Singapore Nursing Board Standards for Nursing Practice state that nurses and midwives have a professional responsibility and accountability to uphold the Standard of care. This includes contributing to the dissemination, interpretation, and development of the standards. Despite medical advances, social and demographic changes, and an increasingly complex healthcare delivery system, nurses must ensure they provide safe quality care. Failure to uphold these standards may result in nurses being held liable in the tort of negligence if their actions cause harm or injury to clients.
Description of a practical situation in which ethical issues arose: Mr Lim, a 70-year-old patient with chronic heart failure, was hospitalized for medical treatment. The medical resident, Dr Peter, prescribed intravenous therapy in the form of a Dextrose 50% infusion. Nurse Su, however, questioned the order and sought clarification from Dr Peter who assured her that he had consulted Dr Lee, the medical officer. Nurse Su then sought the opinion of Nurse May before administering the infusion. Unfortunately, Mr Lim experienced a cardiac arrest and suffered significant brain damage as a direct result of the infusion.
The hospital inquiry has concluded that Mr Lim should receive Dextrose 5% as his infusion, which has deeply upset his family and prompted them to seek legal advice. It is crucial to mention that all names mentioned in this situation are fictional. The ethical issues involved include negligence, defined as the failure to fulfill a duty of care or act reasonably under specific circumstances. Negligence can be unintentional and occurs when someone does or fails to do something that a reasonable person would or would not have done in similar circumstances (Judson & Harrison, 2010, p. 69). To establish a claim of negligence, evidence of duty, breach, direct causation, and damages must be presented (Judson & Harrison, 2010, p.101). Negligence is an essential tort that enables patients who have suffered harm due to a nurse’s lack of care to pursue compensation (Martin, 1996). Nurses or doctors may be deemed negligent if they cause harm by being unaware of well-established nursing and medical research findings (Tingle, 2002).
Both nurses and doctors have the potential to be negligent and commit malpractice, which can lead to Mr. Lim suffering brain damage. Negligence occurs when an individual fails to meet the expected standard of care, resulting in injury (Crisp & Taylor, 2000, p. 427). To establish negligence, three essential elements must be demonstrated by the claimant: a duty of care owed by the healthcare provider, a breach of that duty, and harm caused to the patient as a result (Corcoran, 2000, p. 280).
The concept of negligence entails that the accused party must have a responsibility towards the accuser to take precautions. Additionally, the accuser needs to demonstrate harm resulting from a failure to fulfill this responsibility (Staunton & Chiarella, 2003, p-36). Consequently, in cases where patients experience harm due to their treatment, nurses can be held liable for professional malpractice. Ethics involves employing moral reasoning systematically to determine appropriate actions. Ethical considerations center on what we ought to do rather than what we are capable of doing.
According to Staunton & Chiarella (2003), ethics is relevant to all individuals and encompasses moral concepts, principles, and action guides that should be applied equally. The application of ethics can help prevent negligence or malpractice. Beauchamp & Childress (2001) propose four major principle theories that establish prima facie obligations: autonomy, beneficence, non-maleficence, and justice. Autonomy, as defined by Staunton & Chiarella (2003), refers to the right to self-determination, particularly regarding consent for treatment and access to treatment information.
According to Harris (2005), autonomy is the ability of an individual to have control over their own life and influence their future. It is stated by Harris that patients commonly decline treatment. However, in Mr. Lim’s case, he was not provided with information about his treatment options, which prevented him from refusing or making decisions about his treatment plan.
Concerning beneficence, Hendrick (2000) explains that it involves acting in the best interest of the patient and constantly striving to do good. On the other hand, Beauchamp & Childress (2001) define beneficence as a moral duty to act for the benefit of others.
Both nurses in this situation did not fulfill their duty of ensuring patient well-being and enhancing knowledge and skills, as stated by the Nursing and Midwifery Council Code (2002). Consequently, Mr. Lim suffered cardiac arrest and brain damage due to their negligence and malpractice. Negligence occurs when a nurse fails to prevent harm despite having a responsibility towards the patient, which contradicts the principle of non-maleficence that emphasizes avoiding harm (Hendrick, 2000).When a patient is admitted to the hospital, it is the responsibility of the hospital and its staff to provide care and ensure the patient’s well-being (Tay, 2001). The principle of non-maleficence in healthcare guides nurses in caring for their patients without causing harm (Staunton & Chiarella, 2003, p-29). Nurses must fulfill their duty of care towards their patients and always act accordingly (Nursing and Midwifery Council Code, 2002). Therefore, Dr. Peter, Nurse Su, and May are responsible for Mr. Lim’s well-being and should avoid causing him any harm while providing care.
Despite suffering brain damage, Mr Lim holds both doctors and nurses accountable for their negligence and malpractice. In ethics, the concept of justice encompasses fairness and equal distribution of burdens and benefits. Justice as fairness requires impartiality and neutrality in interactions with others, while justice as equal distribution addresses resource allocation issues (Staunton & Chiarella, 2003).
According to Beauchamp & Childress (2001), justice can be defined as the fair distribution of burdens and benefits, particularly in healthcare where patients should receive the healthcare they are entitled to. Wilmot (1997) added that justice also includes the right to freely express an opinion and have it considered without bias. The Nursing and Midwifery Council Code (2002) mandates nurses to continue caring for patients, respecting their involvement, and not making judgments about treatment based on their behavior (Wilmot, 1997).
Breach of duty refers to the failure of nurses to exercise the necessary care and skills expected from professionals in their specific nursing situation (Cournoyer, 1989, p-143). Nurses are responsible and accountable for maintaining professional conduct and adhering to nursing practice standards set by the regulatory board. Their primary duty is to provide safe, competent, and ethical nursing care to the client (Singapore Nursing Board, 2011, standard 2).
Due to their pharmacological deficits, both nurses in the above scenario failed to check the five rights when administering medications. This indicates a failure to adhere to the Singapore Nursing Board’s Standard 3, which requires nurses to constantly strive for knowledge and skill acquisition in order to provide evidence-based practice and improve care quality. Nurse Su neglected to monitor Mr Lim’s condition after administering intravenous Dextrose 50%. Consequently, both nurses breached their duty of care towards Mr Lim, which may lead to further malpractice.
Staunton & Chiarella (2003) discussed four major bioethical principles: Autonomy, Non-maleficence, Beneficence, and Justice. Non-maleficence, which means “above all, do no harm,” (p. 29) was disregarded by both nurses in the scenario. Consequently, they caused Mr Lim to suffer cardiac arrest and brain damage as a result of a medication error. Beneficence, on the other hand, involves doing good things in the care or treatment of patients (Staunton & Chiarella (2003), p-29). Therefore, the nurses and doctor responsible for Mr Lim’s care should prioritize doing well for him.
According to Beauchamp & Childress (1996), it is argued that our obligation to avoid causing harm is more important than our obligation to promote good, especially when promoting good may pose risks to others or ourselves. Staunton & Chiarella also pointed out that nurses have the right and legal obligation as professionals to question doctors’ orders if they believe the treatment ordered is inappropriate or incorrect, or if the patient has not been adequately informed about the consequences of the treatment (p-69).
Nurse Su questioned Dr Peter about the treatment prescribed before administering the medication to Mr Lim. However, she did not escalate her concerns to the consultant or pharmacist for clarification. Dr Peter also breached his duty of care by failing to meet the standards expected of a medical resident in the medical ward. When Nurse Su questioned the orders, it should have prompted Dr Peter to double-check the entry he made in the inpatient medical records. He mistakenly wrote “IV dextrose 50%” instead of “IV dextrose 5%”.
Dr Peter should not evade his responsibility by simply stating that he had consulted Dr Lee. If Dr Lee advised Dr Peter to administer dextrose 5%, he would also be held accountable. When uncertain, Dr Peter could also seek guidance from the pharmacist regarding the orders. Damage is the central element in negligence, with “physical, financial, and psychological damage” being the three specific types of damage that the courts acknowledge and compensate for (Staunton & Chiarella, 2003, p-73).
The relationship between the damage and the negligent act necessitates a direct or causal link connecting the defendant’s breach of duty of care to the plaintiff’s harm. Failure to demonstrate that the breach caused the damage will result in no compensation being given (Staunton & Chiarella (2003), p-76). Physical damage is defined as the clear physical injuries suffered by the plaintiff, typically easily recognizable (Staunton & Chiarella (2003), p-74).
Mr Lim suffered a medication error that caused him to experience cardiac arrest and extensive brain damage, possibly permanent. As a result, he has incurred financial damages due to prolonged hospitalization and additional treatment costs. Furthermore, his family may face the need to quit their jobs or hire expensive long-term care assistance for him. Additionally, Mr Lim’s health condition may necessitate further hospitalization.
The courts are increasingly recognizing psychological damage, also known as nervous shock, which refers to ongoing psychological damage suffered by an individual as a result of directly experiencing or witnessing a traumatic event. This damage can manifest as chronic neurosis or depression and can be medically diagnosed (Staunton & Chiarella, 2003, p-74). In the case of Mr Lim’s health condition, his family members may also experience psychological damage from their encounter with his situation. Staunton & Chiarella (2003) discuss both specific and general damages that can result from such experiences.
Mr. Lim experienced general damages, which are difficult to quantify in terms of money, such as pain and suffering and loss of enjoyment of life, both currently and in the future (p-81). He suffered these damages due to negligence or malpractice from both doctors and nurses who were responsible for his care. According to Staunton & Chiarella (2003), the doctrine of vicarious liability is a common-law principle that holds employers responsible for the negligence of their employees if the patient experiences harm as a result (p-85).
According to Ellis & Hartley (2001), employers are held accountable for hiring qualified individuals and creating a functioning environment with necessary supervision to prevent errors or harm (p-40). It is important for the hospital to keep their policies and procedures manuals updated and aligned with medical and nursing standards. Nurses and midwives are expected to practice professionally and adhere to the nursing standards set by regulatory boards. The primary duty is to provide safe and ethical nursing care to clients, as stated by the Singapore Nursing Board (2011), Standard 2. It is crucial for all medical and nursing staff to familiarize themselves with the organization’s policies and procedures in order to avoid malpractice claims when they faithfully follow them (Kothare, 2000).
Regrettably, healthcare professionals in the organization failed to follow medication administration protocols and remain informed about the current standard of care during their work. Both nurses neglected to assess the care they delivered, resulting in a medication mistake that caused Mr Lim to suffer cardiac arrest and brain damage. Nonetheless, this does not imply that the individual’s personal liability is transferred to the employer. Instead, it is the employer who bears responsibility for the negligent act (Staunton & Chiarella, 2003).
If the family members of Mr Lim wished to take legal action against the hospital, the hospital would be responsible for malpractice because both nurses and doctors were employed by the hospital. They did not behave as reasonably and prudently as professionals should. Consequently, the hospital was held responsible because they failed to ensure their staff’s competence in adhering to the guidelines. Nurses Su and May violated their duty of care by providing care that fell below the standard expected of a reasonable nurse. As professionals, nurses are obligated to provide safe and competent care to their patients in a responsible and accountable manner.
Staunton & Chiarella (2003) state that registered nurses should possess specific knowledge and expertise in relation to drugs. This knowledge and expertise should prompt nurses to carefully question drug orders in certain situations instead of blindly obeying instructions. However, in this case, both nurses failed to fulfill the duty of care in following the standard of nursing care. This standard requires nurses to comprehend the medications they administer and use their judgment when following medication orders.
As the Staff nurse in-charge of Mr Lim, Nurse Su is responsible for providing safe, competent, and ethical care to her patients (Singapore Nursing Board 2011, standard 2). It is expected that she applies her education and clinical practice knowledge to ensure the provision of safe and effective nursing care, which includes promoting the well-being of her clients and reporting any unsafe practices (Singapore Nursing Board 2011, standard 2). However, Nurse Su did not meet the required standards for a qualified staff nurse working in the medical ward.
Nurse Su, upon seeing the orders, approached Dr Peter to inquire about them. It is within the nurse’s right to question the drug orders if they have any doubts or if they appear to be incorrect. However, Nurse Su should refrain from starting the infusion after Dr Peter mentioned that he had verified it with Dr Lee. As a professional nurse, it is not sufficient to solely ask Dr Peter when uncertain about the orders. Nurse Su should also inform Dr Peter that the order is intended for an elderly patient and remind him that the patient has chronic heart failure.
Nurse Su should consult her experienced colleague or escalate the issue to the consultant in charge of Mr. Lim or the pharmacist regarding the orders. It is important for Nurse Su to clarify whether Dr. Peter is being dishonest or if Dr. Lee has appropriate medical experience. Nurse Su should keep these doubts in mind. Furthermore, it is crucial to document all this information clearly, accurately, legibly, and concisely in the medical record, as documentation plays a vital role in ensuring safe patient care. It is an integral part of each nursing action and cannot be separated from the actual nursing care provided (Beckmann, 1996).
Nurse May, as her colleague, did not fulfill the responsibility of providing care in a responsible and accountable manner as stated by the Singapore Nursing Board (2011, standard 2) when countersigning to administer medications. It is important to determine if she actually checked the IV solution when signing off on the medication record. Additionally, did she consult Nurse Su or Dr. Peter regarding the orders? As a professional nurse, Nurse May could have taken the initiative to question Dr. Peter about the incorrect order if she had any doubts, as medication errors should not be made by healthcare professionals.
The Singapore Nursing Board (2011) stated that Nurse May did not fulfill her duty to protect her clients’ well-being by recognizing and reporting unsafe practices or providing safe, competent, and ethical care. Additionally, both Nurse Su and Nurse May neglected to check for adverse reactions of IV dextrose 50% on elderly patients. The administration of concentrated dextrose at a rapid rate may lead to the development of hyper-osmolar syndrome, resulting in hypo-volemia, dehydration, mental confusion, and loss of consciousness (Dextrose, 2007).
The nurses failed to monitor Mr Lim’s serum glucose concentrations and vital signs frequently during the IV infusion. This led to Mr Lim experiencing cardiac arrest and brain damage. It highlights a pharmacological deficit in both staff nurses, as caution should be taken when administering IV dextrose 50% to elderly individuals who are susceptible to glucose intolerance and hyperglycemia (Dextrose, 2007).
According to Wolf (1989, p-8), medication error refers to mistakes related to drugs and intravenous solutions. These mistakes occur during various stages of drug preparation and distribution, including prescription, transcription, dispensing, and administration. Medication error can be categorized as acts of commission or omission. Examples include administering the wrong drug, incorrect dosage, administering via the wrong route or to the wrong patient or at the wrong time, providing a contra-indicated drug to the patient, administering at the wrong site, using the wrong drug form or infusion rate, using expired medication, or errors in the prescription.
Errors can occur intentionally or unintentionally (Wolf, 1989). Dr Peter made a mistake by prescribing Dextrose 50% instead of Dextrose 5%. Staff Nurses Su and May administered the wrong medication to Mr Lim due to their lack of knowledge and negligence. As a result of this medication error, Mr Lim suffered a cardiac arrest and brain damage, leading his family to consider complaining or taking legal action.
Conclusion: If both Staff Nurses Su and May were to prioritize patient safety and act in accordance with their professional responsibilities, these unnecessary actions could have been avoided. As a result, Mr Lim would not have suffered any harm and would not need to stay in the hospital longer than necessary. Wallace (1996) noted that damage suffered by the plaintiff can be physical, financial, or psychological/emotional.
The damage that Mr Lim has suffered is physical, but his family could also experience financial damage due to the long-term hospitalization expenses and psychological damage from the ordeal they have gone through. Therefore, Mr Lim’s family may seek compensation for specific damages, such as the cost of his medical treatment. This case scenario emphasizes that medication errors resulting from negligence or malpractice are crucial to ensuring safe patient care (Staunton & Chiarella, 2003).
Legal issues may arise when a health care professional engages in malpractice or negligence, leading to errors in providing high-quality care to patients. In the specific case mentioned above, a medication error occurred due to the lack of knowledge on medication by both the doctor and nurse involved. As a result, Dr. Peter, Dr. Lee, and the staff nurses Su and May would be held accountable for their actions, which caused harm to Mr. Lim. The head department would impose disciplinary actions on both doctors and both nurses for their professional misconduct. The doctors would be referred to the medical board for further disciplinary action, while the staff nurses would be referred to the Nursing board for the same purpose.
References
1. Beckmann,J. P. (1996) Nursing Negligence:Analyzing Malpractice in the hospital setting. USA:SAGE publications Ltd.
2. Beauchamp, T. L. & Childress, J. F. (1996). Principles of Bioethics (5th edn). Oxford University Press, New York.
3. Beauchamp, T. L. & Childress, J. F. (2001). Principles of Bioethics (5th edn). Oxford University Press, New York.
4. Crisp, J. & Taylor, C. (2000). Potter and Perry’s Fundamental of Nursing. PP 426-427. St Louis: CV Mosby.
5. Cournoyer, C. P. (1989). The Nurse Manager and the Law. USA: An Aspen Publication.
6. Dextrose. (2007). http://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?id=21293&type=display [On-line] (Accessed on 2012, June 01).
7. Ellis, J. R., & Hartley, C. L. (2001). Essential of Law for Health Professionals. Sydney: Harcourt.
8. Harris, G. (2005). Ethical Issue in Community Care. J Community Nurse 19(12): 12-16.
9. Hendrick, J.(2000).
The following sources discuss law and ethics in nursing and healthcare:
1. “Law and Ethics in Nursing and Health Care” by Stanley Thornes, Cheltenham.
2. “Nurse’s Legal Handbook” (4th ed.) by V. S. Kothare. Published by Springhouse Corporation in Pennyslavia.
3. “Law of Negligence” by J. Martin. Published in Primary Health Care, volume 6, issue 2, on page 13.
4. “The Code of Professional Conduct” by the Nursing and Midwifery Council, located in London.
5. “Standard of Practice for Nurses/Midwives” by the Singapore Nursing Board, published in 2011.
6. Singapore Nursing Board’s website (https://www.snb.gov.sg), accessed on June 01, 2012.
7. “Staunton, P., & Chiarella, M.” (2003).
Nursing and the Law (5th ed). London: Churchill Livingstone. 16. Tay, S. K. (2001). Medical Negligence: Get law on your side. Singapore: Time Book International. 17. Tingle, J. (2002). Clinical negligence and the need to keep professionally updated. Br J Nurse 11(20): 1304-6 18. Wallace, M. (1996). Health care and the law: A guide for nurse: Sydney: The Law Book Company. 19. Wilmot (1997). The Ethics of Community Care. Cassell, London. 20. Wolf, Z. (1989). Medication errors and nursing responsibility. Holistic Nursing Practice, 4(1): 8-17.
