Avoiding Liability Bulletin – May 17, 2017

It is not unusual for nursing staff to feel a sense of purpose and pride in the work they do with their patients. These feelings are often translated into such phrases as “We are a family,” We work as a team,” “We stick together.”

Such teamwork requires delegation of specific tasks to unlicensed assistive personnel (UAPs) and others that are within their scope of practice. In an interesting study done in 2011, the effect of RN-UAP relationships on patient care quality and safety was evaluated.1 The UAP term was used to include many titles that assistive staff are given, including CNAs, UAPs and nurse techs.

The purpose of the study was to identify barriers that would hinder good RN-UAP teamwork and then determine if such interference would affect quality of care and patient safety.

Seven themes were identified that were barriers to RN-UAP teamwork:

  1. Lack of role clarity
  2. Not working together as a team
  3. No conflict management and no feedback skills
  4. Not including UAPs in decision making
  5. Deficient delegation
  6. Not working with the same RN or UAP regularly
  7. “It’s not my job” syndrome2

Not surprisingly, these themes resulted in “diminished patient quality care and increased patient care errors”. One example of these themes’ effects on patient care in the study was when an RN stated that vital signs were not her responsibility and when a patient coded, the RN blamed the UAP.3

Interestingly, many of the barriers listed above center around ineffective communication skills. Good communication skills are essential in eliminating the above-identified barriers to quality patient care and increased patient errors. Communication skills involves not only verbal exchanges but written exchanges as well, especially in relation to documentation in the patient’s record. The link between ineffective communication skills and avoiding professional negligence liability is widespread in nursing literature.

In a benchmark study, 747 malpractice cases involving nurses from 1988 to 1993, “communication negligence” was responsible for 203 (27.17%) of the adverse events (injuries or death) experienced by patients.3

An analysis of 2455 Sentinel Events reported to the Joint Commission in 2004 indicated that the “primary root cause” in over 70% was communication failure, so serious that approximately 75% of the patients died.4

In 2015, CRICO Strategies, in its annual benchmarking report, “Malpractice Risks In Communication Failures”, reported on a total of 7,149 cases of miscommunication with some degree of harm to patients. 37% of those cases were classified as “high severity” of harm, including death. 57% were provider-provider communication failures. And, of the 2,019 cases involving nurses and nursing care, 32% involved a communication error.5

Examples of communication failures in the nursing cases involved those among providers regarding a patient’s condition and poor documentation of clinical findings.6

Clearly, as the research study and the CRICO Annual Report indicate, negative conduct and miscommunication does affect patient care.

They may also affect legal liability as well. Legally, each team member is accountable and responsible for the care they give. If there is a patient injury or death, all team members who were involved with the care of that patient will be legally scrutinized. If a negative tactic or a failure in communication can be linked to the cause of a patient’s injury or death, liability for professional negligence or wrongful death can occur.

Patient care is indeed complex and requires many team members to work with every patient. Avoiding the negative behaviors identified in the above research study and using clear and complete communication of any type with all team members are simple and easy ways to reduce the risk of liability for injury to, or for the death of, a patient.

1. Beatrice Kalisch, PhD, RN, FAAN (2011), “The Impact of RN-UAP Relationships On Quality And Safety”,42(9) Nursing Management, 16-22. The full article of the study is available at: https://www.mobile.journals.lww/nursingmanagement/Fulltext/2011/0900/The_impact-of-RN-UAP-relationships_on_quality_and.3aspx .
2. Id.
3. Janice Pitts Beckmann (1996), Nursing Negligence: Analyzing Malpractice In The Hospital Setting. Thousand Oaks, CA: Sage Publications, 268.
4. M. Leonard, S. Graham, D. Bonacum (2004), “The Human Factor: The Critical Importance Of Effective Teamwork And Communication In Providing Safe Care”. Available at:
www.csap.cam.ac.uk/media/uploads/files/1/leonard-2004-standardised-communication.pdf .
5. CRICO Strategies (2015). Malpractice Risks In Communication Failures: 2015 Annual Benchmarking Report. (CRICO Strategies is a division of The Risk Management Foundation of the Harvard Medical Institutions Incorporated).
6. Shannon Barnet (2016), “5 Thing(sic) To Know About Communication Errors, Nurses And Patient Safety”, Becker’s Infection Control & Clinical Quality. Available at: www.beckershospitalreview.com/quality/5-things-to-know-about-communication-errors-nurses-and-patient-safety.html .


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About the Author

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Nancy Brent

NANCY J. BRENT, MS, JD, RN, received her Juris Doctor Degree from Loyola University Chicago School of Law. Ms. Brent has been in practice for over 40 years and concentrates her solo law practice in education and consultation for nurses, nursing organizations, and health care delivery systems. She also defends nurses before the Illinois Department of Financial and Professional Regulation. Ms. Brent has published and lectured extensively in the area of law and nursing practice.