Martin Chitwood, Scrubs Magazine’s resident attorney gives more tips on how to stay legally protected.
As a licensed professional, nurses have an ethical and legal responsibility to their patients. The standards you are held to are extremely high, and can get you into trouble legally if you don’t take steps to protect yourself. Aside from ensuring that you are always acting in the best interest of your patient, there are 5 steps you should always take that will assist in keeping you out of any legal hot water:
Get Signed Consent Forms
Anytime a procedure is ordered for a patient, they (or their authorized guardian) must sign a form that gives the practitioner consent. The consent form is a legal document stating that the patient:
- Understands what the procedure is for, what it entails, and what the alternatives are
- Has been given the opportunity to discuss this procedure with the physician or provider
- Knows what the risks and the benefits of the procedure are
- Is choosing to sign the forms
In the event that the patient does not want to give consent, there is a space on these forms designated for this as well. If you fail to have these forms signed, whether the procedure is performed or not, you may be held liable if harm comes to the patient as a result.
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Write Down EVERYTHING
Everything that a patient does while in your care is relevant, not matter how trivial it might seem. Document vital signs, medications, food, specimen collections and anything else related to their health onto their chart. This includes observations made during the time spent with them. If you make a mistake on the chart, put one line through it so that it is still legible, yet obviously an error. Then note the corrected information and the reason for the mistake.
Unless you have charted each and every step of the provided care, you could be held liable for any negative outcome. Charting is used to keep track of a patient’s progress, but it is also a great wall of protection for you if something goes wrong.
There are laws mandating that all health care providers are obligated to report suspected abuse in their vulnerable patients. This includes children, the elderly and domestic abuse. Whether the suspected abuse is physical, sexual, emotional or mental in nature, it is your job to the alert the correct authorities. If you fail at this, and something were to happen to that patient at a later date, you could be considered a negligent party in a lawsuit. If you suspect that a patient is being victimized, document your suspicions as well as the authoritative body you reported them to.
According to HIPAA (the Health Insurance Portability and Accountability Act) it is the responsibility of the nurse to keep patient information private, allowing only authorized health care providers access to it. If a patient’s right to privacy is somehow breached, the nurse is usually the first person who will be looked at. The increased use of the internet and electronic data bases has made this an even larger legal issue facing nurses. Protect yourself and your patients by only using secure networks when transferring medical information or storing it.
Manage the Medications
Nurses are instructed to practice the 5 “rights” of medication administration at all times, even if they are just giving a new mom a dose of Tylenol for pain. Those 5 “rights” mean checking that the medication being given is:
- The right dose
- The right drug
- Administered using the right route
- Administered at the right time
- Administered to the right patient
Paying close attention to every detail is crucial for giving medication to patients successfully. Thousands of patients are injured every year in the US for medication errors, some of which even result in death. Follow those 5 “rights” religiously and you can avoid having to protect your career for having given the wrong pills to a patient.
Nursing is not immune to mistakes, and the legal community does recognize that every one made by a nurse is not reason for a lawsuit. Some issues however can be construed as medical malpractice, and you will have to be able to prove that your actions were in line with the best interest of the patient. To protect yourself while caring for your patients, your best defense lies in documenting everything you do, and never deviating from the common standards of care.