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Unit One Legal Aspects of IV Therapy

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1 Unit One Legal Aspects of IV Therapy
LPN-C Unit One Legal Aspects of IV Therapy

2 Scope of Practice R/T IV Therapy
LPN-C = An LPN who has had additional education and has passed an examination to obtain certification in an advanced role permitting him/her to provide limited services in intravenous therapy. LPN-C is the licensed title An LPN can ONLY practice IV therapy under the LPN-C scope in the state of certification

3 Scope of Practice (cont’d)
Application requirements for a certificate to practice as an LPN-C are as follows: Current license to practice as an LPN in the state of Nebraska Successful completion of an approved certification course within one year of certification application Submission of proof of certification course completion Satisfactory passing of board approved exam for certification: 80% out of 100 multiple choice questions (results within 30 days)

4 Licensed Practical Nurse-Certified Act
Purpose: To provide a means by which licensed practical nurses-certified (LPN-C) may perform certain activities related to intravenous therapy To provide for the approval of certification courses to prepare licensed practical nurses- certified (LPN-C) To ensure the health and safety of the general public

5 Scope and Authority of the Practice of LPN-C in the State of Nebraska Title 172, Chapter 102
Perform limited IV therapy interventions under the direction of an RN or licensed practitioner. Observe, initiate, monitor, discontinue, maintain, regulate, adjust, document, assess, plan, intervene, and evaluate with regard to IV treatment. Provide IV interventions only when there is a licensed practitioner or RN assessing the patient at least once every 24 hours ( or more frequently with significant change in therapy or condition).

6 IV therapy is the responsibility of the RN as ordered by the licensed practitioner:
The RN must perform a physical assessment prior to initial IV insertion. The RN need not be on premises in order for the LPN-C to perform directed activities EXCEPT: Initial venipuncture for a peripheral line Central line activities The RN must be present at least once in 24 hours. The RN must be present more than once in 24 hours in cases of a significant change in therapy or client condition.

7 LPN-C IV Activities (*Refer to LPN/LPN-C Comparison Chart)
Expanded scope of practice LPN license AND certification as an LPN-C required Approved certification course Examination General and direct supervision Assessment by RN or licensed practitioner required every 24 hours (or more frequently when change in client’s condition or IV therapy occurs)

8 LPN-C Activities Adult Patients (*Direct Supervision)
Initial venipuncture to upper extremity (with use of 3-inch device or less) NOTE: RN MUST PERFORM FACE-TO-FACE ASSESSMENT OF PATIENT PRIOR TO IV INSERTION Infuse IV fluids and administer medications through a continuous flow central line NOTE: INFUSING FLUIDS AND ADMINISTERING MEDICATIONS THROUGH AN INTERMITTENT CENTRAL LINE IS NOT PERMITTED Administer the initial dose of an approved medication May add 500cc Dextrose 10% as a meal replacement

9 LPN-C Activities Adult Patients (*Under Direction)
Venipuncture to upper extremity (with use of 3- inch device or less) Infuse IV fluids and administer medications through an intermittent OR continuous flow peripheral line Calculate and regulate rate of flow Administer approved medications via push OR piggyback Reinsert, convert and flush peripheral intermittent devices Flush peripheral lock with heparin or saline solution Add pain medication solutions to a PCA pump

10 LPN-C Activities Patient-Controlled Analgesia (PCA)
Pain medication MUST be Prepared by a pharmacist or physician Prepared by the RN Commercially prepared All ordered settings and medications for PCA MUST be Checked by the RN Signed on the PCA infusion sheet

11 LPN-C Activities Pediatric Patients (*Under Direction)
Pediatric Patient = one who is both younger than 18 years of age AND under 35 KG Administer pain medications by PCA Only if medication is commercially prepared or prepared by physician, pharmacist, or RN Always checked by RN after PCA pump has been set per order and before infusion is started RN must sign the PCA infusion sheet Flush intermittent peripheral device May NOT calculate the rate of IV fluid infusions May NOT perform venipuncture

12 Antineoplastic agents Oxytocics
Medications that are NOT approved for LPN-C administration are as follows: Blood Blood products Antineoplastic agents Oxytocics Pitocin Ergotrate Methergine Syntocinon Anti-arrhythmics Hyperalimentation

13 IV administration by the LPN-C of approved medications by approved methods shall be those for which nursing interventions are routine and predictable in nature related to individual responses and adverse reactions. The RN must consider: Adverse consequences How adverse consequences are manifested How adverse consequences are measured What intervention is required How intervention is applied

14 LPN-C Renewal Certification as an LPN-C must be renewed along with LPN license Must complete 5 hours of IV-related continuing education; these hours can be included in the 20 hours required for LPN renewal Renewal of LPN license and certification is due on or before October 31st during odd-numbered years

15 Clinical Competencies for HLTH1210
The LPN must demonstrate the ability to: Select administration site Hands Forearms Antecubitus Upper arm Assemble equipment and set up flow control administration devices Gravity Pump(s)

16 Clinical Competencies (cont’d)
Perform at least 3 venipunctures in the lab and/or clinical area under the direct supervision of faculty Selection of appropriate site Preparation of site Selection of appropriate type/size of catheter Completing the venipuncture Securing the device Problem-solve non-functioning peripheral IV lines Convert and flush a peripheral intermittent infusion device Drawing up correct irrigant

17 Clinical Competencies (cont’d)
Add a fluid to a functioning central venous line Change central line tubing and sterile dressings at insertion site Document the insertion of a peripheral IV Document the administration of select fluids Document the administration of acceptable medications Add a fluid and/or medication to an infusion pump Change tubing Reset administration parameters

18 Pathway to achieving and demonstrating competence in IV therapy
Study the professional and legal implications of expanded practice and accountability Undertake study relating to IV therapy, obtaining knowledge, skills, and evidence for practice Undergo a period of supervision from faculty who is experienced in IV therapy Demonstrate competence

19 It is essential for the LPN to develop a knowledge base in the following areas:
1. Accountability 2. Circulatory anatomy and physiology 3. Fluid and electrolyte balance 4. Techniques and equipment used for IV therapy administration 5. Pharmacology 6. Administration of fluids 7. Risk management relating to IV therapy 8. Possible effects of treatment on the patient physically, socially, and psychologically

20 Elements of Competence
Describes the rationale for administration of medications via IV Describes the risks associated with IV medication administration Demonstrates knowledge of medications routinely administered by IV in the clinical area Describes the signs and symptoms exhibited if a medication reaction occurs Describes and takes appropriate action in the event of a medication reaction Correctly calculates doses, volumes, and rates of medications to be given by IV

21 Elements of Competence (cont’d)
Demonstrates appropriate techniques and actions in preparation of medications for IV administration Demonstrates SAFE practice in the administration of prescribed IV medications Demonstrates appropriate techniques in the administration of IV medications by bolus or infusions-over-time Demonstrates health promoting practices in caring for IV access and medication administration Describes how to act appropriately in the event of a drug error or adverse incident associated with administration of IV medications

22 Elements of Competence (cont’d)
Demonstrates awareness of professional accountability Demonstrates knowledge of available resources related to medication information, local policy, and current evidence for practice

23 The Five Rights of Medication Administration
Right patient Right medication Right dose Right route Right time

24 The Three Checks of Medication Administration
1. Read the label of the medication as it is removed from the shelf, unit dose cart, refrigerator, or dispensing system 2. Read the label of the medication when comparing it with the MAR 3. Read the medication label again before administering the medication to the patient

25 Medication Verification (cont’d)
LOOK at the label for verification of the medication name, dosage, route, and expiration date CHECK the medication itself, NOT just the pharmacy label Be overly cautious with regards to dose, proper dilution, and administration rate Watch decimal points Be aware of the unit Is the medication dispensed in mcg or mg? What is ordered in comparison?

26 Infusion Nurses Society (INS) (781) 440-9408
Recognized globally as an authority in infusion therapy Places the highest priority on the care and safety of patients receiving infusion therapy Dedicated to exceeding the public’s expectations of excellence by setting the standard for infusion care Developed standards of practice backed by evidence-based research Supports professional certification

27 The INS’s Infusion Nursing Standards of Practice
The Standards of Practice have undergone an extensive review process by INS nurses, pharmacists, physician, legal advisors, healthcare clinicians, and manufacturers of infusion therapy products Defines the accountability of nursing in the participation and delivery of specialized nursing care Provides measurable components in establishing nursing competencies, performance improvement criteria, and identification and evaluation of patient outcomes

28 INS Standards of Practice (cont’d)
Used as a framework for the development of organizational infusion-based policies and procedures applicable for all practice settings and all patient populations The Infusion Nurses Society’s Infusion Nursing Standards of Practice include nursing practice, patient care, documentation, infection control and safety compliance, infusion equipment, site selection and device placement, access devices, site care and maintenance, infusion- related complications, nursing interventions, nonvascular access devices, and infusion therapies

29 Legal Aspects of IV Therapy Administration
Legal aspects of IV therapy administration are important as your role as LPN is expanding With the increase in responsibility comes an increase in liability You have a duty to care for the patient without exceeding the scope of your LPN Certification Knowledge of the standards of practice within the bounds of the LPN Certification is critical to malpractice prevention Over 85% of hospitalized patients will receive IV therapy

30 Legal Aspects (cont’d)
Of the 180 million IV’s inserted, 150 million are peripheral IV’s Therefore, there are 150 million opportunities for the nurses who insert peripheral lines to become involved in litigation Most lawsuits involve cases of infiltration and phlebitis that juries feel could have been prevented

31 Liability Issues Infiltration = the leakage of IV solution or medication into surrounding tissue The nurse is responsible for selecting the appropriate device, needle gauge, venipuncture technique, and venipuncture site If an infiltration occurs, the priority concerns include: What was the solution that infiltrated? Could the vesicant cause tissue necrosis? How much of the solution infiltrated? How soon was the infiltration discovered? Was the patient injured by the infiltrate? What injury occurred (i.e. nerve compression, tissue loss, disfigurement, loss of function)?

32 Causes of Legal Action in Nursing Practice
The two most common causes of legal action in nursing practice are Unprofessional practice = failure to conform to minimal standards Professional malpractice (civil action) = professional misconduct or unreasonable lack of skill that results in harm Professional nursing practice is measured based on what a reasonable and prudent nurse would do Measuring tools include the Nurse Practice Act, institutional policy and procedures, the Nurse’s Code of Ethics, and HIPAA

33 Nurse Practice Act Determines the scope of professional nursing practice in a particular state Establishes guidelines whereby the nurse can perform skills or services Describes rules and regulations that provide guidance Establishes educational, examination, and behavioral standards for nurses that protect the public Enforces these requirements

34 Institutional Policy and Procedures
KNOW the specific policy and procedures related to LPN-C functions in your facility Code of Ethics Statement of values developed by the American Nurses Association (ANA) to provide guidance to the nurse and protection for the client and family

35 Code of Ethics (cont’d)
Correlates with the Patient’s Bill of Rights Consists of ethical principles that dictate nursing action: Autonomy = the right to independence Beneficence = doing good for patients Nonmaleficence = doing no harm to patients Veracity = truthfulness Fidelity = an obligation to be faithful Justice = an obligation to be fair to all people In decision-making, the nurse’s choices and actions should ideally reflect three criteria: They should be best-practice clinically They should be within the legal scope of policies, procedures, and practice acts They should be the right things to do morally

36 Dilemmas of Autonomy Involves freedom to take action for self and make decisions that will impact own welfare Ability to determine personal goals Complete understanding of choice Freedom to implement plan or choice Dilemmas of autonomy are often related to beneficence issues Occurs when individuals other than the patient must determine, or attempt to determine, what’s best for the patient

37 Dilemmas of Beneficence
Involves acting in the best interest of others, such as through patient advocacy To contribute to the well-being of others To promote good To prevent harm To remove harm Dilemmas of beneficence occur when health care providers, the patient, and/or family members disagree about what course of action is in the patient’s best interest

38 Dilemmas of Nonmaleficence
Involves the avoidance of intentional or unintentional harm Related to the principle of beneficence Often involves the nurse’s responsibility to “blow the whistle” if another is seen as compromising the patient’s safety The nurse is charged with protecting those that cannot protect themselves, such as the mentally challenged, the unconscious, the weak, and the debilitated Discourages experimental health research that may have a negative outcome Prohibits the performance of unnecessary procedures used as learning experiences

39 Dilemmas of Veracity Veracity = truthfulness
Patients may not be given information about health care treatment or outcomes if the information would cause further harm to the patient Not telling the patient the truth may show lack of respect for others and untrustworthiness of the person telling the lies or omitting the truth

40 Dilemmas of Fidelity Embodies the nurse’s duty to be loyal, faithful, and keep promises Dilemma occurs when the nurse is forced to be loyal and accountable to two opposing interests One situation may be a conflict between duties and loyalties to the patient and the economic needs of the employer -- Example: The nurse is forced to discharge a patient from outpatient care because the patient can no longer pay for services

41 Dilemmas of Justice Encompasses the nurse’s duty to be fair and equitable, and provide access and appropriate care to all patients Begs the question, “Who is entitled to these goods and services?”, when dividing limited health care services One example may be an organ procurement system

42 Moral Dilemmas Moral dilemmas occur when one must make choices that are complicated by uncertainty, psychological pressures, and personal emotions In health care, choices must often be made quickly, further complicating the dilemma Ethics, the law, and best practice do not always agree -- Example: A patient verbalizes to the nurse that she does not want to have surgery, but has given consent because her husband insisted. Since this is not a valid consent via informed consent protocol, the nurse contacts the physician even though the surgery is in the patient’s best interests.

43 The Health Insurance Portability and Accountability Act (HIPPA)
Protects the patient’s privacy, confidentiality, and security of medical information ONLY those who need to know patient information for the care of the patient, and those authorized by the patient to have access to his or her medical information, can lawfully enter a patient’s medical record Take care when faxing patient information Health care facilities must demonstrate that their computer systems are trustworthy enough to be used in court (i.e. software automatically records entries with time, date, and author; when an error is corrected, the software preserves both original and corrected versions)

44 The Patient’s Bill of Rights
Guarantees certain rights and privileges to every patient The nurse shall be an advocate for the patient’s rights The Bill of Rights should be given to each patient upon admission to a health care facility

45 Areas Most at Risk for Malpractice
A study of 747 malpractice claims in which nursing negligence (i.e. failure to adhere to a standard of care) led to a settlement was conducted in 1997 Of the 747 cases, 219 resulted in death 76 of these deaths were related to inadequate communication to the physician 46 were caused by inadequate assessment Medication errors led to 42 deaths 17 resulted from inadequate nursing intervention 21 deaths were caused by inadequate care 7 deaths were due to an unsafe environment 7 were related to inadequate infection control 3 deaths were caused by the improper use of equipment and products

46 Most Common Causes of Lawsuits
Most Common Causes of Lawsuits *All involved failure to maintain a standard of practice Medication and treatment errors Lack of observation and timely reporting on the patient Defective technology or equipment Infections caused or worsened by poor nursing care Poor communication of important information Failure to intervene to protect the patient from poor medical care

47 Factors Impacting Practice Standards
Certain knowledge and skills are essential to nursing practice In court, it is difficult to argue the 5 rights of safe drug administration The public is better informed than they used to be When accidents or injuries occur, the public expects accountability Patients are more acutely ill on admission to the hospital and more invasive treatments are required, which can lead to more accidents Nursing shortage and cost containment increases nurse-to-patient ratios


49 Legal Terms Tort = a wrong committed by an act or an omission
There are two types of torts – Intentional: Assault, battery, restraints as a form of false imprisonment, slander, and breach of confidentiality Unintentional: Negligence Assault = the unjustifiable attempt or threat to touch a person without consent that results in fear of immediately harmful or threatening contact (actual contact need not occur) Battery = the unlawful, harmful, or unwarranted touching of another, or the carrying out of threatened physical harm, REGARDLESS of the intent or outcome

50 Legal Terms (cont’d) Invasion of privacy is an intentional tort that may involve Releasing private information about a patient to a third party Allowing unauthorized persons to read a patient’s medical records Allowing unauthorized persons to observe a procedure Taking pictures of a patient without his or her consent Slander = making false statements about a patient that cause damage to the patient’s reputation

51 Legal Terms (cont’d) Negligence = failure to do something that a reasonable person would do, or doing something that a reasonable and prudent person would not do Malpractice = a type of negligence Committed by a professional person Any professional misconduct, unreasonable lack of professional skill, or nonadherence to the acceptable standard of care that causes injury to the patient The nurse may be held liable for not following the organization’s policy and procedures

52 Malpractice In a malpractice case, four components are required to prove liability – That there existed a duty to act That there was a failure to carry out that duty That harm or injury occurred That the injury resulted from the breach of duty Special legal doctrines apply to cases involving subordinate-superior relationships Respondeat superior (Italian for “let the master answer”) = if an employee is found negligent, the employer must accept responsibility if the employee was acting within scope of practice

53 Liability Each person is liable for his/her own wrongdoings
Nurses are liable in carrying out physician’s orders Nurses have a legal and professional responsibility to be knowledgeable regarding IV fluids, medications that are administered, and techniques for initiating and maintaining infusion devices Risk factors for malpractice suits include infiltration, nerve injury, extravasations, fractured central venous catheters, administration of the wrong medication, and failure to document appropriately

54 Liability (cont’d) Most lawsuits related to IV therapy involve infiltration and phlebitis Infiltration = the leakage of IV solution or medication into surrounding tissue. This is 100% a nursing responsibility Phlebitis = inflammation of the vein wall; often a precursor to sepsis

55 Informed Consent If a surgeon performed surgery without the patient’s consent, the patient could sue for battery, which is legally defined as one person touching another without consent. A physician can be sued for negligent nondisclosure if the patient did not obtain enough information to enable an informed decision. Informed consent must be obtained before central line IV insertions Responsibility to obtain informed consent rests on the physician The nurse’s signature only acknowledges that this is the right patient for the procedure


57 Risk Management for Infusion Therapy
Know venous anatomy and physiology Know appropriate vein selection Use infusion equipment appropriately Clarify unclear orders Refuse to follow orders that you know are not within the scope of safe nursing practice Know the infusion indications, side effects, and special considerations for IV medications Administer medications and/or infusions at the proper rate and within the ordered intervals

58 Risk Management (cont’d)
Assess the patient and monitor the IV site for complications Use proper IV care and maintenance Notify physician promptly of IV complications Know and give appropriate treatments for complications Provide proper patient education Document all aspects of IV therapy, including patient education Follow your institution’s policy/procedures Abide by Nebraska’s Nurse Practice Act and standards of IV practice Keep current in research R/T IV therapy

59 IV Therapy Documentation
In an IV-related lawsuit, nursing skill would be considered secondary to accurate, appropriate, and concise documentation Document ONLY firsthand information What you observed What the patient said or did What you said or did Use the word “observed” instead of “noted”, as noted could describe an item that was written in the medical record Write “No IV-related complications observed” instead of “site is normal” to document your assessment of a complication-free venous access site

60 Documentation (cont’d)
Give details about complications Nursing interventions Physician orders Patient’s comments regarding the complication Patient’s response to treatment Do NOT document opinions Do NOT chart “patient tolerated procedure well”, as the court may view this statement as an opinion and ask how you reached such a conclusion; instead, chart the patient’s own words in quotation marks (i.e. “That wasn’t so bad…”)

61 What DO You Chart? Date and time of insertion of venous access device
Specific vein chosen Gauge and length of infusion device Brand and style of infusion device The solution that is being infused The method of solution infusion Gravity Pump (include name and model of pump) Any comments the patient has made concerning how the infusion site feels

62 Legal Testimony At the legal deposition and in court, you will be asked difficult questions You may be asked vein anatomy and physiology, reasons for choosing certain veins, insertion techniques, etc. You need to make sure you portray yourself as a professional Use scientific terms to name veins and identify insertion sites Saying “I started the IV in the patient’s left hand” may imply that you inserted the cannula into the tissue of the hand instead of a vein. It is better to say “I inserted the IV catheter in the dorsal metacarpal vein of the patient’s left hand.”

63 Legal Testimony (cont’d)
Do not say “I always use that catheter size”, as this does not sound professional. It would be better to say “I chose the smallest catheter size available to promote hemodilution of the infusate and blood flow around the catheter, and to prevent trauma to the wall of the vein” as this demonstrates scientific rationale Do not mention an incident report in the patient record, as the plaintiff’s attorney may attempt to have the document admitted as evidence Never include opinions, accusations, excuses, or suggestions in an incident report, as they are subjective, and can be used against you

64 Legal Testimony (cont’d)
Other questions you may be asked in a legal situation include: What was the anatomic location of the catheter tip? What standards did you follow to monitor the venous access device for complications? How did you determine that the device was functioning properly? When did you recognize the signs and symptoms of the complication? What nursing actions did you take when you recognized the problem?

65 Legal Case Studies Staph infection at the IV site was blamed for a premature delivery; the plaintiff was awarded $8.6 million in a 1992 Florida case In Ohio, a nurse failed to clamp an IV pump regulating the flow of an antibiotic through a central line to a child; this resulted in the delivery of nearly 7 times the prescribed dosage of gentamycin, causing the child to become totally deaf In Pennsylvania, an emergency department nurse placed an IV line that infiltrated the patient’s hand, resulting in reflex sympathetic dystrophy; the patient could not return to work, and was awarded $702,000 in damages

66 Legal Case Studies (cont’d)
Several recent lawsuits have involved allegations that the nurse struck a patient’s radial nerve during insertion of an IV line; this can cause compartment syndrome and requires emergency fasciotomy and skin grafts. Uncorrected compartment syndrome can progress to gangrene and amputation of the fingers. A New York case involving finger amputation related to radial nerve damage resulted in a $40 million jury verdict (this was later reduced to $5 million)

67 Legal Case Studies (cont’d)
When monitoring an IV line, listening to your patient is just as important as monitoring the infusion site, IV pump, and tubing In the case of Frank versus Hillsborough County Hospital in Tampa, Florida, the patient’s frequent complaints of pain were ignored; the patient suffered permanent nerve damage and later obtained an award of almost $60,000

68 Malpractice Insurance
Your employer may have liability coverage that covers the individual nurse By obtaining your own malpractice insurance policy, your best interest will be upheld rather than that of your employer “Occurrence coverage” is the best type of policy because it covers any negligent act committed during the policy period regardless of when it is reported Important for cases with minors, who have the right to sue until the age of majority Make sure your policy covers your nursing role Annual rates are higher for “high-risk” nursing

69 Malpractice Insurance (cont’d)
Ensure your policy covers the following options: Misuse of equipment Error in reporting or recording care Failure to properly teach patients Errors in administering medications Mistakes made while providing emergency care outside the employment setting Coverage for a case in which your employer sues you Know the exclusions to your policy Know that no insurance policy will cover you for acts outside your scope of practice or licensure

70 Malpractice Insurance (cont’d)
Make sure your policy allows you to chose your own lawyer Some policies allow the nurse to consent to settlement while others do not; this is important for future professional employment opportunities Court costs, legal fees, and reimbursement for your lost earnings may all be covered in an individual malpractice insurance policy Nebraska State Division of Insurance can review the insurance company’s background, history, and financial stability

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