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Don't neglect the nurse's duty of care: nurses serve as advocates for their patients. When something goes wrong and a doctor breaches the standard of care, the nurse has a duty to speak up.

Article Excerpt
Florence Nightingale established nursing principles--including careful observation and sensitivity to the patient's needs--in her best-known work, Notes on Nursing, in 1860. (1) Almost 150 years later, these principles still resonate in the nursing profession. According to the American Nurses Association (ANA), "The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient." (2)

But what should happen when a nurse's failure to promote or advocate for his or her patient's health, safety, or rights results in injury? Are nurses expected simply to follow doctors' orders, or are they bound to question those orders when something is amiss?

Consider an example: An elderly woman on Coumadin, an anticoagulant, falls and hits her head. She goes to the emergency room with an obvious head wound, but the emergency room physician elects not to order a CT scan, choosing instead to place the woman in the hospital for observation.

The next day, over the course of five hours, the patient deteriorates neurologically. On four different occasions, the nurse informs the attending physician, who is out of the hospital, of the progressive deterioration, but the doctor elects not to visit the patient and instead enters phone orders for medications. The woman becomes comatose and is transferred to another hospital, where she receives a CT scan, and a subdural hematoma is discovered. The woman dies.

When the woman's family files suit, they learn that the physicians have woefully inadequate insurance coverage. Is there a way to impose liability on the hospital for the acts and omissions of its nurses even though the physicians arguably were principally at fault? One area of potential nursing liability that a plaintiff lawyer should thoroughly explore is whether the nurse failed to fulfill his or her duty as an advocate for the patient.

The ANA's Code of Ethics for Nurses describes this duty:

As an advocate for the patient, the nurse must he alert to and take appropriate action regarding any instances of incompetent, unethical, illegal, or impaired practice by any member of the health care team or the health care system or any action on the part of others that places the rights or best interest of the patient in jeopardy. To function effectively in this role, nurses must be knowledgeable about the Code of Ethics, standards of practice of the profession, relevant federal, state, and local laws and regulations, and the employing organization's policies and procedures. (3)

In our hypothetical scenario, this duty required the nurse to follow a chain-of-command protocol to seek consultation with another physician to protect the patient from the attending physician's negligence. The nurse's failure to act as an advocate for the patient was a breach of duty that exposed the hospital to liability for the patient's injuries.

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Evolution of the duty

An early and oft-cited case on the subject of a nurse's duty to question a doctor's orders is the Illinois Supreme Court's 1965 decision in Darling v. Charleston Community Memorial Hospital. (4) The plaintiff in that case went to a hospital with a broken leg. After a cast was placed on it,...

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