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EDITOR'S NOTE: Nancy J. Brent, MS, JD, RN, brings more than 30 years of experience to her role as Nurse.com’s legal information columnist. Brent’s posts are designed for educational purposes only and are not to be taken as specific legal or other advice. Individuals who need advice on a specific incident or work situation should contact a nurse attorney or attorney in their state.
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By Nancy J. Brent
MS, JD, RN
Legal information columnist and attorney
The day after Ben was admitted to the ICU, his condition started to deteriorate. Initially, his 5 p.m. blood pressure was 81/53, below the threshold ordered by the surgeon. The nurses decided to wait and take a second blood pressure reading and at 6 p.m.; it was 79/45. The nurses contacted the surgeon and he ordered Albumin to be given, which was successful in improving the patient’s blood pressure for the next few hours. Later that same evening, the patient’s systolic blood pressure dropped again to 89, but the nurses waited for another reading. The next reading indicated a blood pressure of 80/56 with a heart rate in the 90s. The pulse rate was good and the lungs were clear.

Although the patient’s condition had changed and he was less responsive, falling asleep, complaining of chest tightness and exhibiting symptoms of kidney failure from a lack of blood flow, the nursing staff did not call the surgeon. According to standards of practice, these signs were consistent with the early onset of a heart attack. Neither the surgeon’s physician’s assistant nor his primary cardiologist ordered additional tests or treatments when they saw the patient the next morning. However, when the surgeon saw the patient, he ordered additional blood work and tests and took the patient for a cardiac catheterization. The patient died during the procedure from an anoxic cerebral event. Mrs. Williams, the patient’s wife and executrix of his estate, followed Indiana’s procedural requirements and filed a claim against the hospital, alleging professional negligence on the part of the hospital’s ICU nursing staff who cared for Ben. A jury returned a verdict on behalf of Mrs. Williams. The hospital appealed the decision. In affirming the jury trial decision, the Indian Appeals Court relied heavily on the testimony of Mrs. Williams’ expert witness, who clearly stated had the ICU nurses immediately notified the surgeon of the patient’s vital signs when they were below those he established for the patient, the patient would still be alive. In short, their failure to notify the surgeon caused the patient’s death. It is unclear why the nurses did not follow the parameters set by the surgeon and why they did not contact him when Ben’s behavioral condition also changed. Whatever the reason, their failure resulted in the patient’s death.
In keeping with the special skills and expertise of a critical care nurse, always:
  • Notify the patient’s physician or advanced practice nurse immediately when there is a change in the patient’s condition — time is of the essence.
  • Document completely the notification and if further patient orders are given.
  • Remember to practice critical care nursing consistent with standards of practice and the obligation of your legal standard of care.
  • Be ever mindful when caring for all patients.
  • Remember critical care nursing is built upon basic nursing knowledge and skills — never ignore their importance when caring for patients with an actual or potential high-risk health problem.
  • Remember you and only you are responsible and accountable for your care or non-care of patients.
As an employee, you also carry the potential liability of the employer on your shoulders under the legal doctrine of respondeat superior.

The physicians in this case were not held negligent because of an Indiana procedure that requires a case to go before a medical review panel before a lawsuit is filed. The panel held that the hospital, through its ICU nurses, and not the physicians, were responsible for the patient’s death.
Critical care nurses provide the highest nursing care in all practice settings — in short, wherever critically ill patients are found. This is a unique characteristic of this nursing practice.
But one thing that is not unique to this professional role is the potential for legal liability. Like nurses in other specialties, critical care nurses risk inclusion in a lawsuit for professional negligence if a patient is injured or dies during their provision of care. From 2000 to 2012, a common professional negligence/malpractice claim against nurses included the failure to update a physician on a patient's condition.
This type of claim may not happen often, and certainly not with critical care nurses. However, the following 2011 Indiana case (Elkhart General Hospital v. Williams) which involved ICU nurses, illustrates that it does happen.
Ben Williams’ cardiac stress test and echocardiogram were abnormal. His coronary angiogram showed severe blockages in the coronary arteries: a 95% blockage in the left main coronary artery and a total blockage of the mid-portion of the right coronary artery.

A cardiac surgeon was consulted who recommended immediate bypass surgery, which was done that day. The surgery was done without any complications and the patient was admitted to the ICU. Ben’s condition became stable and he was able to talk.

The surgeon had given specific instructions to the ICU nursing staff. They were to call him if the patient’s heart rate fell below 60 or rose above 120, if his systolic blood pressure fell below 90 or rose above 150, if his respiratory rate was greater than 28 or if his urine output was below 30.

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