Case Study:
Mrs. Brown’s Chart
You are a nurse in a multiphysician office that treats oncology patients. Mrs. Brown, a patient seen by Dr. Watson in your office, was recently diagnosed with invasive cancer. She started radiation treatments last week. Her husband attends her radiation treatments and office visits with her and seems to be very devoted. They both are very interested in her progress.
Although they have asked many questions during the last two office visits and you have given truthful answers, Dr. Watson’s interactions have sometimes been a bit short and you felt that Mr. and Mrs. Brown may have left with unanswered questions. In addition, Dr. Watson has not shared much with them yet about Mrs. Brown’s prognosis as he continues to refine his differential diagnosis.
Today, when you walk into Mrs. Brown’s exam room, you find Mr. Brown reading her electronic record on the computer tablet that was inadvertently left on the counter in her room. The look on his face is one of feeling overwhelmed and confused.
CONSIDER:
Identify several alternatives for action that you have. Discuss what you would do and why. Is there a problem here? What follow-up is indicated?
Analysis
The nurse needs to determine the most important goal in this situation. Possible goals include (a) eliminating Mr. Brown’s access to the medical record as soon as possible, (b) protecting the privacy of Mrs. Brown, (c) gathering more information, or (d) becoming an advocate for the Browns.
In solving the case, it is apparent that not enough information has been gathered. Mr. Brown has already viewed at least a portion of his wife’s electronic medical record. Usually, the danger in patients’ families reading a patient’s record lies in the direction of their not understanding the information contained within or the patient’s privacy being invaded because the patient has not consented to family members’ access to their records.
Using this as the basis for rationale, the nurse could use the following approach:
Clarify that Mr. Brown has Mrs. Brown’s permission to read her records by asking her directly.
Ask Mr. Brown if there is anything in the electronic health record that he did not understand or anything that he questions. You may even ask him to summarize what he has read. Clarify the things that are appropriate for the nurse to address, such as terminology, procedures, and nursing care.
Refer questions that are inappropriate for the nurse to answer to the physician and let Mr. Brown know that you will help him in talking with the physician regarding the medical plan and prognosis.
When finished talking with Mr. Brown, the nurse should secure the electronic health record.
The nurse should notify Dr. Watson about the incident and Mr. Brown’s concerns and assist the Browns in obtaining the information they have requested.
Conclusion
The nurse first gathered more information before becoming the adversary or advocate. It is possible that the Browns had only simple questions to ask and that the problem was a lack of communication between staff and their patients rather than a physician–patient communication deficit. Legally, patients have a right to understand what is happening to them, and that should be the basis for the decisions in this case.
Option #1:
Who Is Responsible for Harm to This Patient? You Decide
You are a surgical nurse at Memorial Hospital. At 4 PM, you receive a patient from the recovery room who has had a total hip replacement. You note that the hip dressings are saturated with blood but are aware that total hip replacements frequently have some postoperative oozing from the wound. There is an order on the chart to reinforce the dressing as needed, and you do so. When you next check the dressing at 6 PM, you find the reinforcements saturated and drainage on the bed linen. You call the physician and tell her that you believe the patient is bleeding too heavily. The physician reassures you that the amount of bleeding you have described is not excessive but encourages you to continue to monitor the patient closely. You recheck the patient’s dressings at 7 and 8 PM. You again call the physician and tell her that the bleeding still looks too heavy. She again reassures you and tells you to continue to watch the patient closely. At 10 PM, the patient’s blood pressure becomes nonpalpable, and she goes into shock. You summon the doctor, and she comes immediately.
CONSIDER:
What are the legal ramifications of this case? Using the components of professional negligence outlined in the table below, determine who in this case is guilty of malpractice. Justify your answer. At what point in the scenario should each character have altered his or her actions to reduce the probability of a negative outcome?
COMPONENTS OF PROFESSIONAL NEGLIGENCE
Elements of Liability
Explanation
Example: Giving Medications
- Duty to use due care (defined by the standard of care)
The care that should be given under the circumstances (what the reasonably prudent nurse would have done)
A nurse should give medications accurately, completely, and on time. - Failure to meet standard of care (breach of duty)
Not giving the care that should be given under the circumstances
A nurse fails to give medications accurately, completely, or on time. - Foreseeability of harm
The nurse must have reasonable access to information about whether the possibility of harm exists.
The drug handbook specifies that the wrong dosage or route may cause injury. - A direct relationship between failure to meet the standard of care (breach) and injury can be proved.
Patient is harmed because proper care is not given.
Wrong dosage causes the patient to have a convulsion. - Injury
Actual harm results to the patient.
Convulsion or other serious complication occurs.
Option #2
Lawsuits and Liability
Discuss the following questions:
Do you believe that there are unnecessary lawsuits in the health-care industry? What criteria can be used to distinguish between appropriate and unnecessary lawsuits?
Have you ever advised a friend or family member to sue to recover damages that you believed they suffered as a result of poor-quality health care? What motivated you to encourage them to do so?
Do you think that you will make clinical errors in judgment as a nurse? If so, what types of errors should be considered acceptable (if any) and what types are not acceptable?
Do you believe that the recent national spotlight on medical error identification and prevention will encourage the reporting of medical errors when they do occur?
OPTION #3
Is It Really Informed Consent?
You are a staff nurse in a surgical unit. Shortly after reporting for duty, you make rounds on all your patients. Mrs. Jones is a 36-year-old woman scheduled for a bilateral salpingo-oophorectomy and hysterectomy. In the course of conversation, Mrs. Jones comments that she is glad she will not be undergoing menopause as a result of this surgery. She elaborates by stating that one of her friends had surgery that resulted in “surgical menopause” and that it was devastating to her. You return to the chart and check the surgical permit and doctor’s progress notes. The operating room permit reads “bilateral salpingo-oophorectomy and hysterectomy,” and it is signed by Mrs. Jones. The physician has noted “discussed surgery with patient” in the progress notes.
You return to Mrs. Jones’s room and ask her what type of surgery she is having. She states, “I’m having my uterus removed.” You phone the physician and relate your information to the surgeon who says, “Mrs. Jones knows that I will take out her ovaries if necessary; I’ve discussed it with her. She signed the permit. Now, please get her ready for surgery—she is the next case.”
CONSIDER:
Discuss what you should do at this point. Why did you select this course of action? What issues are involved here? Be able to discuss legal ramifications of this case.
OPTION #4
Where Does Your Responsibility Lie?
Mrs. Shin is a 68-year-old patient with liver cancer. She has been admitted to the oncology unit at Memorial Hospital. Her admitting physician has advised chemotherapy, even though she believes that there is little chance of it working. The patient asks her doctor, in your presence, if there is an alternative treatment to chemotherapy. She replies, “Nothing else has proved to be effective. Everything else is quackery, and you would be wasting your money.” After the doctor leaves, the patient and her family ask you if you know anything about alternative treatments. When you indicate that you do have some current literature available, they beg you to share your information with them.
CONSIDER:
What do you do? What is your legal responsibility to your patient, the doctor, and the hospital? Using your knowledge of the legal process, the Nurse Practice Act, patients’ rights, and legal precedents (look for the case Tuma v. Board of Nursing, 1979; The Law, Science & Public Health Law, n.d. (Links to an external site.)), explain what you would do and defend your decision.
OPTION #5
Legal Ramifications for Exceeding One’s Duties
You have been the evening charge nurse in the emergency department at Memorial Hospital for the last 2 years. Besides yourself, you have two LVNs and four RNs working in your department. Your normal staffing is to have two RNs and one LVN on duty Monday through Thursday and one LVN and three RNs on duty during the weekend.
It has become apparent that one of the LVNs, Maggie, resents the recently imposed limitations of LVN duties because she has had 10 years of experience in nursing, including a tour of duty as a medic in the first Gulf War. The emergency department physicians admire her and are always asking her to assist them with any minor wound repair. Occasionally, she has exceeded her job description as an LVN in the hospital, although she has done nothing illegal of which you are aware. You have given her satisfactory performance evaluations in the past, even though everyone is aware that she sometimes pretends to be a “junior physician.” You also suspect that the physicians sometimes allow her to perform duties outside her licensure, but you have not investigated this or actually seen it yourself.
Tonight, you come back from supper and find Maggie suturing a deep laceration while the physician looks on. They both realize that you are upset, and the physician takes over the suturing. Later, the doctor comes to you and says, “Don’t worry! She does a great job, and I’ll take the responsibility for her actions.” You are not sure what you should do. Maggie is a good employee, and taking any action will result in unit conflict.
CONSIDER:
What are the legal ramifications of this case? Discuss what you should do, if anything. What responsibility and liability exist for the physician, Maggie, and yourself? Use appropriate rationale to support your decision.
OPTION #6
To Float or Not to Float
You have been an obstetrical staff nurse at Memorial Hospital for 25 years. The obstetrical unit census has been abnormally low lately, although the patient census in other areas of the hospital has been extremely high. When you arrive at work today, you are told to float to the thoracic surgery unit. This is a specialized unit, and you feel ill prepared to work with the equipment on the unit and the type of patients who are there. You call the staffing office and ask to be reassigned to a different area. You are told that the entire hospital is critically short staffed, that the thoracic surgery unit is four nurses short, and that you are at least as well equipped to handle that unit as the other three staff who also are being floated. Now, your anxiety level is even higher. You will be expected to handle a full RN patient load. You also are aware that more than half of the staff on the unit today will have no experience in thoracic surgery. You consider whether to refuse to float. You do not want to place your nursing license in jeopardy, yet you feel conflicting obligations.
CONSIDER:
To whom do you have conflicting obligations? You have little time to make this decision. Outline the steps that you use to reach your final decision. Identify the legal and ethical ramifications that may result from your decision. Are they in conflict?
OPTION #7
Is It Your Responsibility to Force the Surgeon to See His Patient?
Jimmy Smith is a 19-year-old male who had a severe compound fracture of his tibia today in football practice. He returned from the surgery to set and cast the leg at 4 PM today. The evening shift reported that he was having quite a bit of swelling from the severe trauma that accompanied the fracture, but that the toes on the effected leg were warm and he had good pedal pulses.
By the time you received report tonight at 11 PM, and went to check on Jimmy, you felt that his pedal pulses were slightly diminished and his foot was slightly cool to the touch. By 2 AM, you felt the swelling had increased slightly and his toes were quite cool although they were not blue.
You phoned his physician and he was quite upset to be awakened in the middle of the night. He instructed you to put ice on the cast and to elevate Jimmy’s leg higher to reduce the swelling. He promised you that he would see Jimmy first thing in the morning. As the night wears on you become increasingly alarmed. By the time the night supervisor arrived at 4 AM, you were so concerned that you asked her to check the casted leg. The supervisor rushed out of the room and said, “The circulation in this boy’s leg is severely compromised, why haven’t you gotten the doctor here to cut the cast?”
CONSIDER:
Have you committed malpractice? Has the doctor? What is the nurse’s responsibility in reporting a patient condition’s to their physician? Examine the elements of malpractice. If there is permanent damage to Jimmy’s leg, who will be liable for the failure to take action soon enough to prevent injury?
Scenarios from:
Marquis, B. L., & Huston, C. J. (2017). Leadership roles and management functions in nursing: Theory and application(9th ed.). Philadelphia: Wolters Kluwer Health.
Sample Solution
