LEGAL ASPECT

1. LEGAL ASPECT Advanced Anesthesia 2

2. � The reason for the innovation of the Nurse Anesthetist was simple, the very evident need for better service, which can only come from primacy of work.�Agatha Hodgins

3. What Constitutes the Legal Practice of Nurse Anesthesia Chalmers vs Nelson 1935 Magit vs Board of Medical Education 1952

4. American Legal System Constitutional Law overriding legal force common law state law

5. Common Law Judge Made Precedent �stare decsis� (law changes)

6. STATE LAW

7. Court System Federal Limited Jurisdiction Maritime violation federal statutes controversies individual and government between states State Municipal District (trial court)

8. State Supreme Court Commonwealth (State) state matters Superior individuals

9. State Courts Cont Municipal Lower Children's Common pleas District Justice of the Peace

10. Federal Supreme Court Federal Courts of Appeal Circuit Courts

11. Anatomy of a Lawsuit � Once you receive the notice that you have been sued, your life changes from that moment on�

12. Civil Law Suit Three Stages Preliminary Trial Appeal

13. I Preliminary Stage Complaint filed with court Response-defendant Pleadings Discovery obtaining fact

14. Deposition Oral Questions/Answers Verbatim Oath

15. Interrogatory More discovery Expert Witnesses Key Points

16. Settlement

17. II Trial Jury Selection Case Outline

18. Plaintiff Case Opening Statement Witness

19. Defendants case Open Statement Witnesses

20. Closing Statement

21. Deliberation Jury

22. III Appeal Precedence Both Parties Argue Case

23. Arbitration Settlement without Litigation Cannot Appeal

24. Burden of proof Clear and Convincing Evidence Preponderance of Evidence

25. Who has Burden of Proof Plaintiff must find evidence of all elements of malpractice Res ipsa loquitor burden then shifts to defendant

26. Res Ipsa Loquitor The Act Speaks for itself Conditions Causative event does not occur without negligence Causative factor is in complete control of the defendant Damage is not due in any part to plaintiff�s negligence

27. Negligence Per Se �When the parties fail to comply with a statute designed for the protection of citizens, it is not necessary that actual negligence be proven.� ie Violation of hospital regulations

28. Four Elements to Malpractice 1 Duty (What was the duty owed by the practionier) 2 Breach (Was level of care provided) 3 Cause (Was the breach the cause of the injury) 4 Damage (Was the damage caused by the breach)

29. Other factors of legal concerns

30. Standards of Care Set by the profession Licensing laws CRNA�s are first RN�s Must exercise professional judgment Must be aware of scope of practice

31. Informed consent Law of torts (civil wrongs) Battery unconsented touching physical violence Informed consent does not protect from malpractice

32. Abandonment The Anesthetist is required to provide continued care until the anesthetist is duly relieved . Patients relationship with the health care provider has ended

33. Punitive Damages Based on value Compensation Aggravation Malice Conscious disregard Set by juries

34. Statutes of Limitations State Laws Exceptions Plaintiff Disabled Children Discovery of Negligence

35. Medical Malpractice A breach of Duty Breach of contract Intentional torts Negligence

36. Medical malpractice claims Compensation to a patient for injury Civil claims Criminal claims Role of insurance Deterrence Quality assurance

37. What must be shown Legal duty Injury/Causation Breach Damages

38. What must be shown Establishment of a �Legal Duty� Contractual relationship Express or implied consent Good Samaritan exception Scope of duty Treat in accordance with acceptable practice Continue until natural termination of relationship

39. Types of Claims Breach of contract Breach of warranty Intentional tort Assault and battery Defamation False imprisonment Invasion of privacy Misrepresentation Outrage (intentional infliction of emotional distress) Violation of civil rights

40. Professional Negligence Standards of Care The reasonable CRNA Local, State or National Standards School rule Reasonable prudence

41. Proving Standard of Care/Breach of Standard of Care Expert Testimony Negligence Per Se/ Statutory Liability Common Knowledge Doctrine Res Ipsa Loquitor Strict Liability Causation and Damages Loss of a Chance

42. Determination of Damages Actual or Compensatory damages Economic loss Medical and rehabilitation treatments Loss of earnings Non economic loss Pain and suffering Punitive Damages Usually awarded only in egregious cases

43. Basis for Claim Inadequate informed consent Poor record keeping Mismanaged airway Inattention to details Violation of Standards Cover ups

44. Overview of Standards Through/complete preop assessment Obtain informed consent Formulate anesthesia care plan Adjust care plan Monitor patients condition Accurate/timely documentation Transfer responsibility to qualified provider Adhere to proper safety precautions Minimize risk of infection Assess outcomes Maintain patients basic rights

45. Most frequent claims Pre anesthesia assessment 59% Anesthesia administration 19% Recovery 9% ER and Airway 7% Difficult airway 5%

46. Average 2006 payout for CRNA claims Appropriate Care $122, 000 Inappropriate Care $250,000

47. Most Frequently Reported Claims Teeth 17% Adverse outcomes 9% Baby 9% Death 7% Cardiac Arrest 6% Pt monitoring 5% Hypoxia 5% Equipment 4% Nerve 4% Intubation .04%

48. Most Costly Claims C arrest $250,00 Aspiration $175,00 Adverse $105,00 Oxy/hypoxia $105,00 Pt monitoring $105,00 Eye $75,000 Baby $75,000 Others $50,000 2004

49. Most frequent procedure identified in claims General surgery Orthopedic Gynecologic Plastics ENT In order Most to Least

50. Most Frequent Claims Resulting from Death or Brain Injury ENT Obstetrics Gynecologic General Surgery Orthopedic Plastics Most Least

51. Summary Follow the Standards Read, know and understand the Standards Incorporate the standards into your practice Monitor your practice to assure that you are meeting the standards

52. Following Orders does not shield CRNA�s from Liability