NIKKI LIND [continued]: They’re there for a reason. Those things are in place because we’ve ironed out the kinks. They figured out what we need to do, and that’s why we do what we do. We need to follow those procedures, we follow our orders sets. You have lots of education when you’re in those areas,
NIKKI LIND [continued]: as well– why we’re doing what we’re doing. And that’s why they’re important because there could be bad outcomes. And we never want that to happen.
HEALTH CARE PROVIDER: After you pump up, you slowly release the valve.
NARRATOR: In an attempt to keep health care costs under control, more of the work of nursing is being shifted to unlicensed assistive personnel and CNAs. By taking over some of the lesser-skilled and less-critical tasks, CNAs free up registered nurses for supervision and to concentrate on the critical portions of the nursing process itself.
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NARRATOR [continued]: The use of more licensed vocational and licensed practical nurses, certified nursing assistants, feeding assistants, and even personnel with limited training, such as orderlies and hospital volunteers, has created, in many facilities, more of a team approach to nursing, with more tasks delegated
NARRATOR [continued]: to the lesser-skilled personnel. But even with delegation, responsibility remains largely with a registered nurse. In general, unlicensed assistive personnel must be under the supervision of a registered nurse and can only do tasks that a registered nurse has
NARRATOR [continued]: delegated to them. However, effective delegation extends far beyond the act of simply telling someone to go do a task. It requires a high level of critical thinking and professional judgment. According to the American Nurses Association and the National Council of State Boards of Nursing,
NARRATOR [continued]: the guidelines for effective delegation can be summarized using the five Rs– the delegation or assignment must be the right task given under the right circumstances to the right person using the right instructions. And the person delegating must also
NARRATOR [continued]: provide the right supervision and evaluation. The nurse must determine the right tasks for delegation to assistive personnel. It is important to remember that the registered nurse may never delegate any portion of the nursing process that depends on his or her professional judgment.
NARRATOR [continued]: for example, the assessment of a patient, developing and evaluating the nursing plan of care for the patient, and interpreting and analyzing data are the responsibility of the registered nurse and cannot be delegated because they require the nurse’s knowledge, expertise, and judgment.
HEALTH CARE PROVIDER: How is her temperature doing?
NARRATOR: To ensure the right circumstances, the nurse must always take into account the patient’s condition, the setting, and the available resources when delegating any task.
HEALTH CARE PROVIDER: Her temperature is 99.
HEALTH CARE PROVIDER: Heart rate?
HEALTH CARE PROVIDER: Is 60.
NARRATOR: When dealing with a critical patient, the nurse should not be assigning duties that he or she should be assessing themselves. Of course, when selecting a person to delegate to, the nurse must take into account the knowledge and skill level of that individual. And once a task is delegated to an unlicensed person,
NARRATOR [continued]: that person may not subdelegate the task to someone else. The delegated task must be clearly described, including all the details about what, when, and why. Delegation does not end a nurse’s responsibility.
NARRATOR [continued]: The person delegating must either supervise the task or assure that supervision is available. If necessary, the registered nurse must teach the skill being delegated to the person and supervise the performance of the task. There can be no delegation unless there is an appropriate level of supervision.
NARRATOR [continued]: Supervision means initial and ongoing direction, including direct observation if necessary. And the nurse must remain available for procedural guidance and evaluation of the task. Remember, it is negligence on the part of the nurse if the nurse fails to delegate or supervise properly.
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HEALTH CARE PROVIDER: Call the doctor. I need to have help in here right now.
NARRATOR: In some states, the nurse also may be found legally responsible for any harm to the patient that results.
HEALTH CARE PROVIDER: And we’ve upped her IV?
HEALTH CARE PROVIDER: We have upped her IV.
HEALTH CARE PROVIDER: OK.
HEALTH CARE PROVIDER: Emily, Can you hear us? [INTERPOSING VOICES]
HEALTH CARE PROVIDER: Can you hear us?
HEALTH CARE PROVIDER: Can you please call her doctor straight away, please? We need an OR right away.
NARRATOR: Studies have identified the most common legal allegations that have resulted in successful negligence lawsuits filed against nurses. The most common is patient falls. According to the Centers for Disease Control, more adults over 65 die from fall-related injuries
NARRATOR [continued]: than any other condition. Guidelines have been established for mitigating the risk of patient falls. Many hospitals have established frameworks for assessing risk factors for patient falls, implementing intervention for reducing the risk of falling and protecting the patient from injury if a fall should occur.
NARRATOR [continued]: Staff must maintain responsibility for patient safety at all times, even when family is present. Always refer to the most up-to-date policies and procedures of your institution. Another common problem leading to negligence lawsuits is the improper technique and maintenance of IV lines. One example would be a failure to use proper ascetic technique
NARRATOR [continued]: when starting the IV. And another would be failure to monitor the IV- insertion site often enough, allowing the development of an infection or infiltration. Other patient- safety issues are also a problem. One example is not contacting the physician prior to the placement of restraints and ensuring
NARRATOR [continued]: that you have followed the institutional policy by not properly assessing the patient or documenting the use of alternative interventions to restraints. A major source of negligence lawsuits is medication errors. According to one study in 56 facilities, the most common types of medication errors
NARRATOR [continued]: are administering the improper dosage, or administering a medication to the wrong patient, or failing to administer a needed medication. Medication errors are most often caused by distractions, and especially heavy workloads. But that is no excuse for a very serious breach of duty.
NARRATOR [continued]: Additional breaches involving medications may include such things as failure to recognize signs and symptoms of drug toxicity, failure to request an order for drug levels, failure to use aseptic technique, failure to document the injection site, failure to check for drug allergies,
NARRATOR [continued]: and failure to identify potential medications side-effects that placed the patient at risk– for example, giving an antihypertensive agent to a patient who already has low blood pressure, or giving antiplatelet medication to a patient who has active bleeding. Administering medication according
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NARRATOR [continued]: to the doctor’s orders is a common nursing task. If the nurse fails to follow the orders, she or he will be liable for malpractice if the patient is injured. The nurse may also be liable for negligently following otherwise proper orders, like injecting a medication into muscle instead of a vein, or injecting the wrong patient.
DANIEL GIROUX: I just had a case three years ago against a facility, wherein a physician’s letter– or his number 1 actually look like a 4. And my client ended up getting 4 micrograms of dilaudid rather than 1 microgram of dilaudid.
DANIEL GIROUX [continued]: And she went into respiratory distress within 20 minutes and died within 60 minutes.
NIKKI LIND: It’s hard to question a doctor when they’re giving you an order or they are in a situation, because sometimes I’ve come in– like when I work with residents or less-seasoned doctors, they sometimes are put into situations where they’re not always 100%,
NIKKI LIND [continued]: and they don’t have 100% of the knowledge that they need to take care of that situation. And so there have been instances where the nurse has more experience, and so they will question what their orders are and what their follow-up processes, or what their plan of care is. And you can suggest seeking another doctor’s opinion
NIKKI LIND [continued]: or just bringing to light, this is what I think is going on, or this is what I think might be the outcome if we don’t look at this.
