medico - legal aspects
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Medico - legal
Aspects
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Law
Ordinarily the term Law means a body of rules to guide
human action.
Definition:
The lawis a system ofrights and obligations which
the state enforces.
Green
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Law-Definition:
Definition:
Defined as the sum total of rules and regulations by
which a society is governed, law is created by people
and exist to regulate all persons
Guido
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Medico legal issues
Any case of injury or ailment where some
criminality is involved is called Medico legal
cases(MLC)
It is legal presumption that medical officer is
capable of identifying such cases.
Medico legality is judged by the history furnished
by the patient coupled with the finding in the
physical examination
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Medico legal issues and emergency department
Following categories of cases coming to casualty or brought to
casualty are to be labeled as medico legal:
1. Cases of injuries and burns, circumstances of which make
itprobable that someone has committed an offence
2. All cases of suspected or evident poisoning or intoxication
3. Allvehicular, factory or unnatural accident cases,
wherethere is likely hood ofpatients death
4. Suspected or evidentcriminal abortions
5. Suspected or evident sexual assault
6. Unconscious cases where its cause is not clear or notnatural
7. Cases brought dead with improper history, creating
suspecion of an offence
8. Cases referred from court or otherwise age estimation
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Disposal of medico legal casesa) The above cases, whether brought by the police or somebody
else ,must be labeled as medico legal in casualty department,
if not registered else where.
b) Request of the patient or the accompanying relatives or
friends for not registering the case as medico- legal, should
not be agreed
c) Any case among the above list even if brought several daysafter the incident, shall be registered as medico-legal and an
opinion regarding the case be given according to the present
condition of the patient
d) A fresh medico- legal report may not be prepared if the casebroughthad been registeredas medico- legal in some hospital
e) Treatment in all medico- legal cases takes precedence over
medico- legal formalities especially when the condition of the
patient is serious
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Procedure of medicolegal casesAll medico- legal cases are supposed to be register and then
inform to the police. Appropriate prescription forms are to be
filled for preparing medico legal reports. In such cases,
identification data, date and time of arrival, date and time of
examination, name and address of the attendant of the patient
is to be recorded in each and every case.
Specimens relevant to the case should be properly sealed,
labeled and send for investigation, eg: in a stabbed victim theinjury should be encircled, signed and then the specimen should be
handed over to the police in a sealed cloth parcel.
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Negligence And
Malpractice
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NEGLIGENCE
Negligence is the failure/ omission of an
individual to do something which a
reasonably prudent person would do, or
doing something which a prudent &
reasonable man would not do.
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NEGLIGENCE
In other words negligence is conduct that falls
below the standard of care which is established
by the law for the protection of others against
unreasonable risk or harm
It is characterized chiefly by inadvertence,
thoughtlessness or inattention
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What constitutes deficiency in service
or negligence
Deficiency of service means any fault, imperfection,
shortcoming or inadequacy in the quality, nature
and manner of performance which is required to be
maintained
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What constitutes deficiency in service or negligence
Reaction of injection
Patient left unattendedwhile there were complications.
Leaving patient in care ofunqualified compounder.
Foreign material left inside during operation
Death during operation.
Post operative care.
Refusal to admit the patient.
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What does not constitute deficiency in service or negligence
Performance of duty to the best of ability.
Adopting one out of two recognized schools of
medicine.
Complainant failed to establish deficiency in service.
Patient having some medical history.
Patient of heart attack.
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Common problems for which the nurses are often found
negligible are
1. Failure to use aseptic technique where required
2. Leaving a foreign object in a patients body during surgery,
ie: errors in sponge, instrument or needle count in surgical
cases
3. Failing to respond promptly to patient symptoms of
impending disaster
4. Failing to protect an infirm patient from falling
5. Administering wrong medicine to a patient
6. Administering a medication inappropriately, IV therapy,
errors resulting infiltration or phlebitis
7. Administering a care in such a manner that apatient suffers
injury, eg improper handling of hot water bagsburn to
patient.
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NEGLIGENCE
If nurses give care that does not meet the standards, they
may be held liable for negligence.
Nurses are responsible for performing all procedures
correctly and exercising professional judgement as they
carryout doctors orders and duties not ordered by for
which they have authority.
Any nurse who does not meet accepted standards of
practice or care or who performs duties in a careless
fashion, runs a risk of being found negligent.
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Malpractice
Malpractice is a negligence or carelessness by a
professional person. So, it concerns professional action and
in the failure of a person , with professional education and
skill to act in a reasonable and prudent manner.
In other words , it is unreasonable professional conduct, lack
of skill or fidelity in professional duties, evil practice or
illlegal or immoral conduct.
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Six elements of malpractice suit
1. The nurse(defendent) owed a duty to the client(the plaintiff),
ie. There should be an evidence that the nurse owed a duty to
the client ,eg: failure to monitor clients response to treatment
2. Breach of the duty of care owed to the patient, ie. There
should be an evidence that the nurse failed to meet the
prevailing standards of care. e.g. failure to communicate
change in status to other care provider
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Six elements of malpractice suit
3. Foreseeability not maintained: Foreseeability include the concept
that certain events may reasonably be expected to cause specific
results. For example, in children wards, falling of children from
bed is common, i.e. There should be an evidence that the client
suffered due to lack of foreseeability by the nurse
4. Evidence of causation which means that the nurses action or
lack of action directly caused harm to the patients and not
merely that patient had some type of harm. So there should be an
evidence that nurses failure to meet their duty are likely to cause
client injury, i.e failure to provide patient education
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Six elements of malpractice suit
5. Evidence that nurses failure was direct cause of client
injury, e.g. if a client falls
6. There should be an evidence of damage. Damages are valid
as malpractice which is intentional and unintentional.
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Measures to overcome malpractice
Follow standard of care, give competent health
care, and develop an empathetic interpersonal
relationship with the client
Follow careful and accurate documentation
Be up to date with current practices
Be sensitive to common sources of clients
injuries like fall
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Legislations And
Regulations Related ToCritical Care
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Legal safeguards in nursing practice
Licensure: All nurses who are in nursing practice have to
posses a valid licensure from State Nursing Council/INC
Good Samaritan law: In response to health care professionals
fear of malpractice claims, most states enacted Good
Samaritan law that exempt doctors and nurses from legal
liability when they render first aid during emergency. A nurse
who renders assistance at an accident scene is to held same
standard of skill, competence and judgement that would be
applied to a reasonably prudent person with the same
preparation.
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Legal safeguards in nursing practice
Good rapport: Developing good rapport with the client is
very importantto prevent malpractice.
Standards of care: All professionals practicing in medical
field are held to certain standards when administering care. It
is always better to follow standards of care to avoid
malpractice and do not attempt anything beyond the level of
competence.
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Legal safeguards in nursing practice
Contracts: It is a written or oral agreement between two
people in which goods or services are exchanged. According
to Section 13 to the Indian Contract Act, Contracts the
word means saying that two or more person are said to
consent which they agree upon the same thing in the same
sense. Treating a person with out obtaining consent can
lead to a charge of assault (unwillful attempt or threat to
harm another)and / or battery(unauthorized touching of a
patient)
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Legal safeguards in nursing practice
Drug maintenance : the two acts which control the use of
poison in medicine are,
Misuse of Drugs Act 1971
Dangerous Drug Act 1965 & 1967
The act aims at checking the unlawful use of the drugs
liable to produce dependence or cause harm if misused.
Drugs affected by this act is referred to as controlled drugs.Eg: Cocaine, Opium, Pethidine etc
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Other Legal protection in nursing practice
1. Civil rights act (CRA)-1964
2. Americans disability act (ADA)- 19673. Occupational safety and health act (OSHA)- 1970
4. National labor relations act(NLRA)-1974
5. Sexual harassment- 1980
6. Individual express contract7. Employees at will
8. Good Samaritan law
9. Age discrimination in employment Act(ADEA)- 1992
10. Health insurance portability and accountability act
Laws applicable to nursing practice
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Laws applicable to nursing practice
1. The right to refuse to treat except in emergency situation
2. The right to sue for fees
3. The right to add title or description to name
4. Unregistered practitioners are not allowed to hold
appointments in public or local hospitals
5. The Indian Penal Code states that poisonous drugs be kept in
separate containers, properly labeled and marked.
6. There is a duty of secrecy to the patients records, it must be
treated as confidential unless the practitioner is called upon to
give evidence in court
Laws applicable to nursing practice
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Laws applicable to nursing practice
7. Fundamental duties
a. To exercise a reasonable degree of skill and knowledge intreating patients
b. Once a relationship to a patient has been established,there is
an obligation to attend to the patient as long as necessary ,
unless the patient request for withdrawal or notice is givenof intension to withdraw
c. A practitioner must give personal attention to his cases and
answer calls with reasonable promptness
d. Children must be protected from harming themselvese. Special prevention must be taken in case of adult who are
incapable of taking care of themselves
Laws applicable to nursing practice
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Laws applicable to nursing practice
8. Dangerous diseases must be reported
9. Nurses are considered solemnly responsible for their own
professional act irrespective of the employing agency
A fine is the usual penalty imposed for disobeying the law
stated above, although imprisonment also is possible.
C P t ti
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Consumer Protection
Act (CPA)
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Consumer Protection Act
Health care delivery system has grown up into an
industry today and health service consumers are
better informed than in the past about health and
illness. Through newspapers, magazines, televisions
and other multimedia more information is available
to the consumer
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Consumer Protection Act
Many of them are aware of their rights and demanding
a voice and partnership in the delivery of health care
services. Years ago, heath care professionals especially
physicians were considered as all knowing experts. Very
few patients questioned them. Now consumers of health care
are demanding to have a say in matters affecting their health
care.
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Consumer Protection Act
As consumers have become more aware of their rights,
conflicts between patients and health care professionals and
institutions have developed.
Nursing is affected by this kind of situation in which
nurses are also expected to answer questions, explain
procedures and respect this rights and request of the
patient. Nurses are challenged to become advocates for clients
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Consumer Protection Act
An act to provide better protection of the interests
of the consumers and for that purpose to make
provisions for establishment of consumer councils and
other authorities for the settlement of consumersdispute and for matters connected therewith.
It is enacted by the Parliament in 1986, has been
drastically amended and its scope is greatly widened by
the amendment of 1993.
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Section 2 of the actConsumer means any person who hires or avails
of any services for a consideration which has
been paid or promised or partly paid and partly
promised.
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Section 2 of the act
Servicemeans service of any description
which is made available to potential users .
Health care services will be service, if they
are obtained for consideration.
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Section 2 of the act
and that in the event of any deficiency in
the performance of such services , the
aggrieved party can invoke the remedies
provided under the act by filing a complaint
before the consumer forum having
jurisdiction.
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ADVANTAGES OF CPA OVER CIVIL COURT
1. Limited time is needed for decision and
action (period of 3 months).
2. No court fee is payable
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COMPLAINT & COMPLAINANT
Complaint: meansany allegations in writing made
by a complainant .
Complainant: means
(a)a consumer
(b) any voluntary consumer association
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WHO IS LIABLE TO CPA
1. Doctors with independent practice
2. Private hospital charging all.
3. All hospital having free as well as paying
patients, they are liable to both.
4. Doctors or hospitals paid by an insurance
scheme for treatment of a client or an employer
for the treatment of an employee.
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WHO IS NOT LIABLE TO CPA
Doctors in hospitals , which do not charge their
patients.
Hospitals offering free services to all patients.
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(2) State level: At this level the claim for
compensation is enhanced toRs: 520 lakhs &high
court judge & 2 other members chair it.
(3) National level: Here the compensation claimed
is more than 20 lakhs .This forum constitutes ofasupreme court judge ,4 other members.
PROVISION FOR APPEAL
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PROVISION FOR APPEAL
Within 30 days from the date of decision , appeal
can be filed in the higher commision
1. Appeal against district forum before state
commision .
2.Appeal against state commission before national
commision.
3.Against national commission before supreme
court.
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PREVENTIVE STEPS AGAINST LITIGATION
Precautions may be summarized as Dos & Donts
SOMEDOS
-Mention your qualifications on the prescription.
-Mention date & timing of consultation.
-Mention age, sex, weight (child).
-In complicated cases record history of illness &
physical findings about the patient.
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SOME DONTS
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SOME DONTS
-Do not hesitate to discuss the case with your colleagues.
-Do not hesitate to discuss the case with patients or
attendants.
-Do not allow substitutions.
-Do not attent a patient if you are sick, exhausted or under
effect of alcohol.
-Do not adopt experimental method in treatment
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LIMITATION
Limitation period : the district forum ,the
state commission or the national
commission shall not admit a complaint
unless it isfiled within 2 yearsfrom the date
on which the cause of action has arisen.
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Bill of rights of a patient,
Euthanesia
Cli t Ri ht
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Clients Rights
Clients are protected by law (invasion of privacy)
against unauthorized release of personal clinical
data, such as symptoms, diagnoses, and
treatments.
Nurses, as well as other health care personnel, may
be held personally liable for invasion of privacy .
Litigation arise from the unauthorized release of
client data.
Clients Rights
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Client s Rights
Confidential information, however, may be released
with the clients consent.
Information release is mandatory when orderedby a
court or when state statutes require reporting child
abuse, communicable diseases, or other incidents.
Nurses have a legal and ethical responsibility to
become familiar with their employers policies and
procedures regarding protection of clients
information.
Clients Rights
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Client s Rights
Medical records are the key written account of such client
information as signs and symptoms, diagnosis, treatment, and
responses to treatment.
These records contain important data for insurance and other
expense claims and are used in court in the event of litigation.
Health professionals are becoming more aware of the
implications of clients rights as society in general becomes
more aware of every human beings basic rights.
The Client Bill of Rights
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The Client Bill of Rights:
1. The client has the right to considerate and respectful
care.
2. The client has the right to obtain from his or her
physician complete current information concerning
diagnosis, treatment, and prognosis in terms the client
can be reasonably expected to understand.
The Client Bill of Rights:
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g
3. The client has the right to receive from the physician
information necessary to give informed consent prior to thestart of any procedure or treatment. . . . Where medically
significant alternatives for care or treatment exist, or when the
client requests information concerning medical alternatives,
the client has the right to such information to know the name of
the person responsible for the procedures or treatment.
4. The client has the right to refuse treatment to the extent
permitted by law and to be informed of the medical
consequences of his or her action.
The Client Bill of Rights:
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The Client Bill of Rights:
5. The client has the right to every consideration of privacy
concerning his or her own medical care program.
6. The client has the right to expect that all communications
and records pertaining to his or her care should be treated as
confidential.
7. The client has the right to expect that within its capacity a
hospital must make reasonable response to the request of a
client for services.
The Client Bill of Rights:
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The Client Bill of Rights:
8. The client has the right to obtain information as to any
relationship of the hospital to other health care and
educational institutions in so far as his or her care is concerned [
any professional relationships among individuals, by name, who
are treating him or her.
9. The client has the right to be advised if the hospital proposes to
engage in or perform human experimentation affecting his orher care or treatment. A patient has the right to refuse to
participate.
The Client Bill of Rights:
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The Client Bill of Rights:
10. The client has the right to expect reasonable continuity of
care.
11. The client has the right to examine and receive an
explanation of his or her bill regard less of source ofpayment.
12. The client has the right to know what hospital rules and
regulations apply to his or her conduct as a client.
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Legal responsibilitiesof nurses
Legal responsibilities of nurses
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Legal responsibilities of nurses
1. Responsibilities of appointing and assigning: Ns
administrator must be aware of the legal restrictions affecting
personnel appointment and assignment; she should screen the
staffs appropriately before appointing them.
2. Responsibility in quality control:Nurse administrator must
ensure and report quality of nursing services.
3. Responsibility for equipment: To protect the patient and
employee from injury, the nurse manager must ensure that all
patient care equipments are fully functional and defective
equipments are promptly repaired or replaced.
Legal responsibilities of nurses
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Legal responsibilities of nurses
4. Responsibility for observation and reporting
5. Responsibility for record keeping and reporting
6. Responsibility to protect the public
7. Responsibility for death and dying
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Role of nurse in legal
issues
Role of nurse in legal issues
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Role of nurse in legal issues
The following are the leadership roles and
managerial functions of a nurse manager in legal and
legislative issues. He or she;
1. Serves as a role model by providingnursing care that
meets and exceeds accepted standard of care
2. Is current in the field
3. Reports substandard nursing care to appropriate
authorities
Role of nurse in legal issues4 F t / ti t l ti hi th t
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4. Fosters nurse/ patient relationships that are
respectful, caring and honest, thus reducing the
possibility of future lawsuits
5. Joins and actively supports professional
organizations to strengthen the lobbying efforts of
nurses in health care legislation
6. Practices nursing with in the area of individual
competence
7. Prioritizes patients rights and welfare first in
decision making
Role of nurse in legal issues
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Role of nurse in legal issues
8. Demonstrates vision, risk taking etc in
determining appropriate legal boundaries
9. Is knowledgeable while responding to legal issues
related to nursing practice
10.Delegateto subordinates wisely
11.Understand and adhere to hospital policies and
procedures
Role of nurse in legal issues
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Role of nurse in legal issues
12.Monitors subordinates
13.Uses foreseeability of harm in delegation and
staffing decision
14.Increases staff awareness in legal issues
15.Provides educational and training opportunities
for staff on legal issues affecting nursing practice
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Records and reports
Records and reports
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Records and reports
The medico- legal patients clinical record is a
brief account of the personal and medical history
of the patient, results of diagnostic tests, findings
of medical examination, treatment and nursing
care, daily progress notes and advice on discharge.
Records and reports
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1. The records are kept under safe custody of the nurse
in each ward
2. No individual sheet is separated from the complete
record
3. Records are kept in place, not accessible to patients
and visitors
4. No stranger is ever permitted to read the record
5. Records are not handed over to legal advisors with out
the written permission of the administration
Records and reports
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Records and reports
6. All hospital personnel are legally & ethically obligated to keep
in confidence all the information provided in the records
7. All records are to be handled carefully, careless handling can
destroy the records
8. All records are to be filed according to hospital custom, so
that they can be traced easily. Records can be arranged
Alphabetically
Numerically
Geographically
Records and reports
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Records and reports
9. All records are identified with the biodata of the
patient such as name, age, ward, bed no, OP no etc
10.Medico legal records are never sent out of the
hospital with out the doctors permission.
Reference is made by writing separate sheets and
sending to the agency who requests for them Eg:
discharge summary