the ma#ority of the &embers ofthe 7oard shall be holders of degree in nursing. 4rovided, further, hat the3hairperson shall be a holder of a masterAs degree in nursing>

0. @ave at least ten (+ years of continuous practice of profession prior toappointment< 4rovided, however, hat the last %ve (K years of which shall bein the 4hilippines> and

K. Not have been convicted of any oense involving moral turpitude>

rovided!hat the membership to the 7oard shall represent the three ( areas ofnursing, namely< nursing education, nursing services and community health nursing

!ec. KRequirements


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he incumbent 3hairperson and &embers of the 7oard shall continue to serve fothe remainder of their term under 6epublic )ct No. 90 until their replacementshave been appointed by the 4resident and shall have been duly quali%ed.

!ec. . 3ompensation of Ioard >embers.5 he 3hairperson and &embers of theshall receive compensation and allowances received by the 3hairperson andmembers of the professional regulatory boards.

!ec. P. Administrative #upervision of the Ioard! 3ustodian of its Records!#ecretariat and #upport #ervices.5 he 7oard shall be under the administrativesupervision of the 3ommission. )ll records of the 7oard, including applications fore/aminations, administrative and other investigative cases conducted by the 7oardshall be under the custody of the 3ommission. he 3ommission shall designate thesecretary of the 7oard and shall provide the secretariat and other support servicesto implement the provision of this )ct.

!ec. 8. owers and &uties of the Ioard.5 he 7oard shall supervise and regulate thepractice of the nursing profession and shall have the following powers, duties andfunctions>

. 3onduct the licensure e/amination for nurses>*. 2ssue, suspend or revoke certi%cates of registration for the practice of

nursing>. &onitor and enforce quality standards of nursing practice in the 4hilippines

and e/ercise the powers necessary to ensure the maintenance of eIcient,ethical and technical, moral and professional standards in the practice ofnursing taking into account the health needs of the nation>

0. Gnsure quality nursing education by e/amining the prescribed facilities ofuniversities or colleges of nursing education and those seeking permission toopen nursing courses to ensure that standards of nursing education areproperly complied with and maintained at all times. he authority to openand close colleges of nursing andMor nursing education programs shall be

vested on the 3ommission on @igher Gducation upon the writtenrecommendation of the 7oard>

K. 3onduct hearings and investigations to resolved complaints against nursepractitioners for unethical and unprofessional conduct and violations of this)ct, or its rules and regulations and in connection therewith, issue subpoenaad testi%candum and subpoena duces tecum to secure the appearance ofrespondents and witnesses and production of documents and punish withcontempt persons obstruction, impending andMor otherwise interfering withthe conduct of such proceedings, upon application with the court>

9. 4romulgate a 3ode of Gthics in coordination and consultations with theaccredited professionals organi'ations of nurses within one ( year from theaectivity of this )ct>

. 6ecogni'e nursing specialty organi'ations in coordination with the accreditedprofessional organi'ation> and

P. 4rescribe, adopt, issue and promulgate guidelines, regulations, measures anddecisions as my be necessary for the improvement of the nursing practice,advancement of the profession and for the proper and full enforcement of this)ct sub#ect to the review and approval by 3ommission.

!ec. +Annual Report.!5 he 7oard shall at the close of its calendar year submit anannual report to the 4resident of the 4hilippines through the 3ommission giving adetailed account of its proceedings and the accomplishments during the year and


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making recommendation for the adoptions of measures that will upgrade andimproved the condition aecting the practice of the nursing profession.

!ec. .Removal or #uspension of Ioard >embers.- he 4resident may removed orsuspend any members of the 7oard after having been given the opportunity todefend himselfMherself in a proper administrative investigation, on the followinggrounds>

. 3ontinued neglect of duty or incompetence>*. 3ommission or toleration of irregularities in the licensure e/amination> and. Bnprofessional, immoral or dishonorable conduct.

A!ICL" I;"KAMINA!I5N AN+ "GI/!A!I5N

!ec. *.Eicensure ;amination.5 )ll applicants for license to practice nursing shalbe required to pass a written e/amination, which shall be given by the 7oard in suchplaces and dates as may be designated by the 3ommission< 4rovided, hat it shalbe in accordance with 6epublic )ct No. P8P, other known as the :463&oderni'ation )ct of *+++.;

!ec. .$uali"cation for Admission to the Eicensure ;amination.5 2n order to beadmitted to the e/amination for nurses, an applicant must establish, to thesatisfaction of the 7oard, that. 7e a member of good standing in the accredited professional organi'ation of

nurses> and


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the 4hilippine 3harity !weepstakes $Ice and 4hilippines )musement and Laming3orporation, which shall equally share in the cost and shall be released to theDepartment of health sub#ect to accounting and auditing procedures< 4rovided, hathe Department of @ealth shall set the criteria for the availment of this program.

!ec. 0. -ncentives and Iene"ts.5 he 7oard of Nursing, in coordination with theDepartment of @ealth and other concerned government agencies, association ofhospitals and accredited professional organi'ation shall establish an incentive andbene%t system in form of free hospital care for nurses and their dependentsscholarship grants and other non-cash bene%ts. he government and privatehospitals are hereby mandate to maintain the standards nurse-patient ratio set bythe Department of @ealth

A!ICL" ;IIP"NAL AN+ MI/C"LLAN"57/ P5;I/I5N

!ec. K. rohibitions in the ractice of Nursing. 5 ) %ne of not less than "iftythousand pesos (4K+,+++.++ nor more than $ne hundred thousand pesos(4++,+++.++ or imprisonment of not less than one ( year nor more than si/ (9years, or both, upon the discretion of the court, shall be imposed upon or

b. who uses as invalid certi%cate of registrationMprofessional license, asuspended or revoked certi%cate of registrationMprofessional license, or

an e/pired or cancelled specialMtemporary permit> orc. who gives any false evidence to the 7oard in order to obtain a

certi%cate of registrationMprofessional license, a professionalidenti%cation card or special permit> or

d. who falsely poses or advertises as a registered and licensed nurse oruses any other means that tend to convey the impression that heMsheis a registered and licensed nurse> or

e. who appends 7.!.N.M6.N. (7achelor of !cience in NursingM6egisteredNurse or any similar appendage to hisMher name without having beenconferred said degree or registration> or

f. who, as a registered and licensed nurse, abets or assist the illegalpractice of a person who is not lawfully quali%ed to practice nursing.

. any person or the chief e/ecutive oIcer of a #uridical entity who undertakesin-service educational programs or who conducts review classes for both locaand foreign e/amination without permitM clearance from the 7oard and the3ommission> or

0. any person or employer of nurses who violate the minimum base pay ofnurses and the incentives and bene%ts that should be accorded them asspeci%ed !ection * and 0> or

K. any person or the chief e/ecutive oIcer of #uridical entity violating anyprovision of this )ct and its rules and regulations.


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A!ICL" IKFINAL P5;I/I5N/

!ec. 9.;nforcement of this act.5 2t shall be the primary duty of the 3ommissionand the 7oard to eectively implement this )ct. )ny duly law enforcement agenciesand oIcers of national, provincial, city or municipality governments shall, upon thecall or request of the 3ommission of the 7oard, render assistance in enforcing theprovisions of this )ct and prosecute any persons violating the same.

!ec. .Appropriations.5 he 3hairperson of the 4rofessional 6egulation3ommission shall immediately include in its program and issue such rules andregulations to implement the provision of this )ct, the funding of which shall beincluded in the )nnual Leneral )ppropriations )ct.

!ec.P.Rules and Regulations.5 Cithin ninety (8+ days after the aectivity of this)ct, the 7oard and the 3ommission, in coordination with the accredited professionaorgani'ation, the Department of @ealth, the Department of 7udget and&anagement and other concerned government agencies, shall formulate such rulesand regulations necessary to carry out the provision of this )ct. he implementingrules and regulations shall be published in the $Icial La'ette or in any newspaper

of general circulation.

!ec. 8.#eparability 3lause.5 2f any part of this )ct is declared unconstitutional, theremaining parts not aected thereby shall continue to be valid and operational.

!ec.0+.Repealing 3lause.5 6epublic )ct. No. 90, otherwise known as the:4hilippine Nursing )ct of 88; is hereby repealed . )ll other laws, decrees, orders,circulars, issuance, rules and regulations and parts thereof which are inconsistentwith this )ct are hereby repealed, amended or modi%ed accordingly.

III Nursing Law and Legal Issues

A. Guide 6uestions of Legal and Political Issues in NursingProfession

. Discuss the meaning of medical malpractice and negligence.

*. Gnumerate and e/plain the purpose of negligence law.

. Gnumerate and e/plain the elements of negligence

0. G/plain and give a situation or e/ample on the following legal terms innursing

a Doctrine of 6es 2psa 1oquitorb Doctrine of "orce &a#eurec Doctrine of 6espondant !uperior


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d 3aptain 5of- the- ship doctrinee Lood !amaritan !tatutesf 2ncompetence

K. G/plain and give an e/ample of torts.

9. Chat are the e/ample of intentional tortsJ

. Discuss the meaning of crime, misdemeanor and felonies.

P. ) conspiracy to commit a crime e/ists when two or more persons agree tocommit a felony and decide to do it. 4erson who commit felonies are eitherprincipals, accomplices or accessories. G/plain the underlined term ofelonies.

8. Chat are the circumstances aecting criminal liabilityJ G/plain and give an e/ampleof each circumstance on criminal liability.

+.Chat are the most common allegations of nursing malpracticeJ Chat mightbe the reason why these are the common allegation of malpracticeJ

.Chat are the common nursing negligence cases along treatmentcommunication. &edication, and monitoringMobservingMsupervisingJ

*.he following are summaries of %ve randomly selected malpracticecases in which nurses were named as defendants. hey illustrate therange of actions that result in breaches of standards of care. )s afuture professional nurse how would you avoid these incidents in thehospital.

i. "ailure to follow standards of care.

ii. "ailure to use equipment in a responsible manner.

iii. "ailure to use equipment in a responsible manner.

iv. "ailure to document

v. "ailure to act as a patient advocate.

1. Medical Malpractice Cases Involving Nurses

)s you read through these medical malpractice cases ask yourself the followingquestions< ( 6eid ,*++

a @as a situation such as the one described ever happened to youJ

b 2f so, how did you respond at the timeJ

c 3ould a similar situation happen to youJ

d 2f you found yourself in a comparable situation and were directlyresponsible for the patients care, how would you actJ

e 2f you were the nurse manager on duty, how would you respondJ


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3ase < NurseAs negligence was grossly apparent.

3ase *< Negligence can be premised upon a failure to act.

3ase < "ailure to observe and communicate may be negligence.

3ase 0< Duty to notify physician of important changes in patientAs condition.

3ase K< 2ncorrect administration of in#ection in#ures patient.

3ase 9< Nurses have a duty to protect their patient from danger.

3ase < &isuse of equipment results in nurse being found negligent.

3ase P< Duty to inform physician of change for the worse in patientAs condition

3ase 8< he nurseAs failure to act was negligence.

3ase +< Nurse was negligent in administering in#ection

3ase < "ailure to observe the patient and keep the physician informed.

3ase *< Qiable cause of action against nurse and case remanded for trial.

1. Legal Issues in Nursing# &Aien *==2'

. 2dentify four common areas of nursing liability and give an e/ample of a deviationfrom the standard of care for each.

*. 2dentify two types of patients who are at a high risk of falling and discuss nursing

interventions that are appropriate to minimi'e the risk.

. 2f a patient falls and is in#ured, discuss the liability issues involving the nurse whois assigned to that patient. Chat should be documentedJ0. 2f a physician writes an order for a medication and mistakenly orders adangerously high and very unusual dose, is the nurse automatically protectedlegallyJ Chat should the nurse doJ

K. &any types of equipment are used in patient care today. Discuss the types ofin#uries that can result from not knowing how to use the following types oequipment ( !ection

a 3ontinued neglect of duty or incompetence>

b 3ommission or toleration of irregularities in the licensure e/amination> and

c Bnprofessional, immoral or dishonorable conduct.

. hat are the quali"cations for the nursing student to be admitted to theEicensure ;amination for Nursing,


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Documents

POLITICAL SCIENCE-Philipine Legal and Political Issues in Nursing