When I take the deposition of a registered nurse (RN), I often ask questions about the administration of medications. Nurses and their attorneys often try the “Nuremberg defense” of “I was just following orders,” but in reality, nurses owe their patients a higher level of care.
Texas Board of Nursing Rule 217.11(1)(C) requires all nurses (not just RNs) to know the rationale for and the effects of medications and to correctly administer them.
• Rationale: Nurses have to understand the reason for a medication prescribed by a physician, physician assistant (PA), or nurse practitioner (NP).
• Effects: Nurses must know how the patient is expected to respond to the administration of medication and the signs that something is wrong.
First doses of a new medication
Hospitals are required to adopt medication administration policies and procedures that address the timing of medication administration and nursing responsibilities for monitoring patient responses.
This is an issue in a case that we’re currently handling against a Kingwood, Texas hospital and other defendants. We’ll call our client Charles.
The Kingwood hospital has a “First Dose Monitoring” policy and procedure, which says:
• The hospital will maintain a process to monitor the response of the patient to the first dose(s) of a medication, which is new to a patient while the patient is under the direct care of the hospital.
• Nursing will communicate to the patient on all new medications the drug’s indication (what it is for) and common and/or are significant side effects. If the nurse is unsure about the medication indication or side effects, he or she should call the pharmacy for clarification.
• Nursing should assess the patient more frequently for the first hour of administration.
• Nursing will document side effects, if any and the nursing notes.
• Education will take place to ensure that the patient and his or her family understand the allergy/adverse drug reaction and which drugs need to be avoided. Education will be documented in the patient's medical record.
This policy is comprehensive. It clearly requires nurses to do more than simply administer medication following an order. It requires critical thinking and communication with the patient. I wonder how often the hospital’s nurses actually follow the policy. I wonder if how many of them even know it exists, for that matter.
Charles was in the hospital emergency department after being injured in a fall around 7:00 pm. Over the next 9 hours, he was medicated with potent painkillers including ketamine, fentanyl, ibuprofen, and morphine. Despite ongoing severe pain, the emergency physician decided to discharge the patient. After the discharge decision, a registered nurse asked the doctor for yet another pain medication order for Charles. The physician ordered oral Norco.
Just 9 minutes later the nurse discharged Charles and documented that the ER physician was aware of his ongoing weakness. In case you’re wondering what “weakness” means, Charles and his family testified that he couldn’t even stand up or move his legs. The ER doctor and nurses don’t recall. Everyone agrees that it took three people to move Charles into a wheelchair and load him into a vehicle to go home.
Despite the fact that Charles was in a potential polypharmacy state from being given so many powerful narcotic pain medications, the ER nurse disregarded the hospital’s First Dose Monitoring policy and sent him on his way.
Our experts believe that the registered nurse should have at least delayed discharged and spoken up and advocated for more time to evaluate this patient’s condition. Under the hospital policy, 9 minutes is not enough time to evaluate the patient’s response to a new medication—the RN was supposed to monitor Charles closely for 60 minutes. We also believe the nurse should’ve posed more questions asked about Charles’s continued weakness, which would have probably prompted a repeated physical exam by the ER doctor.
Unfortunately, Charles was sent home with an undiagnosed spinal cord injury. According to our spine surgery expert, if he had been appropriately diagnosed and treated, he would have avoided the permanent neurological problems that he now has.
In my view, this case illustrates an unengaged nursing staff that’s going through the motions rather than exercising critical thinking to provide individualized patient care. While the ER nurse’s failure to comply with the first dose policy didn’t lead to a medication complication or adverse event, it was a factor in Charles’ inappropriate discharge from the hospital and contributed to grave harm.
If you’ve been seriously injured because of poor hospital care in Texas, then contact a top-rated, experienced Texas medical malpractice attorney for a free consultation about your potential case.
