Patient Left Unrestrained, #Patient Injured. #Nurses Judgement Call, #nursing #malpractice #nursefriendly #epatient #negligence

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Summary: The decision to use or not use restraints must be made with caution and good judgement. Their intended purpose must be to protect either the patient or others who may be injured by the patient including the staff caring for the client. The ultimate determination of necessity is left with the physician. Often, the moment to moment necessity is determined by the nurse. In this case a nurse did not feel restraining the patient was necessary. When an injury occurred, the patient sued.

The patient was involved in a motor vehicle accident. A head injury was suffered leaving him in a state of confusion and prone to agitation.

"Each year, an estimated 2 million people sustain a head injury. About 500,000 to 750,000 head injuries each year are severe enough to require hospitalization. Head injury is most common among males between the ages of 15-24, but can strike, unexpectedly, at any age. Many head injuries are mild, and symptoms usually disappear over time with proper attention. Others are more severe and may result in permanent disability." 2

Following the head injury, the patient was visibly confused and frequently became agitated. During the course of his admission, an order for "soft" wrist restraints was obtained and implemented to protect the patient from injury related to mental status (personality) changes.

"Personality Changes-Apathy and decreased motivation. Emotional lability, irritability, depression. Disinhibition which may result in temper flare-ups, aggression, cursing, lowered frustration tolerance, and inappropriate sexual behavior."2

On the day of the incident, the nurse on duty had assessed the patient. In her professional opinion restraints were not needed.

"What Is Restraint?

"Restraint" is physical force, mechanical devices, chemicals, seclusion, or any other means which unreasonably limit freedom of movement. hospital staff may use four types of restraint to restrict patients who are acting, or threatening to act, in a violent way towards themselves or others.

Physical restraint--holding a patient for over five minutes in order to prevent freedom of movement.

Mechanical restraint--using a device, such as 4-point or full sheet restraint, to restrict a patient's movement (excludes devices prescribed for medical purposes).

Chemical restraint--medicating a patient against her will for the purpose of restraint rather than treatment.

Seclusion--placing a patient alone in a room so that she cannot see or speak with patients or staff and the patient cannot leave or believes she cannot leave."3

She based this decision on her observation of the patient's mental, physical state and level of consciousness. It is common procedure and protocol in facilities for patient's to be released from restraints when the danger of violence is felt to have passed.

"How Long May Restraint Continue?

When an emergency no longer exists, the patient should be released. Thus, staff should release a patient who, upon examination, appears calm. The total time which a patient may be restrained is limited:"3

Later in the shift, the same nurse was helping the patient get up. In the course of this maneuver, the patient fell and claimed that an injury was sustained.

A lawsuit would be filed against the facility alleging negligence on the part of the nurse. The patient contended that the removal of the restraints breached standards of care.

In the initial trial, the jury was instructed to view the nurse's role as an "error in judgement." Based on this and on testimony on the proper use of restraints, standards of care, the court found for the facility.

The patient appealed.

Questions to be answered:

1. Was the nurse in error to remove the restraints from a patient when she felt they were no longer needed.

2. Did the removal of the restraints directly contribute to the "injury" that the patient claimed to sustain?

3. Were the standards of care governing restraint use adequately maintained?

The plaintiff's arguments sought to convince the jury that poor judgement was exercised by the nurse. It was contended that removal of the restraints and ambulation of the patient put him in harm's way.

With the patient assessed to be calm, the purpose of the restraints, "to prevent the patient from harming himself or others," had been achieved.

The purpose of the restraints had not been to "keep the patient from falling out of bed." The removal of the restraints then, could not be deemed as negligent. There was no duty of care breached in allowing the calm patient to remain unrestrained.

The order was in place to ambulate the patient when stable. In the nurse's opinion, the patient was ready. Another nurse may not have agreed with her actions. The patient under a different nurse's care might have been kept in restraints. A nurse could have "held off" on the order to ambulate.

There was no causative relationship between removing the restraints and the patient's fall. In carrying out orders for ambulation, the nurse was providing proper nursing care.

It's not difficult to picture a lone nurse with an unsteady patient losing control and having the patient slip away. Would this be a breach of duty owed to the patient?

One could argue that the nurse had no business trying to move a patient by herself. One might also observe the staffing patterns at the time and realize the nurse was doing "the best she could."

The decision to remove the restraints was clearly a nursing decision. Often the decision to use them in the first place lies with the nurse too.

This illustrates the leeway and discretion given nurses when carrying out physician's orders. It also shows the typical catch 22 situation some nurses may find themselves in regarding restraint use.

"Historically, conventional wisdom supported using physical restraints, including bed side rails, to "protect and safeguard" residents. Ironically, little documented evidence exists that restraints prevent falls and risk of injury from falls. Clinical studies demonstrate that restraints, conversely, in some instances, precipitate or exacerbate fall risk."4

Both nurses in the above situation would be acting within their scope of practice. Each would be adhering to standards of care.

For the plaintiff to have a case, it would need to proven that either the removal of the restraints or the ambulation of the patient was premature.

This was clearly not the case. The actions of the nurse were in good faith and exercised reasonable concern for the well being of the patient. The fact that the patient suffered a fall is unfortunate, and reasonably unforseeable.

It can be compared to the actions of a physician when dealing with an acute patient. Depending on which course of treatment that physician chooses, the patient might or might not have a favorable outcome.

In either case, as long as the physician exercises reasonable judgement based on established principles of practice, a finding of negligence is unlikely.

It has been well established that Medicine is not an exact science. Outcomes are not guaranteed when prescribing courses of treatment.

They are the result of standard medical practices and individual patient responses. These responses are not always predictable. Basically, the caregiver can only hope for the best.

The same principle applies to Nursing care. Regardless of how accurate assessments are and how diligently orders are carried out, patients may or may not experience favorable outcomes.

When outcomes are unfavorable, it is the constitutional right of the patient or patient's estate to sue anyone felt to be involved.

The court reviewed the facts of the case and a nursing expert's testimony on restraint use. The appeals court agreed that standards of care had been maintained.

There exists today intense pressure from family members, governmental agencies and regulatory agencies to limit restraint use to "only when absolutely necessary." As soon as they are put in use, the plan of care must include provisions for their removal.

Link Sections:

Head Injuries:
http://www.nursefriendly.com/nursing/directpatientcare/head.injuries.htm

Ethics:
http://www.nursefriendly.com/nursing/directpatientcare/ethics.htm

Mechanical & Physical Restraints:
http://www.nursefriendly.com/nursing/directpatientcare/mechanical.physical.re...

Medical Legal Consulting Nurse Entrepreneurs
http://www.nursefriendly.com/nursing/ymedlegal.htm

Sources:

1. RRNL 2 (July 1997)

2. Family Caregivers Alliance Clearinghouse. Revised November 1996. Fact Sheet: Head Injury. Retrieved May 30, 1999 from the World Wide Web: http://www.caregiver.org/factsheets/head_injury.html

3. Mental Health Legal Advisors Committee. No date given. Your Rights in Hospitals Regarding Restraining and Seclusion. Retrieved May 30, 1999 from the World Wide Web: http://www.psychiatry.com/mhlac/basicrights/restraintandseclusion.html

4. Braun, Julie A. & Quish, Clare J. 11/10/98. Illinois Institute for Continuing Legal Education. Physical Restraints And Fall-Related Injuries. Retrieved May 30, 1999 from the World Wide Web: http://www.iicle.com/articles/braun11_10_98b.html

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Texas Legal Nurse Consultants, Nursing Entrepreneurs, Nurse-Owned Businesses

Lisa Edwards, RN, CLNC, Full Disclosure Medical Legal Consulting, Texas Legal Nurse Consultants:"Medical legal nurse consultant serving attorney-clients (plaintiff or defendant) in medical case review, education in all aspects of the medical case, identification of the deviations or adherences to the medical and nursing standards of care, assist in preparation of production or interrogatories, assist in preparation of demonstrative evidence."
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Deborah Hafernick, RN, CLNC, Hafernick Legal-Nurse Consulting, Texas Legal Nursing Consultants:"Medical-legal consulting practice in Houston, Texas, specialing in evaluating cases for merit and interpretation of the medical record for both plaintiff and defense attorneys to help them save money by organizing their cases faster and win because they understand them. Also research and provide medical literature/standards of care for issues that support their case. Testifying expert identification and location, demonstrative evidence development, etc."
Specialty Areas: Cardiac Cathetherization Lab, Medical Malpractice, Nursing Education, Personal Injury, Product Liability, Social Security Disability Claims, Toxic Torts, Workers Compensation
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Linda & Tim Hutchinson, San Antonio, Texas:"My name is Linda, and I've been a Registered Nurse for over 20 years, extensive work exerience in Cardiac, ICU, Psychiatric, Home Health, and LNC/Medical Fraud/Legal reviews). Tim, my husband, enjoyed a successful Military career. For ten years we've owned a national medical cost containment corporation, working 16+ hours days, with NO TIME to enjoy the fruits of our labor!!"
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Tricia West, RN, BSN, MBA/HCM, LNC, P.J. West & Associates, California Legal Nurse Consultants:"PJWA has been doing medical legal consulting since 1980 in the areas of personal injury, medical malpractice, worker's compensation, product liability, Medicare Fraud, Insurance billing Fraud and Risk Management for both the defense and plaintiff. Our goal is to provide you with ethical, timely and exceptional support services. We can make your job easier by assisting with the evaluation of cases for merit, conduct extensive medical legal research, review medical records and provide expert testimony in all specialty areas of nursing."
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Agoura Hills, CA 91301-4019
(818) 707-0051
E-mail Address: Twest@PJWA.com
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Linda J. Weyandt CRNA, Nursing Entrepreneur, Texas:"Providing medical legal research in multiple specialties."
Specialty Areas: Certified Registered Nurse Anesthetist (CRNA), Critical Care, Med-Legal Research and Consulting, Post Traumatic Stress Disorder, PTSD, Psychotherapy,
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See also:

Advantage Medicolegal Consultants, LLC:"Our Legal Nurse Consultants (LNC) are Registered Nurses who aid attorneys in analyzing the medical issues in legal cases. LNC’s are involved in both plaintiff and defense cases. As professionals, LNC’s follow their medical ethics of confidentiality as well as the ethics of the ABA."
D. Bradley Woodall, RN
Advantage Medicolegal Consultants, LLC
19726 Cypresswood Lake Dr.
Spring, Texas 77373
(O)281.350.2235
(F)281.528.0914
Info@LawRN.com
http://www.lawrn.com/

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CN Expert Nurse Consultants:"Darlene Nelson-Richardson is a clinically active Certified Emergency Nurse with 15 years of EMERGENCY, PEDIATRIC, & RADIOLOGY experience. Mrs. Richardson provides objective reviews of medical records and will testify as to her opinions."
CN Expert Nurse Consultants
Darlene Nelson-Richardson, R.N. C.E.N.
San Antonio, Tx 78216
Phone: 210-493-8462 Fax: 210-493-2848
Email: CNLegalnurse7@aol.com
http://www.emergencynurseexpert.com/

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Donna du Bois, MPH, RN, C, CLNC:"Don't waste valuable time determining the merit of a case. I can quickly screen a case, point out merit and potential pitfalls. You can let the client know you gave serious consideration to the case without investing large sums of money in a case that doesn't have merit. I am an experienced Geriatric nurse. My extensive experience in long term care includes 10 years as a surveyor and complaint investigator of Nursing and Assisted Living Facilities for the state of Texas. I owned my own nursing home consulting business after gaining expertise as a Director of nursing for a skilled nursing facility. I have written two books for the long term care industry and am now completing a third. I am certified in Gerontology nursing and legal nurse consulting."
Donna du Bois, MPH, RN, C, CLNC
Maxi Gerontology:
10401 N. Lamar D 105
Austin, Texas 78753
Phone: (512)832-2103
Toll free: (866)832-2103
dduboisrn@austin.rr.com
http://www.maxigerontology.com

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Gray & Associates:"A Legal Nurse Consultant is considered a speciality practice of nursing. Attorney's and other professionals in the legal arena consult with Legal Nurse Consultants because of their expertise in the nursing and healthcare industry. Professional nursing education and the knowledge of health care makes Legal Nurse Consultants unique and valuable partners in the legal process."
Connie L. Gray, RN, CPN, CLNC
Gray & Associates
Phone: (512) 312-2884
Fax 512-295-7050
E-mail: clnc@conniegray.com
http://www.conniegray.com

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Hafernick Legal-Nurse Consulting:"If you get frustrated just looking at a large stack of medical records, let Hafernick Legal-Nurse Consulting show you how using a legal-nurse consultant can help relieve your frustration by increasing your efficiency when preparing your next medically-related case. Such cases include: medical malpractice personal injury toxic tort product liability workman's compensation."
Hafernick Legal-Nurse Consulting
2323 Acacia St. League City, TX 77573
mobile 281.734.4089 fax 281.338.0977
hafernicklnc@ghg.net
http://www.hafernickconsulting.com/

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Legal Nurse Consultants of East Texas:"Linda Morehouse is a Certified Legal Nurse Consultant (CLNC®) and Registered Nurse in the Greater Lufkin-Nacogdoches Texas Area. Registered nurse in the State of Texas since 1982. Areas of experience in nursing include: intensive care nursing, cardiac catheterization lab, surgery, house supervisor, admissions nurse, concurrent review nurse for large HMO/PPO, labor and delivery, psychiatric nursing, emergency room, medical/surgical, skilled nursing, certified Advanced Cardiac Life Support Instructor, certified legal nurse consultant."
Office: 936-897-2408 Fax: 936-897-9030
Email: linda@texaslegalnurse.com
http://www.texaslegalnurse.com/

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Terry Kennedy Arnold, RN, CRRN, CDMS, CCM, CLCP, Life Care Consultants, Inc.: An established medical-legal consulting company specializing in multiple services for the Legal and Insurance fields.
Terry Kennedy Arnold, RN, CRRN, CDMS, CCM, CLCP
Life Care Consultants, Inc.
7826 Trentway St. Houston, TX 77040
713-983-0121, 800-955-9415
http://www.lifecareplans.com

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Lone Star Nurse Consultants:"Kathleen Jackson, principal of Lone Star Nurse Consultants, is a registered nurse with more than 30 years clinical experience. Her clinical experience is in multiple arenas including Cardio-Vascular ICU, Med-Surg ICU, Cardiac ICU, Burn Center/ICU, Cardiac, Medical, Oncology, Orthopedics, Urology, Nephrology, Neurology, OB-Gyn, Pediatrics, Neo-Natal, Psychiatric, Rehabilitation, Extended Care, Occupational Nursing, and Case Management."
Kathleen L Jackson RN CCM CLNC LCP
Lone Star Nurse Consultants
PO Box 62 Seguin, TX 78156-0062
Phone/Fax: (830) 305-2165
Kathy@lonestarLNC.com
http://www.lonestarLNC.com

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Medco Associates, Inc.:"Medco Associates, Inc. maintains a vast network of physicians, dentists, nurses and other health-related experts actively working in their respective fields of expertise. We support our clients with highly professional experts representing every major medical specialty and in very specific areas of the healthcare arena. But specialization alone isn’t enough. Well-educated, credentialed professionals are essential to your case. All of our physicians are board certified in their specialties. Our nurses, who all possess either Master's degrees or Ph.D.s, are experienced leaders in the nursing profession with excellent analytical and writing skills."
Medco Associates, Inc.
Susanna Neahusan, M.Ed., RN Director of Operations
1603 Olympus Dr. Austin, TX 78733
800-341-6461 T: 512-263-0322 F: 512-263-7265 E: info@medcoassociates.com
http://www.medcoassociates.com/

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Med-Expertise, LLC:"Med-Expertise has provided medical litigation support to the legal community since 1992. Founded by, Wilma J. Couch, a degreed registered nurse, the company today is recognized as a leader in providing customers with individualized medical knowledge and data necessary to obtain a successful verdict for all types of litigation. Our overall breadth of services offers our customers a complete turnkey program."
Med-Expertise, LLC
Melissa J. Couch, Vice President
10777 Westheimer, Ste 1055 Houston, TX 77042
Phone: 713-914-0112 Fax: 713-914-0162 E-mail: mcouch@med-expertise.com
http://www.med-expertise.com

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P&S Legal Nurse Consultants, Inc.:"P&S Legal Nurse Consultants, Inc. serves attorneys, insurance companies and hospitals on medical related cases. We are committed to providing quality expertise to our customers. Our company includes a staff with over 20 years of extensive nursing and related healthcare experience in both management and clinical areas."
P&S Legal Nurse Consultants Inc.
9597 Jones Road, Houston, TX 77065
P. Svanhaniel Crim BSN, RN, CNN, CLNC E-mail: SCRIM78683@aol.com
Patricia M. Torres BA, BSN, RN, CLNC E-mail: pmtorres@wt.net
Phone:281-550-6433
Fax: 713.849.3375
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RN Network Review Corporation:"Led by its founder Judia Sarich RN BSN CLNC, RN Network Review Corporation is committed to delivering quality litigation support services to plaintiff and defense attorneys. Ms. Sarich has over thirteen years of nursing experience including intensive care, hospital administration and management. Backed by an extensive network of qualified nurses and expert witnesses, we are well positioned to provide superior service to both the medical and legal communities."
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1534 Shady Grove Circle
Rockwall, Texas 75032
Toll Free Phone 866-806-5666
Fax 866-806-5666
E-Mail mail@RNNetworkReview.com
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Sharon Ort LNC Services:"First and foremost, as a nurse, I am dedicated to the proper care of the elderly and infirm. When in my charge, my goal is to give the highest quality care, well above accepted standards of care with proper balance of resultant outcomes to expenditures. As a legal nurse consultant, it is to give honest, informed, diligent effort to my clients in a highly effective & professional manner. "I am fortunate to have been introduced to nursing in a strong three-year program of intense training and affiliations at a major medical center. After thirty years experience while earning an RN, BSN & MSN with honors, I understand the difficulties of the job of caring for the elderly and the increasing pressures of the task. I applaud the nurses who serve well and the healthcare corporations who support them properly." Sharon Ort LNC Services
Telephone: 979-779-6030
E-mail: sharonort@verizon.net
http://www.legal-nurse-tx.com

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Article Index:

The 10 Biggest Mistakes Experts Make During Depositions:"The discovery depositions of expert witnesses are increasingly playing an important role in the litigation process. Under Federal Rule of Civil Procedure 26 (4) A: “A party may depose any person who has been identified as an expert whose opinions may be presented at trial.” With this in mind, we turn to the ten biggest mistakes experts make during their depositions. #1 – Waiving The Reading of Signing Of The Deposition Transcript At the start of most depositions, counsel will agree on stipulations. Use of the most common stipulation is that the deponent waives the right to read and sign the deposition transcript. The expert who is interested in accuracy should not agree to this waiver lightly. Experts who agree to waive the reading and signing are agreeing to a document’s accuracy without even seeing the document."
SEAK, Inc.
P.O. Box 729, Falmouth, MA 02541 Courier: 316 Gifford St., Falmouth, MA 02540
Customer Service (508) 548-7023, Orders (508) 457-1111, Fax (508) 540-8304
seakinckb@aol.com
http://seak.com/10_biggest_mistakes_experts_make.html

10 Biggest Mistakes Physicians Make in Writing Their IME Reports:"The Independent Medical Evaluation (IME) reports that physicians prepare are playing an increasingly important role in workers' compensation cases, personal injury litigation, and long-term disability claims. Each year physicians prepare hundreds of thousands of IME reports which are read and utilized by judges, hearing officers, and plaintiff and defense attorneys to decide and settle claims. Physicians are frequently called upon at depositions, hearings, or trials to support, justify, and defend each and every word of their IME reports. With this in mind, we turn to the 10 biggest mistakes physicians make in writing their IME reports."
SEAK, Inc.
P.O. Box 729, Falmouth, MA 02541 Courier: 316 Gifford St., Falmouth, MA 02540
Customer Service (508) 548-7023, Orders (508) 457-1111, Fax (508) 540-8304
seakinckb@aol.com
http://seak.com/10biggestmistakesphysician.html

Advice on Answering Questions at Depositions:"Avoid Absolute Words You are well advised to avoid, where possible, absolute words such as "always" and "never." Absolute words are frequently an invitation to, and fertile grounds for, cross-examination by counsel. Counsel will attempt to damage your credibility by first getting you to make an absolute statement. She will then use counterexamples in an effort to show the falsity of your statement.
SEAK, Inc.
P.O. Box 729, Falmouth, MA 02541 Courier: 316 Gifford St., Falmouth, MA 02540
Customer Service (508) 548-7023, Orders (508) 457-1111, Fax (508) 540-8304
seakinckb@aol.com
http://seak.com/April_2011_Deposition_Skills.html

Connecting with the Jury:"In jury trials, the jury ultimately decides the case. Their job is to determine the facts of the case. A crucial part of this is determining the credibility of the witnesses. This includes expert witnesses. As such, it is of the highest importance that experts are able to communicate with the jury in a credible and persuasive way. Everything else is secondary. To connect with the jury, an expert needs to understand what juries want and know the best ways to communicate with them."
SEAK, Inc.
P.O. Box 729, Falmouth, MA 02541 Courier: 316 Gifford St., Falmouth, MA 02540
Customer Service (508) 548-7023, Orders (508) 457-1111, Fax (508) 540-8304
seakinckb@aol.com
http://www.seak.com/april_2011_Jury_Trial_Skills_Workshop.html

Opinions and Bases for Opinions, Seak.com:"The main reason expert testimony is presented is to offer an expert opinion. Accordingly, experts can anticipate being closely cross-examined on their opinions. They should also expect to be closely questioned on the bases of these opinions because an expert opinion is only as strong as the facts and reasoning upon which it is based. Questions in these areas are best blunted by carefully and honestly forming an opinion that is based on reliable methodology, a thorough investigation, and solid facts."
SEAK, Inc.
P.O. Box 729, Falmouth, MA 02541 Courier: 316 Gifford St., Falmouth, MA 02540
Customer Service (508) 548-7023, Orders (508) 457-1111, Fax (508) 540-8304
seakinckb@aol.com
http://seak.com/ce2booksamplechapter.html

Stating Opinions and Conclusions in a Defensible Manner:"The main reason an expert is involved in a case is to state her opinion. The principal reason an expert writes a report is to communicate that opinion. The opinion must be communicated effectively and must be expressed in a defensible manner. The authors recommend the following.
SEAK, Inc.
P.O. Box 729, Falmouth, MA 02541 Courier: 316 Gifford St., Falmouth, MA 02540
Customer Service (508) 548-7023, Orders (508) 457-1111, Fax (508) 540-8304
seakinckb@aol.com
http://www.seak.com/webstore/bookReportbookchapter10.asp

Expert Witness Journal, Seak.com:"SEAK has published the Expert Witness Journal since 1988. Available online are all 1998 EWJ feature articles, arranged alphabetically by title. Also available are each of the federal and state cases collected by EWJ impacting expert witnesses."
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Nursingentrepreneurs.com is a networking and resource directory for Nurse-Owned businesses and nurses looking for an alternative to working at the bedside.

If you explore the site a bit, you'll find profiles of hundreds of nurse entrepreneurs around the country. We encourage you to browse around, find a business category you are interested in, then contact the nurse directly. We're available for questions as well. This website is Owned-Operated by Andrew Lopez, RN a Medical/Surgical/Telemetry nurse.

Has your Nurse-owned business been written up in the news? Do you send out a newsletter or regular press releases? We'd like to hear about it!

Our Newest article is from an Arizona Nurse Entrepreneur:

Should You Incorporate Your Registry Business? By Joseph Caracci, RN:"The short answer is yes! When starting a new nurse registry business, you are entering into a legal business environment that requires you to take steps to protect your personal assets, such as your home, your savings, and your retirement. With this in mind, you need to determine which legal form you are going to take for your new registry. Some of the common choices are a sole proprietorship, a partnership, a limited liability partnership (LLP), a limited liability company (LLC), and a corporation."
http://www.nursingentrepreneurs.com/incorporate

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The #1 question, we've been receiving lately is about Starting A Nursing Agency, resource sites & manuals

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• How To Earn Money With Any Kind of Website
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• Article Index:
  
  • Eight Tips for Aspiring Healthcare Entrepreneurs by Megan Malugani, Monster.com:"You may dream about being your own boss, but are you really ready to take the plunge into healthcare entrepreneurship? Besides having a winning idea or service to offer, you must be self-motivated, persistent and energetic, say successful healthcare entrepreneurs. Faye Berger Mitchell, a nutritionist in private practice since 1988 in Chevy Chase, Maryland, and Thom Golden, a former emergency room nurse who founded Doctor Baby Proofer in 1986 in Dallas, offer eight tips to aspiring entrepreneurs:
    http://allhealthcare.monster.com/benefits/articles/2298-8-tips-for-aspiring-healthcare-entrepreneurs

  • How to Use Other People's Money for Your Business, By Matthew Lesko
    
  • The New Power of Advertising, By Jay Conrad Levinson
    The Story of the Hypnotic Writing Monkey, by Joe Vitale
    
  • The Truth Must Be Told, Ted Nicholas

Interesting Reading For Nurse Entrepreneurs, Actual or Soon To Be:

Nurse Entrepreneurs: Tales of Nurses in Business:"This book is vey inspiring! Learn how 50 different nurses brought their vision to reality! Learn some great tips on starting your own business. Nurses don't have to just work at the bedside. Read this book and you will be thinking of how you can make your dream a reality!"

Own Your Own Corporation: Why the Rich Own Their Own Companies and Everyone Else Works for Them:"Rich Dad's-"Own your Own Corporation" is a must read for anyone comtemplating a new business-or someone who already owns their own business. Garrett's direct yet simplistic explanations of the different business entities,the proper and best suited entity for your business-is followed by real-life scenarios which helps drive home the importance of corporate ownership in today's business world. Use Garrett's legal expertise to establish a successful, legally responsible and fiscally protected business...And understand the why's and how's of that ownership."

21 Success Secrets, Success Secret #4- "Do What You Love to Do." Get your FREE CD and find out the other 20 secrets of self-made millionaires.:"Order your FREE CD ($4.95 S&H) from Brian Tracy's acclaimed 21 Success Secrets series. Start with 21 Success Secrets of $elf-Made Millionaires - full of techniques practiced by all men and women who go from rags to riches in one generation. Brian Tracy is a noted success expert. He's trained over 2 million people in 23 countries how to achieve their financial goals faster than ever before."

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  • Make Your Knowledge Sell!:""Make Your Knowledge Sell!" makes it possible for Y-O-U to develop and sell your infoproduct! My co-author Monique Harris started out pretty much like you. She didn't use rocket science to achieve her tremendous e-publishing success."

  • Make Your Net Auction Sell:"As a business, Net auctions are truly a whole new kind of opportunity. To sell at auction just a few years ago, you had to be a Sotheby's, a business liquidator, a car dealer… or some other kind of "traditional" business. Or pay them to do the job."

  • Make Your Price Sell:"Know Your Perfect Price™ in 50 Minutes "Why is the Perfect Price™ so important?" That depends on whether you are considering a new product concept, launching a new product, or managing existing ones... Considering a new product concept? Not sure if it will fly? Imagine if you could know how much people would pay. You'd know if this new idea was worth pursuing... or not (think of the dollars and time saved)."

  • Make Your Site Sell:"Starting a major new business on the Net? Want to improve upon results from an existing Web presence? Or merely looking to build a solid second income stream? Whatever your e-commerce goals, we'll OVERdeliver, no matter how lofty your expectations are. As you will soon see, SiteSell.com products are globally acclaimed by major authorities as best of breed. Yet they are priced so that you can afford them... easily."

  • Make Your Words Sell:"What Do YOU Sell? Want to Sell More? Selling software on the Net? Infoproducts? A service? Million dollar cables for suspension bridges? If you want to sell more... Use the right words. Because words sell, not graphics. If you have any doubts, try this simple experiment."

  • Site Build It :"Site Build It! is the complete, all-in-one traffic-building system. It builds income by giving you all the software, tools and techniques that you need to build targeted traffic... all tied together into a terrific, time-saving, step-by-step process."

  Please select from the following, see also Doing Business Resources:

  Make Money From Any Type of Website! Webmasters will want to check out our Paid Link Affiliate Programs Directory

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Nursing Malpractice Alleged When Suspected Breast Cancer Patient Doesn't Follow Up

See also: Medical, Legal Nurse Consultants, Clinical Nursing Case of the Week, Clinical Charting and Documentation, Nurses Notes, Courtrooms, Disability, Discrimination, Employment, Expert Witnesses, Informed Consent, Medical Malpractice, Nursing Practice Acts, Pensions, Search Engines, Torts and Personal Injury, Unemployment, Workers Compensation, Workplace Safety:

Each week a case will be reviewed and supplemented with clinical and legal resources from the web. Attorneys, Legal Nurse Consultants and nursing professionals are welcome to submit relevant articles. Please contact us if you'd like to reproduce our material.

For a free subscription to our publication:
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Summary: Breast Cancer is a well-defined and treatable if not always curable disease process. Once suspicious findings-lumps, nodules, nipple discharge or other telltale signs of a problem are noted-prompt evaluation and follow-up care is essential. In this case, a patient with a family history of breast cancer presented with a "mass" and was evaluated. She did not follow-up as directed and when she later died of breast cancer, her estate would sue for "failure to diagnose, treat."

The 22-year-old woman was seen at a family planning clinic. Part of the assessment/examination included a routine breast exam. The nurse palpated a mass in the woman's left breast.

"The detection of a lump in the breast is a common occurrence. Although most lumps are not caused by cancer, the possibility of malignancy must always be considered. Thus, from the moment a lump or a suspicious change in texture or resistance is felt in some part of the breast, a series of decisions must be taken to exclude or establish the diagnosis of cancer."2

A family history revealed that the patient's mother had died of breast cancer.

"A cancerous tumor of breast tissue, the most common cancer in women and the second leading cause of cancer death for women in the World. The rate increases between 30 to 50 years of age and reaches a second peak at 65 years of age. Risk factors include a family history of breast cancer, no children, exposure to radiation, young age when menstruation began, late menopause, being overweight, diabetes, high blood pressure, long-term cystic disease of the breast, and, possibly, hormone therapy after menopause. Women who are over 40 years of age when they bear their first child and patients with cancer in other areas also have a greater risk of getting breast cancer."3

The nurse referred her to a nearby breast clinic for evaluation of the suspicious lump. Both a nurse and physician would verify the presence of the finding.

"Beginning symptoms, found in most cases by self-examination, include a small painless lump, thick or dimpled skin, or nipple withdrawal. As the tumor grows there may be a nipple discharge, pain, ulcers, and swollen lymph glands under the arms. The diagnosis is made by a careful physical examination, a breast scan (mammography), and examination of tumor cells."3

The patient was instructed to return in three months for evaluation and follow-up of the suspicious mass. Given the family history and nature of the lump, the patient was instructed that the likelihood of malignancy was high.

The suspicious findings and instructions for the patient to follow-up were communicated to the patient. They were also documented in the patient's chart carefully. It was emphasized that the finding needed to be monitored in light of the patient's family history. Despite this instruction, the woman did not return in three months as directed.

No further evaluation would be documented until two years later when a formal diagnosis of Breast Cancer was made. In addition to the cancer in the breast, metastasis to the neck and arm was noted.

"Tumors are more common in the left than in the right breast and in the upper and outer parts of the breast. Spreading through the lymph system to lymph nodes under the arm (axillary) and to bone, lung, brain, and liver is common. Surgical treatment, depending on the tumor, may be a radical, modified radical or simple removal of the breast (mastectomy), with the removal of axillary nodes."3

A radical mastectomy was performed and followed by standard chemotherapy/radiation treatment. The cancer did not respond to the therapy. The patient, initially suspected of having disease at 22, would die at 25.

Due to patient's lack of follow-up, treatment of the disease was potentially delayed for two crucial years.

"The best chance for successful treatment occurs when cancer is found early. Mammograms, or special x-rays of the breast, can detect more than 90 percent of all cancers and should be part of every woman's breast health program, along with breast self-exam and physical exam by a doctor. If a cancer is found early, it is more than 90 percent likely to be completely curable."3

Following her death, the patient's estate filed a lawsuit against the Family Planning Clinic and the Breast Center nurses & physicians. The suit alleged negligence and medical malpractice in the treatment/diagnosis of the patient's Breast Cancer.

Noting the circumstances of the case, summary judgement was initially handed down in favor of the defendants by the court. It noted that acceptable Nursing/Medical Standards and Procedure had been followed in the assessment, documentation and instruction of the patient with a potential Breast Cancer diagnosis.

The administrator of the patient's estate appealed.

Questions to be answered:

1. Was either the Nursing or Medical staff at either the Family Planning Clinic or Breast Center negligent in their examination or duty to inform the patient of her potential diagnosis?

2. Was prompt and early recognition/treatment of the patient's cancer delayed or hindered by the actions of the nurses or physicians?

3. Was the patient's "failure to follow-up as instructed" responsible for the unmonitored progression of the disease and resulting metastasis?

The court noted that clearly, the woman's potential condition had been identified appropriately. The patient had been informed that she was at high risk for Breast Cancer and that further evaluation was needed. She was made aware of the findings and what they could represent.

No claim of "failure to treat appropriately" could be substantiated.

The court recognized that no treatment had in fact been given by the Family Planning facility or the Breast Clinic. The reason no treatment had been given was strictly due to the patient's failure to comply with stated instructions for follow-up.

The documentation of the early suspicious findings and recommended follow-up instructions were clearly noted in the chart. Noted as well was the fact that the woman did not comply as instructed.

When the cancer was finally detected and treated, it was known that the cancer had spread. At that point the removal of the cancerous breast by itself would not offer a cure.

"If I do get breast cancer, a mastectomy gives me my best shot at survival.

A woman may make the psychological leap of assuming "the more I suffer, the more I deserve to be cured" -- a natural reaction to a frightening disease. Natural but misguided. "Women don't die of this disease because it comes back in the breast, but because of a spread to the bones or liver." "If the cancer hasn't spread before surgery, a mastectomy and breast-preserving lumpectomy, followed by a course of radiation treatments offer the same outcome. And if it has already spread, you need other treatment to cure the distant metastasis."3

The appellate court affirmed the judgement of the lower court.

This case illustrates how crucial early detection and follow-up care of suspicious Breast findings are. It shows also how frivolous lawsuits can be brought against nurses and physicians literally "at will." At no point in the case was there clear evidence of negligence or wrongdoing.

The records show that the initial examination was done quite well. The patient received excellent assessment/guidance when the pre-cancerous findings were initially detected. As a reward for their attention to detail and assessment, the nurses and physicians were dragged into a lawsuit and appeals process.

Despite it's poor chances of success and lack of a case, the administrator of the estate, seeking any type of reward chose to bring the suit. Even after the complaint was initially dismissed, the plaintiff chose to appeal.

For each of the nurses and physicians involved, legal costs needed to be paid and time was lost from employment to attend the depositions, trials and legal proceedings. The fortunate ones among them would have costs covered by malpractice insurance policies.

Commonly, a lawsuit is initiated after an employee has left the facility for another job. An employer in this case is under no obligation to provide legal counsel.

Related Links Sections:

Breast Cancer, Cancer Oncology & Malignancy, Direct Patient Care on: The Nurse Friendly: http://www.nursefriendly.com/nursing/directpatientcare/cancer.oncology.malign...

Breast Self Examinations, BSEs, Cancer, Oncology & Malignancy on: The Nurse Friendly:
http://www.nursefriendly.com/nursing/directpatientcare/cancer.oncology.malign...

Clinical Charting and Documentation, Nurses Notes:
http://www.nursefriendly.com/nursing/directpatientcare/clinical.documentation...

Courtroom Directory:
http://www.legalnursingconsultant.org/legal.nurse.consultants.lnc/courtrooms....

Direct Patient Care Links on: The Nurse Friendly:
http://www.nursefriendly.com/nursing/linksections/directpatientcarelinks.htm

Ethics:
http://www.nursefriendly.com/nursing/directpatientcare/ethics.htm

Mandatory Overtime, Nursing Quality of Patient Care, Short Staffing on: The Nurse Friendly:
http://www.nursefriendly.com/nursing/directpatientcare/mandatory.overtime.nur...

Medical Legal Consulting Nurse Entrepreneurs:
http://www.nursefriendly.com/nursing/ymedlegal.htm

Nursing Shortages, Short Staffing on: The Nurse Friendly:
http://www.nursefriendly.com/nursing/nursing.shortages.short.staffing.htm

Oncology (Cancer) Nurses on: The Nurse Friendly:
http://www.nursefriendly.com/nursing/directory/spec/oncology.html

Radical Mastectomy, Cancer Oncology & Malignancy on: The Nurse Friendly:
http://www.nursefriendly.com/nursing/directpatientcare/cancer.oncology.malign...

Related Nursing Malpractice Cases:

September 5, 1999: Sealed "Rape Kit" Reopened By Nurse. Evidence Inadmissible?
Documentation of observations and findings are basic to nursing practice. Our practice is governed by standards of practice and "protocols" to be followed. In this case, a nurse admitting a rape victim collected and placed in a "rape kit" DNA samples, evidence to be submitted for laboratory analysis. The evidence submission protocol would inadvertently be broken by the nurse. The defense for the rapist would argue this breach made the evidence inadmissible.
State v. Southern, 980 P.2d 3 - MT (1999)
http://www.nursefriendly.com/nursing/clinical.cases/090599.htm

August 29, 1999: Surgeon "Loses Clamp" Behind Patient's Heart During Bypass.
Nurse's Responsibility To Pick Up?
Summary: During any surgical operation, there is an inherent "duty" owed to the patient that the operation will be carried out competently. This includes carrying out specified procedures and taking measures to prevent "foreign" objects from being left in the body cavity. In this case, during a coronary artery bypass grafting, a clamp slipped from the surgeon's sight. It would be found on x-ray later sitting behind the patient's heart.
http://www.nursefriendly.com/nursing/clinical.cases/082999.htm

August 22, 1999: Psychiatric Nurse, Sued By Hospital After Developing Relationship With Client?
Wright v. Mercy Hosp. Of Janesville - 557 N.W. 2d 846 - WI (1996)
Summary: Doctors and Nurses by nature of their positions deal with patients when they are vulnerable, off-balance and emotionally needy. When the population includes the psychiatric patient, the potential exists for a client to develop "feelings" for the caregiver. In this case, a sexually abused mother of three was admitted for multiple mental disturbances. During the course of the treatment, a relationship developed and led to sexual encounters following discharge. When it came to light, the patient successfully sued. The hospital would attempt to recover damages against the nurse following her testimony in defense of the facility. This is commonly called a Subrogation action.
http://www.nursefriendly.com/nursing/clinical.cases/082299.htm

August 15, 1999: Violent Psychiatric Patient Attacks Nurse, No Legal Recourse Against Facility or Psychiatrist?
Charleston v. Larson, 696 N.E. 2d 793 - IL 1998
Summary: It would seem absurd, that if a physician admits and facility assigns a nurse to care for a known violent patient, that it has no legal obligation to protect that nurse against violence. In this case, a psychiatric patient sought admission to facility. On admission, he threatened to attack a nurse. When the patient would follow through on his threat, the nurse was denied legal recourse against the psychiatrist who could have taken precautions against the attack
http://www.nursefriendly.com/nursing/clinical.cases/081599.htm

August 8, 1999: Pregnant Prison Inmate Complains of Miscarriage, Corrections Nurse On Duty Ignores Symptoms?
Ferris v. County of Kennebec, 44 5. Supp.2d 62 -ME (1999)
Summary: Nursing assessment skills are one of our most valuable assets. They allow us to effectively evaluate our patients and communicate significant findings to physicians and other members of the healthcare team. In this case, a pregnant woman with a previous history of miscarriage complained of vaginal bleeding and abdominal discomfort. The assessment performed by the nurse fell negligently short of the required standard of care.
http://www.nursefriendly.com/nursing/clinical.cases/080899.htm

August 1, 1999: Nursing Duty To Patient, "Does Not Guarantee" Safety Or Quality Of Care.
Summary: When a nurse accepts report and responsibility for the care of a patient a duty to the patient is also accepted. This duty is to provide a reasonable standard of care as defined by the Nurse Practice Act of the individual state and the facility Policy & Procedures. In this case, a post-op abdominal aneurysm repair patient was injured after falling from his bed to the floor. When a lawsuit was filed the court initially mistook expert testimony to imply the role of the nurse includes a guarantee of safety.
Downey v. Mobile Infirmary Med. Ctr. - 662 So. 2d 1152 (1995).
http://www.nursefriendly.com/nursing/clinical.cases/080199.htm

July 18, 1999: Good Samaritan Laws & Acts. Do They Cover Nurses Volunteering Nursing Care When A Citizen Goes Anaphylactic.
"Off-duty" healthcare professionals rendering Emergency aid are in most cases "covered" by the Good Samaritan Acts. These are laws enacted in each state that provide some degree of immunity from liability for good faith efforts in giving emergency care. In this case, a nurse and physician were sued for providing assistance in a volunteer function at a "first-aid" station. Good Samaritan "immunity" was not recognized by the courts.
Boccasile v. Cajun Music Ltd. 694 A 2d 686 - RI (1997)
http://www.nursefriendly.com/nursing/clinical.cases/071899.htm

July 11, 1999: Nursing Home Rehabilitation Stay Proves Terminal. Was Quality of Care Given An Issue?
Nursing homes are frequently a patient's destination for rehabilitation following surgery. Common conditions fitting this bill include large bone fractures, hip replacements and stroke. Following these acute episodes, the patients are too unstable to go home and not "sick" enough to have their hospital stays reimbursed by insurance companies. The purpose of admission to a nursing home is to help the patient regain lost function, strength and health. In this case, the patient would remain in the Nursing Home till her death of complications. Lloyd v. County of Du Page, 707 NE.2d 1252 - IL (1999)
http://www.nursefriendly.com/nursing/clinical.cases/071199.htm

Sources:

1. 40 RRNL 4 (September 1999)

2. Canadian Medical Association. 1998. Clinical Practice Guidelines For The Care And Treatment Of Breast Cancer. Retrieved October 24, 1999 from the World Wide Web. http://www.cma.ca/cmaj/vol-158/issue-3/breastcpg/0003.htm

3. Homeopathy Clinic. No Date given. Breast Cancer: Retrieved October 24, 1999 from the World Wide Web. http://www.homoeopathyclinic.com/

The Uniform Resource Locator (URL) or Internet Street Address of this page is
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Send comments and mail to Andrew Lopez, RN

Created on October 24, 1999

Last updated by Andrew Lopez, RN on Monday, January 25, 2010

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