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Nurses' duty to monitor patients and inform physicians
AUGUST 1997, VOL 66,NO 2 O R NURSING
L A W
Nurses‘ duty to monitor patients and inform physicians
N
urses today have a broad scope of responsibility as health care providers that requires them, under some circumstances, to exercise independent professional judgment. When nurses exercise their judgment negligently, they may be held liable because courts hold them to a correspondingly higher level of accountability.
D U N TO MONITOR AND INFORM Nurses have been held liable for their failure to monitor and/or promptly respond to patients by informing physicians of significant changes in patients’ conditions. Under these types of circumstances, nurses have an affmative duty to exercise their professional judgment to ensure that all adequate steps are taken to treat patients appropriately. Weiss v Goldfarb. A recent New Jersey case demonstrates circumstances under which nurses may be held responsible for failing to inform physicians about patients’ conditions. In Weiss v Goldfarb (684 A2d 994 [NJ 1996]), the personal representative of a patient who died after suffering a heart attack during dialysis brought a medical malpractice action against the hospital, three cardiologists, a nephrologist, two nurses, two residents, and the chair of the nephrology department. The complaint alleged that the health care providers responsible for the patient’s care were negligent because they permitted dialysis to take place without monitor-
ing the patient’s heart. The monitoring, the complaint alleged, would have alerted providers to the patient’s heart attack, which then could have been treated to prevent his death. The patient in this case was a 67-year-old man who had come to the dialysis unit from the hospital’s telemetry unit. He had been a patient in the telemetry unit since his arrival at the hospital two days earlier because of a variety of arrhythmia problems, and his heart had been monitored continuously. He suffered from long-term hypertension and various coronary and renal problems. The patient was placed immediately in the telemetry unit on his arrival at the hospital, which meant that he was connected automatically to a cardiac monitor under continuous observation. He arrived at the dialysis unit unconnected to a heart monitor, and the dialysis order from the nephrologist in charge of the patient’s dialysis treatment did not mention cardiac monitoring. The nephrologist visited the patient in the telemetry unit in the morning and decided that his condition was stable and that dialysis could be scheduled for that afternoon. One and one-half hours later, however, a telemetry nurse telephoned a cardiologist because the patient had developed a junctional rhythm, which is an abnormality that indicates potential serious risk to the patient. The patient’s heart rate returned to a normal sinus rhythm after another cardiologist recommended that he 321 AORN JOURNAL
walk around and discontinue certain medication. Although the patient’s entire medical record accompanied him to the dialysis unit, the dialysis nurse looked only at the nephrologist’s orders, as was her usual practice. The initial attending dialysis nurse was not even aware that the patient had come to the dialysis unit from the telemetry unit. In preparing the patient for dialysis, she noted he had an irregular heartbeat. She did not, however, report this irregularity to the nephrologist when she discussed details regarding the dialysis solution with him by telephone. The appellate court held that the trial court erred in dismissing the claim against the attending dialysis nurse and that the question of whether she was negligent for not informing the physician about the patient’s irregular heartbeat before dialysis began should have been submitted to the jury. The court based this conclusion on the testimony of the plaintiff‘s expert that when a dialysis nurse detects an irregular heartbeat, he or she is obligated to notify the physician immediately. This case demonstrates circumstances under which nurses must use their independent judgment to inform physicians when significant changes occur in patients’ conditions or, failing to do this, may be held individually liable. This liability will be imposed even though the nurse follows “the usual practice,” such
AUGUST 1997, VOL 66, NO 2
as the attending dialysis nurse’s checking only the nephrologist’s order. Nurses must familiarize themselves with the relevant standards of care for their areas of nursing. The duty to monitor patients and to inform physicians of significant changes does not mean that nurses are required to practice medicine by passing judgment on the efficacy of a course of treatment. To fulfill the duty of informing physicians, however, nurses must perform competent nursing assessments of patients to determine signs and symptoms significant to attending physicians’ diagnoses and treatments. This information is critical to allow physicians to make proper diagnoses and devise treatment plans for their patients. Berdyck v Shinde. In Berdyck v Shinde (613 NE2d 1014 [Ohio 1993]), a patient brought a malpractice suit against her obstetrician and a hospital for injuries resulting from a seizure. The plaintiff alleged that her injuries were proximately caused by the nurse’s failure to inform the physician that the patient had preeclampsia. The supreme court of Ohio reversed the trial court’s grant of summary judgment to the hospital and found that the question of whether the nurse failed to meet the duty to inform the physician was a jury question. The court noted the expert testimony that indicated that the nurse failed to inform the physician of the patient’s condition because she lacked the necessary knowledge and skill to make a competent nursing assessment of preeclampsia.
The patient, Donna Berdyck, had a history of preeclampsia. She arrived at the hospital at 3 AM complaining that something was wrong and was admitted to the obstetrics unit at 3: 10 AM by an RN. Ms Berdyck complained of
Testimony indicated the nurse lacked the knowledge and skill to make a competent nursing assessment. severe abdominal pain, nausea, and headache. The nurse took her blood pressure at 3:20 AM and found it to be elevated. She did not, however, notify Dr Shinde, Ms Berdyck’s obstetrician. The nurse again checked Ms Berdyck’s blood pressure at 3:40 AM and found it to be elevated, so she contacted Dr Shinde at approximately 4 AM. There was conflicting evidence regarding what the nurse related to Dr Shinde regarding Ms Berdyck’s condition. Five minutes after talking with Dr Shinde, the nurse took another blood pressure reading and discovered that Ms Berdyck’s blood pressure was 192/112. She did not make any further reports to Dr Shinde. Ms Berdyck suffered a grand ma1 seizure, which resulted in paralysis of the left side of her body. The court noted that it was generally agreed that Ms Berdy-
322 AORN JOURNAL
ck’s eclamptic seizure could have been prevented had magnesium sulfate been administered at or shortly before 4 AM. In reversing the trial court’s dismissal of the hospital on summary judgment, the court emphasized that the plaintiff‘s expert testified that an obstetric nurse should be aware of the signs and symptoms of preeclampsia. The nurse should have been aware of the signs and symptoms of preeclampsia so she could make a competent nursing assessment and inform Dr Shinde, allowing him to respond appropriately. CONCLUSION As the cases presented in this article demonstrate, the nurse’s role in the health care arena is expanding, and nurses are becoming an increasingly critical link between patients and physicians. Nurses must take affirmative steps to learn the applicable standards of care for their particular fields of practice. They must have the necessary skills to be able to make independent assessments of patients’ conditions and to be able to recognize signs and symptoms that they must communicate to patients’ physicians. K. SHANNON SMITH JD, ESQUIRE
SUSAN E. ZlEL RN, JD, ESQUIRE NELSON MULLINS RILEY& SCARBOROUGR, LLP COLUMBIA,SC The authors would like to thank Sandra S . Latham, RN, CNOR, staff nurse, Providence Hospital, Columbia, SC,for her help with this article.
L A W
Nurses‘ duty to monitor patients and inform physicians
N
urses today have a broad scope of responsibility as health care providers that requires them, under some circumstances, to exercise independent professional judgment. When nurses exercise their judgment negligently, they may be held liable because courts hold them to a correspondingly higher level of accountability.
D U N TO MONITOR AND INFORM Nurses have been held liable for their failure to monitor and/or promptly respond to patients by informing physicians of significant changes in patients’ conditions. Under these types of circumstances, nurses have an affmative duty to exercise their professional judgment to ensure that all adequate steps are taken to treat patients appropriately. Weiss v Goldfarb. A recent New Jersey case demonstrates circumstances under which nurses may be held responsible for failing to inform physicians about patients’ conditions. In Weiss v Goldfarb (684 A2d 994 [NJ 1996]), the personal representative of a patient who died after suffering a heart attack during dialysis brought a medical malpractice action against the hospital, three cardiologists, a nephrologist, two nurses, two residents, and the chair of the nephrology department. The complaint alleged that the health care providers responsible for the patient’s care were negligent because they permitted dialysis to take place without monitor-
ing the patient’s heart. The monitoring, the complaint alleged, would have alerted providers to the patient’s heart attack, which then could have been treated to prevent his death. The patient in this case was a 67-year-old man who had come to the dialysis unit from the hospital’s telemetry unit. He had been a patient in the telemetry unit since his arrival at the hospital two days earlier because of a variety of arrhythmia problems, and his heart had been monitored continuously. He suffered from long-term hypertension and various coronary and renal problems. The patient was placed immediately in the telemetry unit on his arrival at the hospital, which meant that he was connected automatically to a cardiac monitor under continuous observation. He arrived at the dialysis unit unconnected to a heart monitor, and the dialysis order from the nephrologist in charge of the patient’s dialysis treatment did not mention cardiac monitoring. The nephrologist visited the patient in the telemetry unit in the morning and decided that his condition was stable and that dialysis could be scheduled for that afternoon. One and one-half hours later, however, a telemetry nurse telephoned a cardiologist because the patient had developed a junctional rhythm, which is an abnormality that indicates potential serious risk to the patient. The patient’s heart rate returned to a normal sinus rhythm after another cardiologist recommended that he 321 AORN JOURNAL
walk around and discontinue certain medication. Although the patient’s entire medical record accompanied him to the dialysis unit, the dialysis nurse looked only at the nephrologist’s orders, as was her usual practice. The initial attending dialysis nurse was not even aware that the patient had come to the dialysis unit from the telemetry unit. In preparing the patient for dialysis, she noted he had an irregular heartbeat. She did not, however, report this irregularity to the nephrologist when she discussed details regarding the dialysis solution with him by telephone. The appellate court held that the trial court erred in dismissing the claim against the attending dialysis nurse and that the question of whether she was negligent for not informing the physician about the patient’s irregular heartbeat before dialysis began should have been submitted to the jury. The court based this conclusion on the testimony of the plaintiff‘s expert that when a dialysis nurse detects an irregular heartbeat, he or she is obligated to notify the physician immediately. This case demonstrates circumstances under which nurses must use their independent judgment to inform physicians when significant changes occur in patients’ conditions or, failing to do this, may be held individually liable. This liability will be imposed even though the nurse follows “the usual practice,” such
AUGUST 1997, VOL 66, NO 2
as the attending dialysis nurse’s checking only the nephrologist’s order. Nurses must familiarize themselves with the relevant standards of care for their areas of nursing. The duty to monitor patients and to inform physicians of significant changes does not mean that nurses are required to practice medicine by passing judgment on the efficacy of a course of treatment. To fulfill the duty of informing physicians, however, nurses must perform competent nursing assessments of patients to determine signs and symptoms significant to attending physicians’ diagnoses and treatments. This information is critical to allow physicians to make proper diagnoses and devise treatment plans for their patients. Berdyck v Shinde. In Berdyck v Shinde (613 NE2d 1014 [Ohio 1993]), a patient brought a malpractice suit against her obstetrician and a hospital for injuries resulting from a seizure. The plaintiff alleged that her injuries were proximately caused by the nurse’s failure to inform the physician that the patient had preeclampsia. The supreme court of Ohio reversed the trial court’s grant of summary judgment to the hospital and found that the question of whether the nurse failed to meet the duty to inform the physician was a jury question. The court noted the expert testimony that indicated that the nurse failed to inform the physician of the patient’s condition because she lacked the necessary knowledge and skill to make a competent nursing assessment of preeclampsia.
The patient, Donna Berdyck, had a history of preeclampsia. She arrived at the hospital at 3 AM complaining that something was wrong and was admitted to the obstetrics unit at 3: 10 AM by an RN. Ms Berdyck complained of
Testimony indicated the nurse lacked the knowledge and skill to make a competent nursing assessment. severe abdominal pain, nausea, and headache. The nurse took her blood pressure at 3:20 AM and found it to be elevated. She did not, however, notify Dr Shinde, Ms Berdyck’s obstetrician. The nurse again checked Ms Berdyck’s blood pressure at 3:40 AM and found it to be elevated, so she contacted Dr Shinde at approximately 4 AM. There was conflicting evidence regarding what the nurse related to Dr Shinde regarding Ms Berdyck’s condition. Five minutes after talking with Dr Shinde, the nurse took another blood pressure reading and discovered that Ms Berdyck’s blood pressure was 192/112. She did not make any further reports to Dr Shinde. Ms Berdyck suffered a grand ma1 seizure, which resulted in paralysis of the left side of her body. The court noted that it was generally agreed that Ms Berdy-
322 AORN JOURNAL
ck’s eclamptic seizure could have been prevented had magnesium sulfate been administered at or shortly before 4 AM. In reversing the trial court’s dismissal of the hospital on summary judgment, the court emphasized that the plaintiff‘s expert testified that an obstetric nurse should be aware of the signs and symptoms of preeclampsia. The nurse should have been aware of the signs and symptoms of preeclampsia so she could make a competent nursing assessment and inform Dr Shinde, allowing him to respond appropriately. CONCLUSION As the cases presented in this article demonstrate, the nurse’s role in the health care arena is expanding, and nurses are becoming an increasingly critical link between patients and physicians. Nurses must take affirmative steps to learn the applicable standards of care for their particular fields of practice. They must have the necessary skills to be able to make independent assessments of patients’ conditions and to be able to recognize signs and symptoms that they must communicate to patients’ physicians. K. SHANNON SMITH JD, ESQUIRE
SUSAN E. ZlEL RN, JD, ESQUIRE NELSON MULLINS RILEY& SCARBOROUGR, LLP COLUMBIA,SC The authors would like to thank Sandra S . Latham, RN, CNOR, staff nurse, Providence Hospital, Columbia, SC,for her help with this article.