Essentials of Nursing Leadership and Management, 5th Edition

chapter 3 | Nursing Practice and the Law 29

did not do whatever needed to be done. If a nurse
did not “do” something, that leaves the nurse open
to negligence or malpractice charges.
Nursing documentation needs to be legally
credible. Legally credible documentation is an
accurate accounting of the care the client received.
It also indicates the competence of the individual
who delivered the care.
Charting by exception creates defense difficul-
ties. When this method of documentation is used,
investigators need to review the entire patient
record in an attempt to reconstruct the care given to
the client. Clear, concise, and accurate documenta-
tion helps nurses when they are named in lawsuits.
Often, this documentation clears the individual of
any negligence or malpractice. Documentation is
credible when it is:

■Contemporaneous(documenting at the time
care was provided)
■Accurate (documenting exactly what was done)
■Truthful(documenting only what was done)
■Appropriate(documenting only what could be
discussed comfortably in a public setting)

Box 3-2 lists some documentation tips.
Marcos, the nursing student earlier in the chapter,
violated the right-dose principle and therefore made
a medication error. By signing off on medications for

all clients for a shift before the medications are

administered, a nurse is leaving himself or herself

open to charges of medication error.

In the case of Mr. Harrison, the institutional

personnel were found negligent because of a direct

violation of the institution’s standards regarding the

application of restraints.

Nursing units are busy and often understaffed.

These realities exist but should not be allowed to

interfere with the safe delivery of health care.

Clients have a right to safe and effective health

care, and nurses have an obligation to deliver

this care.

Common Actions Leading

to Malpractice Suits

■Failure to assess a client appropriately

■Failure to report changes in client status to the

appropriate personnel

■Failure to document in the patient record

■Altering or falsifying a patient record

■Failure to obtain informed consent

■Failure to report a coworker’s negligence or poor

practice

■Failure to provide appropriate education to a

client and/or family members

■Violation of internal or external standards of

practice

table 3-1

Common Causes of Negligence

Problem Prevention

Client falls Identify clients at risk.

Place notices about fall precautions.

Follow institutional policies on the use of restraints.

Always be sure beds are in their lowest positions.

Use side rails appropriately.

Equipment injuries Check thermostats and temperature in equipment used for heat or cold application.

Check wiring on all electrical equipment.

Failure to monitor Observe IV infusion sites as directed by institutional policy.

Obtain and record vital signs, urinary output, cardiac status, etc., as directed by institutional

policy and more often if client condition dictates.

Check pertinent laboratory values.

Failure to communicate Report pertinent changes in client status.

Document changes accurately.

Document communication with appropriate source.

Medication errors Follow the Seven Rights.

Monitor client responses.

Check client medications for multiple drugs for the same actions.