PRINTER-FRIENDLY VERSION
Lessons from Litigation
Registered Nurses
Facts of the Case
At 7:30 a.m. Tonya Koonce-Daniels was admitted to Durham Regional Hospital for induction of labor. Her labor was induced because her blood pressure was high, but it appears that her pregnancy had been otherwise unremarkable. She received an epidural for pain at 10:30 a.m. By 3:55 p.m. she was in the second stage of labor, her vital signs were stable and the baby’s heart rate was normal.
The baby, however, was in the occiput posterior position, which meant that she was facing her mother’s stomach rather than her back. Dr. Dingfelder decided to perform a mid-forceps delivery. The baby was in the ‘plus-two” position in the birth canal (she had not progressed to the point where her head was visible during contractions). At 4:04 p.m. Dr. Dingfelder used forceps to rotate the baby 1800 to the proper anterior position.
Lorren Alaine Daniels was delivered at 4:18 p.m. She was blue, unresponsive and was not breathing. She had suffered a cervical spine injury, presumably during the rotation, and was paralyzed from the neck down. She was unable to breathe on her own. She died as a result of these injuries at the age of approximately 7 months.
Suit was brought against Dr. Dingfelder and the hospital. The hospital was sued for the failure of the nurses to stop Dr. Dingfelder from performing the rotation. The hospital was initially dismissed from the lawsuit and Dr. Dingfelder settled with the plaintiffs. The suit was later re-filed against the hospital. The hospital moved for summary judgment after the completion of discovery. The trial court granted the motion and this appeal ensued.
The court of appeals held that the nurses were not required to oppose the physician’s decisions in this situation. The test, at least in North Carolina, whether to impose liability on nurses for failing to oppose a physician’s order is that the “order was so obviously negligent as to lead any reasonable person to anticipate that substantial injury would result to the patient from the execution of such order or performance of such direction.” This test is interesting in that it is a “reasonable person,” rather than a “reasonable nurse” test. This is a high threshold (the negligence must be obvious to the average person) for opposing a physician’s actions, since nurses are considerably better at estimating physician negligence than lay people. Accordingly, the court of appeals affirmed the grant of summary judgment.
Commentary
While it is important that nurses not blindly follow physicians’ orders when they believe them to have been made in error, it is also important that they not challenge physicians’ actions unless they are certain that the physicians’ actions will cause harm. The health care workplace depends upon cooperation and collaboration to a tremendous extent. Requiring nurses to second-guess the medical judgment of physicians could lead to chaos.
The test laid out in this case rests upon a well-reasoned theory. Nurses are not trained to provide medical care; they are trained to provide nursing care. They perform nursing interventions in response to nursing diagnoses. They are not trained in the wisdom of a mid-forceps rotation. Consequently, while they are trained to recognize obvious error, they are not trained to second guess the physician’s medical judgment. More importantly, they should not be held legally liable for failing to second guess, and oppose, the exercise of medical judgment by a physician.
Lessons Learned
There are really two issues for nurses here: when must they challenge a physician’s actions or orders, and when should they challenge actions or orders? This case deals with the former situation, which is the legal scenario. Nurses need to decide for themselves when to deal with the latter situation. Nurses should be encouraged and supported when they challenge an order and go up the chain of command, if they genuinely feel that the patient’s safety is at risk and an error has been made. Nevertheless, this is ordinarily an extraordinary event: it is not to be undertaken lightly and it is not to be undertaken often.
Nurses are a highly trained part of the health care team. Clearly, part of their function is as a double-check on the actions of physicians. Nonetheless, while they need to be vigilant to prevent error, they are not supposed to substitute their judgment for that of the physician.
Daniels v. Durham County Hospital Corp., 615 S.E. 2d 60 (Ct. App. N.C. 2005)
