Nurses: Do You Carry Liability Insurance?

When I was fresh out of nursing school, all bright and shiny, I bought a personal liability insurance policy, because I saw right away how easy it is to make a serious nursing mistake. As years passed, however, I let the policy lapse. At various new employee orientations throughout my career, hospital administrators told us forthrightly,

Umbrella of Safety by jparadisi

Umbrella of Safety by jparadisi

Nurses do not need liability insurance. Nurses are covered under the umbrella of this hospital’s insurance policy. The hospital is the financial deep pocket. No one sues individual nurses.

For years, this made sense. Lately, however, I’ve been rethinking this stance, for multiple reasons:

Stories of hospitals firing a nurse after he or she made a serious (often fatal) mistake are more frequent in the news. Perhaps this occurs because of the terms of the settlement. Perhaps the hospital promises a patient’s family that it will no longer employ the nurse. Or perhaps the nurse violated a hospital policy or protocol, and the hospital agrees not to disclose against the nurse in exchange for laying him or her off. Either way, the public never knows why. Does the umbrella of a hospital’s insurance cover a nurse they fired?

Commercially, the argument for purchasing personal liability insurance, even if the nurse is not fired, is this:

When a serious event occurs, the hospital’s legal department works on behalf of the hospital, not the nurses involved. A nurse’s legal rights and reputation are not the legal department’s priority. In such a scenario, an attorney hired by the nurse, working on her behalf and covered by her liability insurance, is a good investment.

Some insurance policies cover the costs incurred when a nurse is called to stand before their state board of nursing for complaints or misunderstandings filed against them.

Those who feel liability insurance is unnecessary argue that it cuts individual nurses “out of the group,” implying that being sued collectively offers more security.

Patient acuity is increasing, as are patient care loads. Many medications bear similar names, but cause very different results. As technology advances, nurses are required to maintain higher levels of vigilance. In the meantime, I’m getting older and acutely of how easy it is to make a serious nursing mistake.

Do you carry nurse liability insurance? Why or why not?

JParadisiRN Guests on RNFMRadio Tonight Oct 14 9pmEST/6pm PST

Great news!  I’m being interviewed on “RN.FM Radio: Nursing Unleashed!”, the newest internet radio station for nurses:

JParadisiRN’s interview is on Monday, 10/14/13  at 9pm EST / 6pm PST. You can listen in here: http://www.blogtalkradio.com/rnfmradio

In my LIVE interview, I plan on discussing The Adventures of Nurse Niki, authentic nurse characters, and writing a fictional nursing blog.

JParadisiRN

JParadisiRN

In preparation for the interview, I wrote a guest post for RNFM Radio:

The Adventures of Nurse Niki: Nurse Characters Doing Nurses’ Work.

If you can’t listen in, bear in mind that the show will be immediately archived and available for listening on Blog Talk Radio (http://blogtalkradio.com/rnfmradio), and will also be quickly available as a free downloadable podcast on iTunes.

Call-in # is: (347) 308-8064.

The link to listen in on Monday, 10/14/13   at 9pm EST / 6pm PST again is: http://www.blogtalkradio.com/rnfmradio

I look forward to connecting with you then!

The Adventures of Nurse Niki Chapter 15: Two Separate Worlds is posted. If you’re a new reader, the chapters are short, so it’s easy to catch up. New chapters are posted weekly on Thursdays.

 Please Like Nurse Niki on Facebook, and follow her on Twitter @NurseNikiAdven

Grief Debriefing Versus Beer for Breakfast: Chapter 11 of The Adventures of Nurse Niki

The Adventures of Nurse Niki
The Adventures of Nurse Niki

The Adventures of Nurse Niki Chapter 11 is posted!

In this week’s episode, Niki reflects on sharing about patient deaths at grief debriefings, and how much extra time nurses already spend at the hospital for continuing education and skills training.

In contrast, Niki and friends from work finally make it to an after shift breakfast. There, they comment on men in nursing, the role of respiratory therapists (every ICU nurse knows skilled respiratory therapists are a crucial part of the health care team), and share thoughts on marriage.

Off the Charts has this to say about The Adventures of Nurse Niki:

This blog is made up entirely of first-person episodes told by a fictional nurse named Niki. Each episode is short, detailed, and engaging, and it’s easy to keep up with it on a regular basis, or quickly catch up if you haven’t yet read any episodes.

                      Jacob Molyneux, AJN senior editor/blog editor

Comments on The Adventures of Nurse Niki blog are limited, however, you can interact with Niki on The Adventures of Nurse Niki’s  Facebook page. Please don’t forget to “Like” it too. Show Niki some love!

Thank YOU!! to the readers following The Adventures of Nurse Niki, the retweets of  @NurseNikiAdven, and those who not only Like Nurse Niki’s Facebook Fan Page. The support is very much appreciated!

Last Minute Sick Calls Wreak Havoc on Nursing Units

Awhile back my husband, employed at a hospital, came home from work saying, “Hey, if you’re thinking about going back to PICU nursing, they’d probably hire you tonight. They’re down three nurses from sick calls.” 

by jparadisi

by jparadisi

Ah, yes — sick calls and their impact on nurse-to-patient staffing. Is there any phone call that wreaks more havoc on nursing units than the last-minute sick call?

In the outpatient setting where I work, sick calls from coworkers are not as dire as they are in hospital settings. Even if I detect a slight grimace in the voice of the nurse on the other end of the phone as she sizes up the day’s schedule, she always says, “I hope you feel better. Get some rest,” and I know that she means it. We take care of one another that way. In fact, we encourage one another to stay home when sick — not only to protect our patients, but also because we don’t want exposure to one another’s illnesses.

Not all nursing units share this courtesy, however. Years ago, I worked for a hospital with centralized staffing. Schedulers, not nurses, received and tracked all staff sick calls within the hospital. For the one I spoke to, calling in sick wasn’t enough. She demanded a diagnosis: “What exactly do you have?”

Never exposed to this sort of interrogation over a sick call before, I was annoyed.

“I have projectile vomiting and diarrhea,” was my response.

She ended the conversation abruptly, after excusing me from work.

It’s hard to argue with projectile vomiting and diarrhea.

Some hospitals have developed methods for dealing with unexpected sick calls, such as float pools of resource nurses with a variety of skill sets, scheduled on call for several units. In others, nurses agree to come in for an ailing coworker, who then picks up one of that nurse’s shifts, offering the unit nursing coverage while avoiding overtime.

It’s contradictory to urge nurses to give compassionate patient care if their employer does not treat them compassionately, too. Sick calls cost healthcare institutions money, no doubt, but it is unrealistic to believe sick calls are completely preventable.

Staffing is an ongoing dilemma in healthcare: There often are not enough nurses, and just as often, there are too many. Like Goldilocks looking for a place to rest, we strive to get a staffing number that’s just right. This predicament is unlikely to disappear, so why not be civil about it?

How does your institution manage nurse sick calls? Have you or another nurse been penalized for sick calls? Has your institution developed solutions?

Waiting in Line at the Post Office, Yet Again

Yet again, I’m waiting in line at the post office to mail packages. Frequent readers of JParadisiRN are probably thinking, “Holy carp. I thought she said she’s a nurse. She spends more time at the post office than in a hospital.”

The White that Binds (Pinnning Ceremony) jparadisi 2010

The White that Binds (pinning Ceremony) jparadisi 2010

Actually, I don’t, but I do mail packages at the post office throughout the year. This is the penalty of an ambitious child who moved far away from some of the people she loves most in the world to follow her dreams. Mailing gifts acknowledges the birthdays I am not present to celebrate.

I’ve noted similarities between hospitals and post offices before. Today’s line is much shorter than they are at Christmas. Regardless, the seasonal change does not remedy all the coughing and runny noses among those waiting.

The worst cough belongs to a woman already standing at the window loudly questioning the clerk about every conceivable option available for mailing the midsized envelope she clutches. Her hair is held by a twist-tie in a messy ponytail, revealing a rash on her pale face, which is positioned 18 inches from the postal clerk’s face. The woman coughs often, in a peculiar fashion: She lifts her face to the ceiling and covers her mouth with her fist while turning her entire body 180 degrees. This creates the effect of a Rain Bird sprinkler, spraying fat water droplets (or, in this case, respiratory droplets) upon the clerk and throughout the lobby.

It gets worse. After 20 minutes of asking the clerk questions and coughing, the woman ends the exchange by saying, “Thank you.” She replaces the envelope into her tote, and leaves without mailing it. I fear the people in line in front of me may knock her senseless, but she leaves unmolested.

At the very same moment, a second clerk returns from a back room, scrutinizes the long line, and says to the first clerk, “You certainly fell behind while I was on break.”

Exasperated, the soggy clerk responds, “I had a person asking a bazillion questions.” She beseeches those of us in line for support. One customer says, “You were very kind.” The others nod and mumble in agreement.

What does this story have to do with nursing? Directly speaking, not much. Yet I can’t help but connect the similarities between the postal clerk, nurses, and the special skills required to work with the public, sometimes at the risk of our own health. Topping off this encounter with criticism from a coworker who is unaware of these special qualities after a particularly stellar performance dampens the spirit, like water from a Rain Bird sprinkler.

The lessons learned: Our jobs are hard. Be kind. Look for the positive in coworkers and in yourself. Don’t wait until Nurses’ Day to recognize staff and colleagues.

Nine Fictional Clinicians I’d Like to Meet (Yeah 9 Not 10. I’m Picky)

In nursing, where years of working long hours can leave us feeling at times as if the tumor always wins, finding meaning is essential to happiness. People find meaning in different ways — some through spiritual practices such as meditation, others at a church, temple, or faith center.

photo by jparadisi

photo by jparadisi

When I can’t make sense of life by other means, I find meaning within inspirational themes of literature and art. Sometimes that meaning surfaces by way of humor. It’s been said that laughter is the best medicine. Maybe, at its finest, humor becomes a place where science, humanity, and art converge.

With humor in mind, last year, Scrubs magazine posted a list of “Top fictional nurses and docs YOU want to get trapped in an elevator with.” Getting stuck in an elevator would cause me the same escape anxiety that makes a wolf chew off its paw to escape a metal trap. However, the article did make me think about my favorite fictional nurses and doctors, and what I would say to them if I ever met them.

Here’s my list of clinicians and what I would say to each:

  • Dr. Frankenstein: In light of your previous laboratory experiments, what is your position on stem cell research?
  • Major Margaret “Hot Lips” Houlihan, RN ( M*A*S*H, TV version ): Thank you for evolving from a rule- and sex-obsessed stereotype into a nurse comfortable with being compassionate, smart, and sexy. TV audiences would have been satisfied with just sexy.
  • Alex Price, RN ( An American Werewolf in London ): Exercise caution if you’re going to date your patients.
  • Phil Parma, RN ( Magnolia )You are an unsung hero, the home health nurse. You take on the pathos of the dying and their families alone. Without judgment, and through unorthodox means, you found a way to fulfill your dying patient’s last wish.  And when no one is looking, you grieve.
  • Hana, RN ( The English Patient ): Make more time for self-care and fun, instead of dating guys who are as self-destructive as you.
  • Gaylord Focker, RN ( Meet The Fockers ): Dude, if you were my coworker, we’d be BFFs.
  • Dr. Hawkeye Pierce ( M*A*S*H ): What time is happy hour?
  • Catherine Barkley, RN ( A Farewell to Arms ): Have you ever felt, like I do, that your dialogue is written in a way that sounds as if Hemingway never spoke to an actual woman?
  • Jenny Fields ( The World According to Garp ): You are the fictional nurse I’d most like to meet, despite your shortcomings. Your fierce independence is both a blessing and a curse. Despite this, you are a true healer, demonstrating profound love of humanity in all its diversity, weaknesses, and beauty. You inspired me before I knew I would be a nurse. I pray to have a heart as open and generous as yours someday. I think of you often.

Which favorite fictional doctors or nurses would top your list?

The Damaging Effect of Preciosity

Preciosity is over-refinement in art, music, or language, especially in the choice of words.

Nurse as Sisyphus by jparadisi 2012

Nurse as Sisyphus by jparadisi

I am struggling with preciosity while writing this post. A clever idea isn’t coming, and I feel distress, because I need to wrap it up. If I cannot write something profound, then at least I should be entertaining.

Preciosity is an art term with a negative connotation. An artist should never hold something she makes so precious that she cannot bring herself to change or even destroy it, because the bit of paint or brush stroke that’s considered precious enslaves the painting.

Writers are familiar with preciosity too. Sometimes the best-loved words are the very ones that need editing to clarify the thought. Any precious bit a writer or artist insists on retaining becomes an obstacle to the larger creative process, very often ruining the result.

Being a nurse also requires a resistance to preciosity. The best care plans are never perfect. A beautifully constructed work schedule becomes overwhelming, because of a staff sick call or unexpected admissions. We administer a medication, and the infusion is delayed or halted, because the patient has an allergic reaction to it. We are disheartened by the recurrence of disease in a favorite patient. On very bad days, we make an error.

There is no preciosity allowed in either art or nursing. Everything is up for grabs and can change in a heartbeat. Nurses striving the hardest for preciosity are the most doomed to disappointment in colleagues, patient outcomes, and themselves.

A good day of patient care cannot be summoned on command from a nurse any more than a masterpiece can be summoned from an artist or the next great American novel (or a blog post) can be summoned from a writer. Some days, both in nursing and in art, the best you can do is show up and try your best.

At the end of a shift, you may have made someone feel better, but perhaps all you did was prevent that person from getting worse. Likewise, after painting all day, you may end up taking a palette knife to the canvas and scraping all that newly applied paint to the floor, so that you can start again tomorrow.

Seated in my favorite chair while writing this post on a laptop, I struggle to keep myself from deleting it. Some days, both as  nurse and a blogger, this is the best I can do.

Lessons About Medication Errors From Baseball

In the commercial, three guys are standing around a grill, talking about baseball. One of

painting by jparadisi

Baseball Card by jparadisi

them quotes a stat.

Another one says, “Really? Are you sure?”

The first guy says, “I’m 99.9 percent sure.”

The third guy says, “Then you don’t know.”

I don’t remember what product was advertised. I remember the commercial because the question of certainty came up regarding a medication order.

I was reviewing the chemotherapy orders:

  • Patient name and identifiers: √
  •  Orders are dated with today’s date: √
  •  The chemotherapy ordered is appropriate for the patient’s diagnosis: √
  •  The dosage is correct: Uh oh. Wait a minute.

The total dose (in milligrams) did not equal the product of milligrams times meter squared (m2). The reason was easy to spot, however.
The chemotherapy infusion was to be administered as a continuous infusion over two days. The order read:

xxxx mg of chemo drug X m2 = xxxx mg X 48 hours = total dose of chemo drug

The doctor meant to write:

xxxx mg of chemo drug X m2/every 24 hours = xxxx mg X 48 hours = total dose of chemo drug

I was 99.9 percent sure, which means I wasn’t certain. Unlike quoting baseball stats, there is no room for uncertainty in chemotherapy administration. Interestingly, a pharmacist felt 99.9 percent certainty was good enough and mixed the cassette sitting in front of me.

To be fair, this was not the patient’s first infusion. The pharmacist mixed the chemo based on past orders. Using a previous record to predict a result in the future is the definition of betting, which works in baseball, but not so much when administering chemo.

I called the office where the order originated. The nurse on the other end of the phone pulled up a copy of the order. “Oh, he meant to write every 24 hours. If I write that and fax it back to you, will that work?”

“Yes it would,” I said. “Are you certain?”

“I’m 99.9 percent sure.”

“Certain enough to sign your name to an order?” I asked.

There was a pause, and she said, “I’ll have the doctor take a look, sign it, and fax it back to you.”

I thanked her.

The corrected order, signed by the doctor, arrived on the fax machine. The checklist was successfully completed, and the infusion started.

I was 100 percent certain the infusion was correct.

Do you ever feel like the nurse holding everything up? What’s your opinion? Would you trust your familiarity with a patient’s past orders and go ahead with the infusion? Does your work environment support nurses delaying treatment while verifying orders?

Vacation!

At The Pool photo by jparadisi 2013

At The Pool photo by jparadisi 2013

JParadisiRN is on vacation this week. I’ll write a new post soon from a refreshed perspective. Meanwhile, if you haven’t read my oncology blog for TheONC, or latest post for AJN Off The Charts, this is a good week to catch up.

Cheers!

Tips for Learning Chemotherapy Administration

I attended a chemotherapy and biotherapy course. Most of the nurses attending had administered chemotherapy for years, but a group of nurses new to oncology sat at the far end of the table. By the end of the first day of class, none of them had spoken a single word after the morning’s introductions.

photo by jparadisi

photo by jparadisi

Concerned, I approached the instructor. She had noticed their lack of participation too and told me these nurses had expressed feeling overwhelmed by the amount of knowledge needed to safely administer chemotherapy.

I can relate. I recall, years ago as a pediatric ICU nurse, admitting a patient in anticipation of tumor lysis syndrome (TLS). Although chemotherapy certified nurses administered the chemo, I was responsible for the patient’s well-being in the ICU. I asked a lot of questions, probably too many. Weary of me, the oncology nurse coordinator remarked, “You worry too much. It’s just chemo.”

Somewhere between this coordinator’s cavalier attitude and the paralyzing fear of a nurse unfamiliar with oncology is the middle ground for teaching chemotherapy and biotherapy administration. Here are some suggestions:

Fear is the nurse’s friend. Fear makes you look up medications and regimens you are unfamiliar with administering. It makes you ask a more experienced coworker for help. It makes you call the oncologist for clarification of orders when you are unsure, but don’t let it paralyze you. Fear is your friend. Embrace it.

Build on what you already know. Safe administration of all medications, including chemotherapy, is founded on the cornerstone of The Five Rights:

  • Right Patient
  • Right Medication: In oncology, this includes becoming familiar with the overarching chemotherapy regimen ordered.
  • Right Dose
  • Right Route
  • Right Time

Right Now is what my husband, a hospital pharmacist, jokingly refers to as the “sixth right,” as in, “the doctor wants the chemotherapy given right now.” While promptness is a virtue, chemotherapy administration is similar to teaching a small child to safely cross a street: “Green means go when safe.” Don’t give the chemo until all the double checks are completed to satisfaction.

Teach evidence-based practice, not your old war stories. None of us older nurses are as entertaining to new nurses as we think we are. As a preceptor, keep your pearls of wisdom short and relevant to the teaching situation.
“Knowledge isn’t knowing everything but knowing where to find it,” said my ninth grade algebra teacher. Teach new oncology nurses the value of looking up medication administration information in your facilities’ policies and up-to-date references. Assuming the information provided by a coworker is reliable instead of looking it up yourself is unprofessional, and won’t hold up as your defense in a sentinel event review.
What helpful advice would you offer new oncology nurses?
What oncology references do you find particularly helpful?