Question for LJ Hospital Procedure Genie

[mollyringle]

A question for those who know how hospitals work (or spend a lot of time watching House or Scrubs):

When a nurse gives a terminal cancer patient his requested and allowed dose of morphine to ease pain, does she record the time and dosage on his chart, or somewhere else? Or do the computers hooked up to him sense and record the dose, or what?

Also: if a patient dies of an accidental overdose of morphine, what are the odds that the hospital would fire the nurse responsible but not tell the family the real cause of death? For instance, might they--to avoid investigation and lawsuits--tell the family that the patient died in his sleep of his terminal cancer? Yes, of course it's wrong, but does it happen? I'm figuring, in this scenario, the nurse might not protest, because if they did make the facts public, she could lose her nursing license; whereas by simply having to leave this particular hospital, she could still get work as a nurse elsewhere.

And yes, this is just for a story; no need to worry.

Thanks in advance!

Comments

[kallistei.livejournal.com]

I don't know about the procedures in the US, but I could tell you about the UK, if you think that'd be helpful.

[mollyringle.livejournal.com]

Story's set in the US, so that would be what I need. But if I change locale, I'll come to you! :)

[impetuousnote.livejournal.com]

Ok this may or may not help but I'll give it to ya anyway just in case.

When my sister had major surgery she was hooked up to a morphine machine and she had a little button that she could push whenever she wanted more. It would then dispense a certain pre-set amount of morphine. No one recorded it, but I believe she could only push the button a certain number of times and then her dosage would run out for that timeframe and she would have to wait a while until she could push the button again. Make sense?

Of course it may be an entirely different setup for people who are terminally ill.

[mollyringle.livejournal.com]

Aye, I've heard of those machines. From comments so far, it sounds like I'll have to recraft my scenario, so possibly I may yet have use for the button...

[randomslasher.livejournal.com]

It really sort of depends on whether or not the patient is on palative care. Generally for terminal cases still in the hospital, the patient is more or less given whatever dosage needed to keep him or her out of pain, and there's not a whole lot of interest in whether or not it kills them, because the goal is to just keep them comfortable. Often, too, the patient is on a morphine PCA pump, and the amount he or she can receive is based on what's programed into the pump itself.

That said, the dosage is generally supposed to be recorded in charts, and the doctor, not the nurse, prescribes the recommended amount. Also, for terminal cases, it might be difficult to tell whether the morphine or the disease caused the death. Overdosing on narcotics causes respiratory arrest, and there's no "set" amount of what will kill someone--it varies from person to person and case to case--so if the patient was very sick it'd be difficult to tell what actually caused the death.

About the only circumstance in which an error of the sort you're describing could occur could be a med error--someone forgot to record something and the patient received more than the recommended amount--but nurses are very very rarely fired for med errors.

That said, regardless of the circumstances, if the cause of death was known the hospital would not lie about it to the patient's family. But a lawsuit would basically go nowhere if the patient was in fact terminal, because it would be, as mentioned, extremely difficult to prove that the morphine and not the disease caused the failure.

Hope that helps!

[randomslasher.livejournal.com]

Also, a nurse wouldn't lose her license over a single med error, either.

You might also look into hospitals' liability policies, particularly given terminal cases; I'm fairly certain that when a patient is terminal, even if they're not on comfort care, the hospital isn't going to be particularly legally vulnerable for an accidental death due to drug overdose if it were to keep the patient out of pain. I'm not positive on that one, because that's more legal than I ever really got, but again: the culpability of the hospital in a case like this would not be very great if the patient was terminal anyway.

Another thing to consider: if the patient ISN'T on palative care, he is probably a full code, meaning he'd be hooked up to a telemetry and as soon as he went into cardiac arrest, an alarm would sound at the nurse's station and they'd attempt resuscitation. Ergo, even if the hospital believed it would be responsible and wanted to try to cover for it, a "the patient died in his sleep but no one noticed or attempted resuscitation" story wouldn't fly, because they would've coded the patient.

[randomslasher.livejournal.com]

One more and I swear to God I'm done (I keep rereading my own comments and thinking of more to say):

The main reason a hospital wouldn't lie to the family is because the legal ramifications would be far greater for a lie like that than they would be for an accidental death of a terminally ill patient, primarily because if the patient were terminally ill, it would basically be impossible to determine exactly what killed him anyway. The hospital probably wouldn't KNOW for sure, even if an accidental overdose was suspected. Cause of death therefore would be confined to the actual system failure--respiratory, in this case--but whether the morphine or the disease process caused said failure would be pretty difficult to say, and there would basically be no legal interest in determining said cause in a terminal case, particularly an advanced terminal case.

Good lord I should organize my thoughts more.

[mollyringle.livejournal.com]

Cool, someone with knowledge! Thank you! *corrals you*

OK, from your comments I'm thinking my original setup isn't going to work. I shall therefore reroute my idea and propose new questions:

What would a nurse have to do to lose her hospital job? I'm looking for an accidental patient death--probably a non-terminal case is a lot more serious, given your comments. But now I'm thinking that if she did such a thing, she would face a lot *more* than losing her job. Would she also lose her license, and undergo jail time, or at least a fine? Is there any way she could work again in the nursing field?

This stuff is going to be backstory, so it's flexible, but ideally the nurse:
a) accidentally killed someone,
b) lost her hospital job (over it or for some other reason),
c) gets a new nursing job in a retirement home, and
d) feels bound to hang onto it for reasons (a) and (b).

But I'll try to be flexible for ol' reality. :) Thanks again!

[randomslasher.livejournal.com]

In terms of reasons she could lose her job, the most plausible reason would be diverting narcotics. However, I'm getting the impression you want to have the whole thing be accidental, so in terms of potential med errors she could make, your best bet would probably be to have her misread an order. One idea we came up with (I was discussing this with my mom, who's a nurse, and my dad, who's a former lawyer currently in nursing school) was Insulin--it's a high-risk substance to administer, so generally you have to have two nurses sign off on it, but if, say, your character ignored that rule, or for some reason had to administer insulin and didn't have anyone else available to double-check the dosage, and misread the order, she'd not only be liable for the accidental death, she'd be liable for breaking hospital protocol (which happens pretty frequently over minor things but can get you into double trouble, if something goes wrong).

In terms of repercussions, apparently every state's laws are a little different, but she'd certainly be vulnerable in terms of her job and potentially her license, and the family could decide to bring a malpractice suit against her. I don't think she'd end up doing jail time for an accidental death, but a heavy fine and suspension of license is possible. In terms of whether she'd be able to work again, I imagine that'd be more a state-to-state thing; there might be some sort of parole system or something like that, and it'd definitely be on her record, which would make it rather difficult to get another job in the field.

[randomslasher.livejournal.com]

I have no idea what your scenario is, but one other possibility that could be interesting would be if she had to settle for a job as a nurse assistant instead of a nurse, say if licensing laws or just the fact that she had such a spot on her record made it difficult for her to get a nursing position...

[mollyringle.livejournal.com]

That actually might work better than my earlier ideas. She'd start out that much more dejected if she were demoted. Also, if her new assistant job was in a small private retirement home rather than a big hospital, would job titles and duties be less set in stone? I've heard that retirement/assisted living facilities have highly varying degrees of quality and consistency in their care...but then I suppose the same is true of individual hospitals.

[randomslasher.livejournal.com]

Nurse assistantships I could ALL kinds of help you with, as I was one for two years. Her exact duties would be much fewer and a lot dirtier (baths, cleaning up after incontinent patients, the like) but given that she'd have the knowledge, if you wanted her to jump in and do something nurse-y it's definitely conceivable. Even in the bit hospital where I worked, the nurses would occasionally delegate things to the assistants that weren't technically our job; I was fully capable of turning off an IV pump long enough to thread a new gown through the line. I know from floating down to other floors that nurse assistants weren't technically supposed to be able to do that. So there you go! Plus, if it were not the best quality nursing home, the accountability might be pretty much crap...

[mollyringle.livejournal.com]

This is good stuff! OK, based on your comments I've looked up some nursing malpractice issues online, and it seems I can take this in directions you've indicated. For instance, a nurse may be in a situation where she legally needs authority from a doctor before acting to save a patient--say, a blood transfusion--but if the doctor fails to respond to her page, the death of the patient could still be considered the nurse's fault, if she was seen as not having tried hard enough to summon help.

Or, similarly, if a nurse failed to inform a doctor about warning signs like heart or blood pressure irregularities, which led to the patient's death, she could be held responsible--I found a couple cases like that. Even found one in which a nurse accidentally let an air embolism into a central venous line (ooh, check the lingo!), resulting in cardio-pulmonary arrest, and ended up on the bad end of a $17 million settlement.

Given how overworked nurses are, and how they seem to have all kinds of accountability with not very much authority, I'm starting to think there could be numerous possibilities for my character's bad luck. Any of this sound at all believable? :)

[randomslasher.livejournal.com]

All sounds quite reasonable! Not reporting signs would be more on the side of negligence, so if you wanted to keep it as "an honest nurse who made an honest mistake" then I'd go with a med overdose or an embolism or something, yeah. Or maybe even something that wasn't actually her fault but landed on her head? If someone under her, a student or even an aid, did something that she should've caught, the responsibility would ultimately be hers, I think...

[mollyringle.livejournal.com]

Perfect. I think I'll go with an embolism. Woo! :) Thank you again--and thank your folks for me too! I will go ahead with a separate post to check over these items, which will overlap with legal stuff too, and hope that either you or someone else can verify believability on those fronts.

So much work for a teeny backstory, but it's better than having a reader throw the book aside after the first page because it clearly was never fact-checked. :)

[kimuracarter.livejournal.com]

My dad is a doctor and has quite a few elderly patients. This is not a direct answer to your question, btw, as the above person knows more than I do. But he did tell me something a bit interesting that I would like to pass on to you. When the family is informed that the patient is terminal, the staff confirms that the family wants to keep the patient as comfortable as possible. Therefore, when the nurses are worried because the patient is still in pain after their assigned dose of pain meds, my dad says to go ahead and give them more. At that point, the patient's comfort is more important than the risk that the extra pain killers will cause their heart to stop. So, there's never a "let's give this patient a lethal dose to end their pain" moment. It's just, "Let's give them enough to keep them comfortable."

[mollyringle.livejournal.com]

This makes sense, though I didn't know about it before. Given that comment, and randomslasher's, I'm thinking I better come up with a new scenario. Thank you!

[elycia.livejournal.com]

In one of the comments above, you asked: What would a nurse have to do to lose her hospital job? I'm looking for an accidental patient death--probably a non-terminal case is a lot more serious, given your comments. But now I'm thinking that if she did such a thing, she would face a lot *more* than losing her job. Would she also lose her license, and undergo jail time, or at least a fine? Is there any way she could work again in the nursing field?

I read a true story in an old Guideposts about a nurse who accidentally killed a patient and had to deal with the repercussions. The patient *was* dying of cancer, though he was expected to live maybe a couple of months more. He had a catheter surgically inserted in a vein below the collarbone for administration of chemotherapy drugs and other IV medications, and the catheter had to be cleaned several times a day to keep it from clogging. The nurse came in at night to take readings and clean the catheter. That was done by filling a large syringe with sodium chloride (glorified salt water) and injecting the sod. chlor. into the port of the catheter. When she entered the room, the patient was asleep, and one of his adult kids was there, asleep in a chair. She didn't want to disturb them, so she didn't turn on any more lights. Instead, she picked up what she was pretty sure was the right vial from the box of tubing, supplies, etc. that stayed in his room, and just to be sure, she held it up to the night light to check. It had a blue label, as it was supposed to, and she was just able to make out the word "chloride." Okay, fine. So she filled the big syringe and injected it into the catheter. But the patient, who should have slept through the procedure, suddenly sat bolt upright in bed, clutching his chest, and he immediately collapsed. She called a code, thinking maybe the injection had dislodged a blood clot, and the code team responded, but the patient couldn't be revived.

Feeling oddly disquieted, she went back to the room later, mentally going over what had happened, and she chanced to get down on the floor to look for the bottle of sodium chloride, which she'd dropped in the excitement. To her horror, what she found wasn't sodium chloride, but potassium chloride (which causes instant and v. v. painful cardiac arrest). It also had a blue label, and it wasn't even supposed to BE in use on that particular floor; she had no idea how it had gotten into a venipuncture/cleaning kit, but the fact was, she'd failed to check properly, and she'd killed a patient.

She knew nobody would know if she didn't tell; the doctors had ruled it a death from a blood clot related to his chemo treatments. But her conscience demanded she tell, and so she eventually did. Though the hospital authorities understood that she didn't do it on purpose and that the mistake wasn't entirely her fault, she was still fired from the hospital and suspended from nursing for (I think) two years, during which she and her kids nearly starved as she worked mostly office temp jobs that people offered her. If I'm not mistaken, she was on probationary status of some sort for a period after she was allowed to resume nursing again. I should also imagine (though I don't recall it being mentioned in the article) that a person would have to go through some sort of training and/or recertification to prove he/she still knew his/her stuff before being allowed to practice nursing again after a 2-year absence.

I would imagine that a suspended nurse would be able to work as a "health care aide" during suspension. Such aides are the folks with limited training who do the vast majority of the grunt work in nursing homes and inpatient rehab centers: feeding patients, changing beds, taking patients to/from rehab, etc. etc. It would definitely be a "step down" for a registered nurse, but it would put food on the table during a suspension.

(continued)

[elycia.livejournal.com]

*mutter mutter bloody stupid LJ comment line limits mutter mutter*

As I was saying...

I'd be really surprised if an accidental patient death like the one I read about would garner jail time; probably the worst charge that could be levied would be involuntary manslaughter, and with no aggravating circumstances, most judges might not even give probation; community service would be the most likely sentence. A civil suit from the victim's family for negligent homicide would be more likely, but the hospital has insurance out the wazoo to cover such situations; the nurse herself, having acted as an agent of the hospital, wouldn't be personally liable (and it would probably be settled out of court anyway).

One of my cousins is a supervising RN who has worked in everything from oncology to emergency/trauma during her 35-year career. If you get your scenario firmed up, and you'd like me to run it by her for a reality check, I'd be happy to do it.

Good luck!

[mollyringle.livejournal.com]

Very useful! Thank you! Good to know I don't need to deal with the legal side, actually. Having my character quit her hospital job in a massive guilt attack would be sufficient for my plot purposes.

I like this potassium chloride idea. I may have to look that up in more detail and steal it. I remember from Chem class that KCl was one of those bottles with the huge poison warning stickers all over it. :)