This week we covered risk management and legal responsibilities of the nurse leader. Honestly, this is one of the parts of being a nurse leader that terrifies me the most. I don't want to have to make these kinds of difficult decisions regarding risk management, and legal stuff is so far from my thing, it's actually kind of funny to imagine myself dealing with much of it.
For our discussion this week, we were given this case study (modified from Nurses Service Organization (NSO)):
A 27 year old male patient was brought to the emergency department (ED) by paramedics. The patient was intoxicated, agitated, and aggressive. The patient was a frequent flyer in the ED. The patient's behavior limited the RN and ED staff from completing a comprehensive initial assessment. For the patient's safety, four point physical restraints were ordered by the ED physician. The RN requested that ED security apply the restraints, in accordance with hospital policy. Policy dictated that security perform a check of the patient for contraband.
The RN assigned the patient to a quiet seclusion room to decrease stimulation. The hope was to allow the patient to sleep and calm the patient. Per protocol, the RN assigned to care for the patient performed monitoring and assessment checks every 15 minutes. The RN missed one check due to a critically ill patient having complications. The RN documented the missed check along with all the completed checks in the patient's medical record.
Shortly after the last documented check, where the patient was resting and appeared more comfortable in the four point restraints, the patient attempted to free himself from the restraints by burning the restraints with a cigarette lighter. The linen on the gurney caught fire, resulting in 2nd, 3rd, and 4th degree burns to 25% of the patient's body. Both hands were burned, with the loss of two fingers on one of the hands. The patient required multiple surgeries and was left permanently disabled. The source of the cigarette lighter remains undetermined.
For our discussion this week, we were given this case study (modified from Nurses Service Organization (NSO)):
A 27 year old male patient was brought to the emergency department (ED) by paramedics. The patient was intoxicated, agitated, and aggressive. The patient was a frequent flyer in the ED. The patient's behavior limited the RN and ED staff from completing a comprehensive initial assessment. For the patient's safety, four point physical restraints were ordered by the ED physician. The RN requested that ED security apply the restraints, in accordance with hospital policy. Policy dictated that security perform a check of the patient for contraband.
The RN assigned the patient to a quiet seclusion room to decrease stimulation. The hope was to allow the patient to sleep and calm the patient. Per protocol, the RN assigned to care for the patient performed monitoring and assessment checks every 15 minutes. The RN missed one check due to a critically ill patient having complications. The RN documented the missed check along with all the completed checks in the patient's medical record.
Shortly after the last documented check, where the patient was resting and appeared more comfortable in the four point restraints, the patient attempted to free himself from the restraints by burning the restraints with a cigarette lighter. The linen on the gurney caught fire, resulting in 2nd, 3rd, and 4th degree burns to 25% of the patient's body. Both hands were burned, with the loss of two fingers on one of the hands. The patient required multiple surgeries and was left permanently disabled. The source of the cigarette lighter remains undetermined.
- As the ED Nurse Leader, what would be your course of action with the staff, patient, and the hospital?
- Why would you take that action?
- What are the legal ramifications?
- What changes need to occur to prevent this from occurring again?
This assignment was difficult for me. Honestly, I don't feel that the nurse in charge of the patient did anything wrong. Yes, those 15 minute checks are extremely important, but I guess what it comes down to is an ethical dilemma. At what point do you sacrifice one patient's (the patient in restraints) care for another patient's (the critically ill patient with complications) care? If I would have been in the same situation, I also would have been most concerned with the critically ill patient. The case study doesn't completely explain what that patient is experiencing, but if those complications are life threatening, how can I, in good faith, walk away from this patient to look in on a patient in restraints? I guess these kinds of issues are so difficult for me because I can honestly see myself in the situation and I can only guess at what I would do and how I would handle it.
What I decided was that my course of action with the staff would be to stress the importance of the 15 minute checks. I know that as a nurse, it can be extremely difficult to make time for a patient like that, especially when you have a critical patient. I would make sure to make suggestions for nurses in the department for things they can do in similar suggestions, such as asking another nurse (especially the charge nurse) to help them for a few minutes. I would also use this opportunity to stress the importance of teamwork. Nurses are busy people, and I totally get that, but if you have a second to help your teammate (coworker), you could really alleviate stress and potentially even reduce the risk of patient harm.
My course of action with the hospital would be to examine the policy related to restraints. I would have thought that with a patient in four point restraints, they should be required to have a one-to-one sitter with them at all times while they were in restraints. I would make a push for the hospital to further examine this policy (or lack of policy) and possibly make changes that would allow the nurses to more effectively care for these kinds of patients. Maybe if a nurse has a patient in four point restraints, they are only allowed to have one or two other "non-critical" patients. Maybe if a patient is in four point restraints, they are required to have a one-to-one sitter at all time. The 15 minute checks... perhaps monitoring could be done by the sitter (a CNA), and then the assessments by the nurse. This would allow the nurse to perform the checks more quickly and not feel like they were "stuck" in this patient's room while they were neglecting other, more "critical" patients.
Legal ramifications could be that the nurse or even the hospital is sued. The nurse could also lose her job, or even her license.
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As I mentioned, this kind of stuff is what terrifies me to be a nurse leader. I really, really don't want to have to ever deal with a situation like the one presented in this case study. I would feel so bad if the nurse lost her job, and like I mentioned before, I think it's because I can understand how she got into this situation, and I can see myself in a similar situation. The main thing I would have done differently would have been to attempt to get another nurse involved to help me. Then again, if you are dealing with a life and death situation with a critical patient, the nurse might not have even noticed that it was time to check her restraint patient until she had already missed the check. Ugh, such a difficult situation. I just don't know if I'm prepared to deal with everything that comes with being a leader.
My course of action with the hospital would be to examine the policy related to restraints. I would have thought that with a patient in four point restraints, they should be required to have a one-to-one sitter with them at all times while they were in restraints. I would make a push for the hospital to further examine this policy (or lack of policy) and possibly make changes that would allow the nurses to more effectively care for these kinds of patients. Maybe if a nurse has a patient in four point restraints, they are only allowed to have one or two other "non-critical" patients. Maybe if a patient is in four point restraints, they are required to have a one-to-one sitter at all time. The 15 minute checks... perhaps monitoring could be done by the sitter (a CNA), and then the assessments by the nurse. This would allow the nurse to perform the checks more quickly and not feel like they were "stuck" in this patient's room while they were neglecting other, more "critical" patients.
Legal ramifications could be that the nurse or even the hospital is sued. The nurse could also lose her job, or even her license.
As I mentioned, this kind of stuff is what terrifies me to be a nurse leader. I really, really don't want to have to ever deal with a situation like the one presented in this case study. I would feel so bad if the nurse lost her job, and like I mentioned before, I think it's because I can understand how she got into this situation, and I can see myself in a similar situation. The main thing I would have done differently would have been to attempt to get another nurse involved to help me. Then again, if you are dealing with a life and death situation with a critical patient, the nurse might not have even noticed that it was time to check her restraint patient until she had already missed the check. Ugh, such a difficult situation. I just don't know if I'm prepared to deal with everything that comes with being a leader.
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