Evan is a psychiatric nurse working on an inpatient floor in a general community hospital. Mr. Girardi has been in a car accident, which has landed both him and his daughter in critical care. Because of Mr. Girardi’s extensive injuries, his physicians prescribe that he be put on light sedatives that do not induce coma but keep him sleepy and calm. They simultaneously decide not to immediately inform him of his daughter’s critical condition. The rationale for both decisions is their concern that he does not cry, which would cause extended damage to his perforated lung. Mr. Girardi is kept drowsy and motionless and as pain-free as possible. He has asked about his daughter, but when told that the staff will check on her, he is satisfied with that and drifts back to sleep.
Mr. Girardi’s wife arrives to stay with him. It is 3:18 am, and Evan has just administered Mr. Girardi a sedative through his IV set. Mrs. Girardi tells Evan that her husband took his last “kidney stone pill” at 6 pm with his dinner before he and his daughter left the house. “He’s overdue for that kidney stone pill,” Mrs. Girardi says. “He’s not supposed to skip that.”
Evan says, “He shouldn’t take anything else right now, but I’ll check that out.” She assures Mrs. Girardi that she’ll ask the doctor about that and leaves the room.
Fifteen minutes later, Evan returns, explaining that she consulted with the hospital surgeon, who checked with Mr. Girardi’s urologist. The urologist confirmed that the “kidney stone pill” was a painkiller, which, under the circumstances, should be discontinued as long as Mr. Girardi is on the more powerful IV sedatives.
“Oh, that’s okay,” Mrs. Girardi tells Evan. “He woke up a bit while you were gone, and I was able to give him his pills.”
Mr. Girardi suffers moderate complications from the IV sedative and oral analgesic combination, which extends his hospital stay by 2 days. The Girardis feel that the hospital should have been in better control of the overdose, saying that if the staff had been on top of things and supervising more closely, this would not have happened.
1. In the case of Mr. Girardi, do you think this case is most concerned with cause in fact, proximate cause, or foreseeability of harm?
Answer all the questions below each of the scenarios.
2. As Joe, a registered nurse, prepares the medication for the evening shift, he notices that two of his patients’ medications are missing. Both are bedtime Ativan (lorazepam). When he phones the pharmacy to send up the missing medications, the pharmacist responds, “You people need to watch your carts more carefully because this has become a pattern.” Shortly after, another patient complains to Joe that he did not receive his 5 p.m. Xanax (alprazolam). On the medication administration record, Beth has recorded that she has given the drugs. Joe suspects that Beth may be diverting the drugs.
a. What actions can Joe take regarding his suspicions of Beth?
b. If Beth admits that she has been diverting the drugs, should Joe’s next step be to report Beth to the supervisor or to the board of nursing?
c. When Joe talks to the nursing supervisor, should he identify Beth or should he state his suspicions in general terms?
3. One day, Linda arrives at work on the behavioral care unit. She is informed that the staffing office has requested that a nurse from the psychiatric unit report to the ICU. They need help in caring for an agitated car accident victim with a history of schizophrenia. Linda goes to the ICU and joins a nurse named Corey in providing care for the patient. Eventually, the patient is stabilized and goes to sleep, and Corey leaves the unit for a break. Because Linda is unfamiliar with the telemetry equipment, she fails to recognize that the patient is having an arrhythmia, and the patient experiences a cardiopulmonary arrest. Although he is successfully resuscitated, he suffers permanent brain damage.
a. Can Linda legally practice in this situation? (That is, does her registered nurse license permit her to practice in the ICU?)
b. Does the ability to practice legally in an area differ from the ability to practice competently in that area?
c. Did Linda have any legal or ethical grounds to refuse the assignment to the ICU?
d. What are the risks in accepting an assignment in an area of specialty in which you are professionally unprepared to practice?
e. Would there have been any way for Linda to minimize the risk of retaliation by the employer had she refused the assignment?
f. If Linda is negligent, is the hospital liable for any harm to the patient caused by her?
4. A 40-year-old man is admitted to the emergency department for a severe nosebleed and has both of his nostrils packed. Because of a history of alcoholism and the possibility for developing withdrawal symptoms, the patient is transferred to the psychiatric unit. His physician orders a private room, restraints, continuous monitoring, and 15-minute checks of vital signs and other indicators. At the next 15-minute check, the nurse discovers that the patient does not have a pulse or respiration. The patient had apparently inhaled the nasal packing and suffocated.
a. Does it sound as if the nurse was responsible for the patient’s death?
b. Was the order for the restraint appropriate for this type of patient?
c. What factors did you consider in making your determination?