Legal / Ethics

An invitation to error

Pat Lawton, RN was busy — too busy to worry about record keeping. She was working OB, on the short-stay unit (Is there anything else these days?), and it seemed that every pregnant woman in the county decided to have her baby on this particular night. Among her first admissions was a 35-year-old married woman, gravida II, para 0 who had a history of eclampsia. She was in active labor about 6 weeks prematurely. On admission her blood pressure was 185/98 mm Hg, and she had stage 3 pitting edema in both extremities. Both she and the baby were being monitored. Following this admission, four more women in active labor were admitted within an hour. Meanwhile, another woman (admitted on the day shift) was in the final stages of labor, and yet another hold-over from the day shift was being prepared for a C-section. Still another patient — a gravida V, para III — had been in labor for almost 20 hours, and was nearing exhaustion. Pat had called the woman’s obstetrician twice in the 3 hours she’d been “in charge.” His service reported that he was on his way into the hospital, but so far he had not arrived. Pat was the only experienced RN on duty for both labor and delivery, which gave her a total of eight patients in labor, at least three of them with significant complications, and no meaningful help! One new-hire RN without OB experience and three aides completed the evening staff. Pat called the supervisor for more help — and the supervisor promised to see what she could do — but so far, no more help had arrived.

In the midst of this chaos, a physician called and ordered an oxytocin drip for the woman who had been in labor for 20 hours. Pat started the infusion, and it did, indeed, induce labor. By this time, Pat was assisting with the C-section, and the new hire RN monitored the woman receiving oxytocin while the aides monitored the progress of the other women in labor. No other help had arrived, and Pat was too busy to call the supervisor again. Meanwhile, the woman on oxytocin was ready to deliver, so the newly hired RN told an aide to transfer woman while the new hire continued to monitor the other patients in labor. While the mother was being transferred, the aides removed the IV infusion pump without clamping the intravenous line. The hospital was gradually replacing IV pumps capable of free-flow* with IV pumps that automatically stop the flow of medication when the IV pump is disconnected. But, contrary to standard, some of the old ones remained, and it was easy to mistake one type for the other. So, the woman received all the oxytocin that was left – which she no longer needed — within 10 minutes. She survived, but her infant delivered precipitously, and she was torn through the vagina, perineum, and rectum.

Both Pat and the new-hire RN were disciplined in this incident, but neither is entirely clear about what she did wrong: Pat was scrubbed, and the new RN could not leave a unit with three women in active labor unattended. What should these nurses have done?

Case analysis

In the midst of this analysis, let us keep in mind that the one who was hurt the most was the patient, and it is a miracle nothing worse happened. That being said, I can find absolutely no excuse for the abysmal staffing of this unit, and even less for a supervisor who not only failed to send help, but didn’t even show up herself to assess the situation. In my opinion, the nurses who should have been disciplined were the supervisor, the unit manager who posted this schedule, and the administrative nurse who allowed this situation to occur (whether through benign neglect or ignorance). Standards require one-on-one staffing for women in active labor. Say what you will about assigning an aide to transfer a patient in active labor to the delivery room, but under the circumstances, the newly hired RN had little choice. Moreover, there is no excuse for having two types of infusion pumps in the same hospital, no less the same unit. Even if staffing is normal, this “half-and-half’ is an invitation to error. Moreover, the chaos on this unit is a known factor for increasing the risk of error. The responsibility for this error lies with the hospital for having such pumps — contrary to both standards and regulation — operating side by side with pumps that have an automatic shut-off… and for permitting staffing that no one in his or her right mind could consider anything but dangerous.

However, there are things Pat could have done differently. She could have spoken to the obstetrician and delayed starting the oxytocin until staffing had improved. She also could have spoken to the obstetrician doing the C-section and asked him or her to delay it or, if that was not possible, have called the OR and have the C-section done there. Her new hire (why she was on the unit without a preceptor is a mystery to me) was inexperienced in OB, and Pat needed to stay with the laboring women. Moreover, Pat should have persisted in calling the supervisor, or assigned an aide to continue calling the supervisor – nonstop if necessary. If there was no response from the supervisor, then Pat could have called the unit manager at home. If she could not reach the unit manager, then she could have called the administrator on call. I know this is easy to say and difficult to do, but this situation was completely out of hand. Had they no contingency staff? No one on-call? No one cross-trained to help? To prevent such situations, back-up plans are crucial – and if this hospital had one, it was not evident.

Far too often the ethical aspects of safe staffing and safe — or at least adequate — equipment are shoved aside for the sake of expedience. Yet, patients have a legal and a moral right to safe care — and both patients and nurses have a right to expect safe equipment and safe staffing. Everyone on that unit was placed at risk …physical, psychologically and/or morally.


*Free-flow occurs when some older model IV pumps are disengaged and the IV tubing is not clamped off — gravity pulls the remaining liquid into the patients veins, sometimes with astounding speed!

Dr. Leah Curtin, RN, ScD (h), FAAN, is Executive Editor, Professional Outreach, American Nurse Today. An internationally recognized nurse leader, ethicist, speaker, and consultant, she is a strong advocate for both the nursing profession and high-quality patient care. Currently she is Clinical Professor of Nursing at the University of Cincinnati College of Nursing and Health. Dr. Curtin can be reached at LCurtin@healthcommedia.com.

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14 thoughts on “An invitation to error”

  1. Leah Curtin says:

    No Mari,
    I do not think that nurses are at fault for all errors…In this case, I definitely think that management and administration were at fault. The staff were caught in a dilemma not of their making, although I do think that some of their decisions made a bad situation worse…

  2. Mari says:

    People, you included, think nurses are at fault for all errors, no matter how chaotic things are on the unit!

  3. Leah Curtin says:

    I am glad that Anne commented on the dangerous infusion pump…for that was the invitation to error. I also agree with Sharoni: the staffing is shocking, but with financial cutbacksmore administrators are likely to try to cut corners — that, combined with unsafe, even dangerous equipment is more than an invitation to error – it could even be criminal negligence!

  4. Anne says:

    While I agree about the specialty and the floating and the staffing — no one has said a word about the FACT that equipment that should never be used was being used — which is against standards of practice, TJC standards and Federal guidelines. Certainly this never should have happened for all these reasons, but whoever is responsible for allowing this IV pump to remain in use ought to be brought on the carpet!!

  5. Mary says:

    I agree with Sharoni: L&D (in fact all of maternity) is a specialty, and anyone ‘floated’ there should either be certified in the field or should work as a nursing assistant only!

  6. Ruth says:

    I think what is needed is the moral courage to provide safe staffing levels!

  7. sharoni says:

    WOW! I am in shock that this occurred in this century! As a former high-risk L&D nurse & manager, it breaks my heart…for the patients, for the nurses and aides, for the families that could have lost loved ones that evening! The entire structure at that hospital is broken and must addressed before people die. And yes, the buck stops with nursing leadership. Shame on them for not being there…shame! Come on people. wake up…we hold the lives of our patients in our hands. Fix it …now please.

  8. Annette says:

    Moral courage is what is needed here. Although there was acknowledgement of need by all parties involved the moral threshold had been met and the action taken insufficient. Harm was done on multiple levels of care not just to the patient but to staff and the system. What is needed are more bioethical consults at hospitals to review such activity and then to take action to EDUCATE on the value of moral duty.

  9. Louise says:

    I cannot believe that an experienced L&D nurse scrubbed in for a C-section! What was she thinking?

  10. Leah Curtin says:

    Wow, so many comments so soon! In fairness to Pat, I think that she accepted the assignment because it did not seem that desparate at the beginning of the shift. I agree with Clnc that the nursing supervior and the head nurse on that unit should have been disciplined…and the TexasNP, PsychRN and CCRN are right, too. However, with more cuts in reimbursement looming, I am concerned that this kind of situation will become even more common!

  11. gp, CRRN says:

    Too often lately I have witnessed this type of patient care. I agree it is usually the nurses at the bottom of the stack that receive the blame when error occurs. Usually management is trying to contain cost but that cost is at the patient’s expense and the nurse if she is wounded pyschologically enough to leave the profession altogether. This was a tragedic situation that should have never happened. Also many nurses are forced to believe that they cannot refuse an assignment, not true.

  12. Psych.RN says:

    I agree with Cinc why wasn’t the supervisor and mananger held responsible for their negligence? I also wonder why the charge nurse stayed placing herself and the patients in jeapardy. I wonder if she was promised help that never materialized? If I was either of the two nurses left on the unit that night…I would be inclined to take it to the state nursing board as well as Joint commission.

  13. TexasNP says:

    I am left wondering why on earth the nurse accepted the unit with that sort of staffing? Any experienced OB nurse would recognize this as a dangerous situation and, at least in Texas, should have refused to accept the unit until more help appeared.

  14. Clnc-2006 says:

    As a Certified Legal Nurse Consultant, one of my BIG questions is “Why wasn’t the nursing supervisor disciplined?”
    Once again the nurses who are ‘in the trenches’, providing patient care are blamed and (it appears) the nursing supervisor came through the incident without a scratch on her record.

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