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Thomas A. Sharon
Thomas A. Sharon
Contributor • (305) 814-7706

Critical Legal Issues in Critical Care: Standing Orders Notwithstanding

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Many questions come up regarding the failure of nurses to act in a timely manner. The Healthgrades report of July 2004 cited delays in responding to emergent life threatening changes in condition as the leading cause of the 195,000 per year unexpected hospital deaths in the U.S. Hence one might ask why this should be so when every hospital has registered nurses around the clock who are the patient's first line of defense against unexpected adverse outcomes. It would seem that more than many skilled and experienced nurses seem to be unable to make the required snappy decisions to provide what's needed to save lives. This is very strange because we have paramedics roaming the streets providing all kinds of emergency treatment with medical paraphernalia and medications on the basis of standing orders.

Thus, it is reasonable to expect that registered nurses should be able to provide the same type of first line defense in acute care hospitals and other inpatient facilities. However, according to number of hospital deaths by delay, the necessary immediate nursing response is not happening. The answer might well be in the absence of standing orders and/or the lack of providing the necessary education to bring staff nurses to a level where they can act with confidence and without undue hesitation. For example, in cases where there is an obvious life threatening problem, such as a blood sugar below 60, the attending nurse must be able to inject an ampoule of Dextrose 50% without delay. The same is true for starting an intravenous line in cases of shock or severe dehydration.

Case in point: South Florida

Recently, when I was on duty in an emergency room in South Florida, I found myself with 2 patients who had just arrived by ambulance almost at the same time. One had a blood sugar of 1,000 and the other had 30. They were both conscious and stable at that moment. The E.R. doctors where all busy with the four cardiac arrests that were going on at that moment; and there I was with two patients with life threatening conditions. I had to decide on my own which one to treat first and take immediate action. I first gave Dextrose 50% to the lady with the glucose of 30 and then gave insulin to the one with the level at 1,000. The standing orders that existed covered me for the treatments and the prioritization was a function of nursing judgment.

In conclusion, when there is a complaint of damages arising out of delayed response to a potentially life threatening condition, it will be necessary to find out if any standing orders existed and to obtain copies during discovery. It will also be helpful to know what education programs the hospital provides to its nurses to make certain that they have the knowledge to assess potentially life threatening situations and know what action to take without delay.

Tom Sharon is a nursing and patient-safety expert and author of With Liberty and Coverage for All: who shall live, who shall die, and how to survive under Obamacarea complete update on hospital mistakes and the Patient Protection and Affordable Care Act of 2010.