medical-legal aspects of nurse anesthetist practice

Medical-Legal Aspects of Nurse Medical-Legal Aspects of Nurse Anesthetist PracticeAnesthetist Practice

Jeffrey Groom, PhD, CRNA, ARNPFIU Anesthesiology Nursing Program

• A Professional Study and Resource Guide for the CRNAChapters 5,6,7

• AANA General Counsel Gene Blumenreich, JD• AANA Legal Briefs – Newsletter/Journal/AANA Web• Lecture does not constitute legal advice and does

not substitute for the services of an licensed attorney

Medical-Legal Aspects of Nurse Anesthetist

Practice

Relationship of Medicine & Law

• Forensic Medicine• Regulation of service

& health professionals• Regulation between parties

Patients & Providers

Sources of Law

• Constitution– US Constitution– State Constitution

• Statutes– Federal and State– Administrative Regulations

• Common Law– Case law – Doctrine of Stare Decisis– Fair, Consistent, Predictable, Effectuates public policy

Federal – State – Local

Interrelationship of LawsCONSTITUTION

Government

Legislative JudicialExecutive

Administrative Agencies

Enacts

Statutes

Creates

Empowers Enforce

LawsAmend

or Abolish

Administrative Regulations

Interpret Creates

Constitution

Common Law

Create-Execute-Judge

AdministrativeAgencies

Attorney Gen

Boards

CRNA’s and the LAW

• Federal vs State vs Local• Criminal vs. Civil

– Adult/Juvi/Family vs Contracts/Torts

• Substantive vs Procedural• Laws vs. Administrative Rules

CRNA’s and the LAW

ADMINISTRATIVE CRIMINAL CIVILPerception is biggest area of concern is

malpractice (civil)In reality, the numbers show just the opposite….

CRNA’s and the LAW

• Florida Nurse Practice Act– ARNP

• Federal/State Regulatory Statutes– DEA, FDA, HICFA

• Council on Certification of NAs– CRNA

• Practice Facility– JCAHO, Credentialing & Staff Privileges

• Practice Group– Protocols and Policies

• Liability Insurance Provider– Policy Terms – Limits - Provisions

• Medicare and Medicaid Regulations– National Provider Identifier ( http://npienumerator.com/ )

CRNAs and the LAW

• Florida Nurse Practice Acthttp://www.leg.state.fl.us/Statutes/index.cfm?Mode=View%20Statutes&Submenu=1&Tab=statutes

• Laws vs. Administrative Ruleshttp://www.leg.state.fl.us/Statutes/index.cfm?Mode=View%20Statutes&Submenu=1&Tab=statutes

• Department of Health – Medical Quality Assurance Servicehttp://www.doh.state.fl.us/mqa/index.html

• Florida Nurse Practice Acthttp://www.leg.state.fl.us/Statutes/index.cfm?Mode=View%20Statutes&Submenu=1&Tab=statutes

• Laws vs. Administrative Ruleshttp://www.leg.state.fl.us/Statutes/index.cfm?Mode=View%20Statutes&Submenu=1&Tab=statutes

• Department of Health – Medical Quality Assurance Servicehttp://www.doh.state.fl.us/mqa/index.html

• Florida Nurse Practice Acthttp://www.leg.state.fl.us/Statutes/index.cfm?Mode=View%20Statutes&Submenu=1&Tab=statutes

• Laws vs. Administrative Ruleshttp://www.leg.state.fl.us/Statutes/index.cfm?Mode=View%20Statutes&Submenu=1&Tab=statutes

• Department of Health – Medical Quality Assurance Servicehttp://www.doh.state.fl.us/mqa/index.html

• Individual vs Group Practice• Fiduciary Relationship• Privileged Communications

Provider – Patient Relationship

Provider – Patient Relationship

•Contractual Relationship(Service contract vs Sale contract)

–Offer–Consideration–Acceptance

Duty of Providers to Patients• Practice at professional level• Make full disclosure• Protect confidence• Offer continuing treatment• Seek consultation when indicated

Provider – Patient Relationship

Provider – Patient Relationship

Duty of Patients to Providers• Make full disclosure• Full cooperation in treatment• Pay for services rendered

Provider – Patient Relationship

Breech of Contract vs Negligence

DUTIES

1. Professional Care

2. Disclosure

3. Confidence

4. Treatment

5. Consultation

Professional Negligence

Breech of Contract

Intentional Tort

Breech of Duty

Criminal and Negligence

Action

• Abandonment• Assault• Battery• Breech of Confidence• Defamation• False Imprisonment• Fraud• Intentional infliction of emotional harm• Invasion of privacy

Intentional Torts

• Malpractice is negligence within a professional activity

• Tort is a civil wrong committed by:– action or omission– intentional or negligent

Professional Negligence

Most actions for negligence are for: - omission (what should have been done and was not) - negligence (no reason not to have done what was omitted)

Perception- most malpractice is for something done wrong

• Anyone can allege or sue for negligence. (Didn’t listen – Didn’t care)

• Whether or not negligence occurred is decided in court.

• Proof of negligence:– Duty– Breech– Injury– Causation– Damage

Professional Negligence

Dowe, Shaftem & Nailem

305-555-1212

305-555-1212

Analysis of negligence:• Duty – contractual relationship• Breech – standard of care• Injury – substantiated injury• Causation – proximate causation• Damage – special, general, punitive

Professional Negligence

Standard of Care• Reasonable person vs. professional• Local practice vs nationwide• Anesthesia care – single standard of care• Standards of Practice

– Professional Organizations– Practice Standards and Guidelines

• Changing standards– Advances in practice (Washington vs. Washington Hospital – 1987)

– Common law

• Standard of Care in the Courtroom

Professional Negligence

Professional Negligence

Res ipsa loquitur• Defendant in exclusive control• Patient not contributory negligent• Patient did not observe negligence• Could not have occurred otherwise• Common knowledge that the act

would cause injury

Defenses to Negligence Action• Immunity• Conduct met standard of care• Contributory negligence• Comparative negligence• Assumption of risk• Consent

Professional Negligence

1. Dose of anesthetics required to produce general anesthesia is very close to, or exceeds the LD50.

2. General anesthetics deprive patients of their protective respiratory reflexes risking obstruction and aspiration.

3. Airway management problems are not uncommon thus risking hypoxia or anoxia.

4. Some general anesthetics and all muscle relaxants depress or obliterate spontaneous respiration.

Liability of Anesthesiology

• Some components of balanced general anesthesia adversely affect sympathetic activity, vasomotor tone, myocardial function, especially in patients on antihypertensives. Stage is set for potential hypotension, myocardial depression, and circulatory collapse.

• Some forms of regional anesthesia, spinal and epidural, may cause cardiovascular collapse from total spinal or cardiotoxicity.

Liability of Anesthesiology

• Attempts to produce spinal anesthesia may result in a high or total spinal, or produce spinal nerve or spinal cord injury.

• Techniques of invasive monitoring may produce adverse complications or death.

• Short term patient contact, and differing personnel from preop to intraop and postop.

• Team delivery is also team liability

Liability of Anesthesiology

Medical-Legal Aspects of Nurse Anesthetist Practice

Jeffrey Groom, PhD, CRNA, ARNPFIU Anesthesiology Nursing Program