Ellen K. Murphy

NASPE Expert Consensus Document: Use of IV (Conscious) Sedation/Analgesia by Nonanesthesia Personnel in Patients Undergoing Arrhythmia Specific Diagnostic, Therapeutic, and Surgical Procedures

Use of IV (Conscious) Sedation/Analgesia by Nonanesthesia Personnel in Patients Undergoing Arrhythmia Specific Diagnostic, Therapeutic, and Surgical Procedures. This article is intended to inform practitioners, payers, and other interested parties of the opinion of the North American Society of Pacing and Electrophysiology (NASPE) concerning evolving areas of clinical practice or technologies or both, that are widely available or are new to the practice community. Expert, consensus documents are so designated because the evidence base and experience with the technology or clinical practice are not yet sufficiently well developed, or rigorously controlled trials are not yet available that would support a more definitive statement. This article has been endorsed by the American College of Cardiology, October 1997.

Captain of the ship doctrine continues to take on water.

The captain of the ship doctrine, which has been interpreted to mean that the surgeons mere presence in the OR subjects him or her to legal liability for everyones negligence in that room (akin to the responsibility of the captain of a ship who is held responsible for everything that happens on that ship), emerged in 1949 and grew in popularity through the 1950s. The major reason for this doctrines popularity was that injured patients were precluded from suing hospitals under the then applicable charitable immunity doctrine. Charitable immunity declined in the 1960s, and by the 1970s, so too was the captain of the ship doctrine in decline. Pennsylvania, which first used the picturesque phrase in 1949, rejected the doctrine in 1974. In the meantime, it has come under much criticism, even among states that adopted it. Despite this decline and despite court language that sometimes borders on ridicule (e.g., anachronistic, prostrate doctrine, indiscriminate repetition), the felicity of the phrase has kept it alive in some states and in many ORs, even in states that have expressly rejected the doctrine. Even more than 20 years after its first rejection, however, courts still are being asked to adopt the doctrine. In 2001, the Wisconsin Supreme Court declined to adopt the doctrine, adding to the litany of states that have taken an express position against it.

Informed consent: Part III

Perioperative nurses are concerned about their patients understanding the procedures they will undergo. The legal system agrees that patients have the right to be informed about and consent to surgical procedures; informed consent is a legal right. No state, however, has recognized a formal role for the perioperative nurse in the enforcement of this right. Case law has consistently found that the necessary interchange for informed consent is vested in the patient-physician relationship, and it views broadening this legal responsibility as more disruptive than beneficial. When everyone is responsible, it is more difficult to ensure that someone actually talks to the patient. Present law makes that someone the surgeon. The role of the perioperative nurse includes informing the surgeon if the patients informed consent has not been documented in accordance with agency policy, documenting having done so, and taking any additional actions required by agency policy. Perioperative nurses who suspect overreaching by surgeons should inform their administrators. The perioperative nurse should not unilaterally get involved in the physician-patient relationship. The patient has sought the services of the surgeon, not the nurse.

Can the RN first assistant be held liable for patient injury

In summary, if an action of the RN first assistant causes a patient injury, both the primary surgeon and the RN first assistant could be liable. The primary surgeon could be liable for failure to see that the operation was performed with due care. At least one state appellate court has found that this is a nondelegable duty of the primary surgeon. The RN first assistant could be liable if the action that caused the patient injury was not in accordance with what a reasonable and prudent first assistant would have done. If first assisting is included within the scope of nursing practice by rule or statute in that state, the RN first assistant action could be measured against what an RN first assistant would have done, even though first assisting has traditionally been a physicians role. The fact that first assisting may be within the scope of nursing practice for some procedures and patient conditions does not mean the nurse should be allowed to assist on all procedures or in all patient conditions. The institution may have an independent duty to its patients to determine which patient procedures and conditions are appropriate for an RN first assistant.

Applications of the ‘captain of the ship’ doctrine

“Under the “captain of the ship” doctrine the surgeon is likened to the captain of a ship, and it is his or her duty to control everything that is going on in the operating room. Liability is imposed by virtue of the surgeons status, and it can be imposed without actually showing that the surgeon is in control (Thomas vs Raleigh general Hospital 358 SE 2d 222 [WVa 1987]).

Incident reports may or may not be privileged information

Whether incident reports are discoverable depends on the purpose of the reports and the laws of the state where the reports are filed. Subtle differences in state laws and/or how reports are used can make major differences in the determination. These differences are for hospital attorneys to study and consider. In addition to anticipating litigation, hospitals may use incident reports to promote hospital safety and prevent general losses. The hospital, not the nurse, decides if incident reports will be used in a manner more likely to protect the reports from discovery or if protection from discovery is of less concern (either because of state law or corporate philosophy). These decisions will determine how the forms are printed, when reports should be filed, what information is required, how many copies are made, and to whom the copies are distributed. Perioperative nurses need only follow the facilitys policy and procedure for completing and filing incident reports. If the hospital attempts to protect reports from discovery, it is especially important that the procedure be followed precisely.

Preventing a successful malpractice claim.

All of these strategies combine to make it less likely that a suit will be filed. But the strategies of complying with the standard of care and accurately documenting that care also combine to make it less likely that a suit will be successful. Injury is just one element of a successful malpractice suit. The plaintiffs attorney must also convince the judge or jury that the defendant failed to meet the standard of care and that failure caused the patients injury. By complying with the standards of care and documenting that care, the nurse makes it easier for his or her attorney to counter arguments that the standard of care was not met. Accurate documentation can also fortify arguments that the nurses actions did not cause the injury. There is nothing magical about these five strategies. Nurses will recognize each as actions good nurses perform in the course of their practice. Providing good nursing care also provides the best legal protection.