NC Supreme Court rules CRNA can be held responsible for case outcome

[Agast]

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N.C. Supreme Court overrules 90-year-old precedent protecting nurses from legal liability

This is an interesting development. The case at the center of this argument is whether a CRNA can be held liable for poor outcomes, even while under the supervision of an attending physician.

Description of case

A 3-year-old had a mask induction with sevoflurane and suffered a cardiac arrest leading to hypoxic brain injury. If the plan was generated by the anesthesia attending, is the CRNA really at “fault” for method of induction? Also it’s been a while since I’ve done peds but I thought mask induction at that age is standard of care.

 

[GravelRider]

N.C. Supreme Court overrules 90-year-old precedent protecting nurses from legal liability

This is an interesting development. The case at the center of this argument is whether a CRNA can be held liable for poor outcomes, even while under the supervision of an attending physician.

Description of case

A 3-year-old had a mask induction with sevoflurane and suffered a cardiac arrest leading to hypoxic brain injury. If the plan was generated by the anesthesia attending, is the CRNA really at “fault” for method of induction? Also it’s been a while since I’ve done peds but I thought mask induction at that age is standard of care.

Seems like the physician already settled. Why didn’t the CRNA or hospital that employed him settle? Did they think they would be protected by this old precedent? If more of these cases surface, I wonder if the rank-and-file CRNAs will want the AANA to tone down its rhetoric about independent practice? Independent practice sounds great in theory, but when the prospect of full liability is present, all of a sudden it sounds a little more daunting.

 

[Urzuz]

Seems like the physician already settled. Why didn’t the CRNA or hospital that employed him settle? Did they think they would be protected by this old precedent? If more of these cases surface, I wonder if the rank-and-file CRNAs will want the AANA to tone down its rhetoric about independent practice? Independent practice sounds great in theory, but when the prospect of full liability is present, all of a sudden it sounds a little more daunting.

Nah it wont. That requires the independent CRNAs to have insight into their own deficiencies, which is what is missing. They all think that they won’t have a complication since they know everything and are ‘experts’. The only thing that can happen is if/when more of these cases get published in the media, the public may catch wind of the giant charade (“Hi, I’m doctor Jones your nurse anesthesiologist”) and demand better. Doubtful, but it may happen.

 

[abolt18]

Nah it wont. That requires the independent CRNAs to have insight into their own deficiencies, which is what is missing. They all think that they won’t have a complication since they know everything and are ‘experts’. The only thing that can happen is if/when more of these cases get published in the media, the public may catch wind of the giant charade (“Hi, I’m doctor Jones your nurse anesthesiologist”) and demand better. Doubtful, but it may happen.

And if something bad happens, it will be blamed on the patient. "He was a very difficult intubation. She was REALLY sick, nothing more we could do. I don't know why her heart stopped, I just did what I always do; must have had some problem we didn't know about."

 

[secretasianman]

I’m just waiting for the shtstorm of malpractice suits against midlevel mismanagement. There’s so much fxkery out there in primary care, derm, ER, etc that it must be a good time to be a trial lawyer. If that happens that could spur more change in our field.

 

[deleted1130227]

Seems like the physician already settled. Why didn’t the CRNA or hospital that employed him settle? Did they think they would be protected by this old precedent? If more of these cases surface, I wonder if the rank-and-file CRNAs will want the AANA to tone down its rhetoric about independent practice? Independent practice sounds great in theory, but when the prospect of full liability is present, all of a sudden it sounds a little more daunting.

Because this is the first overturning of a multi decade precedent. I wouldn't have settled if I were the CRNA, as long as it wouldn't affect my coverage. I might settle now depending on circumstances.

 

[pgg]

I’m just waiting for the shtstorm of malpractice suits against midlevel mismanagement. There’s so much fxkery out there in primary care, derm, ER, etc that it must be a good time to be a trial lawyer. If that happens that could spur more change in our field.

Doctors and hospitals have deep pockets ... how deep are the midlevels' pockets? What's their usual malpractice coverage? If it's not very high (I have no idea?) then the lawyers may still just prefer to go after the physicians and facilities.

 

[coffeebythelake]

Doctors and hospitals have deep pockets ... how deep are the midlevels' pockets? What's their usual malpractice coverage? If it's not very high (I have no idea?) then the lawyers may still just prefer to go after the physicians and facilities.

When "just a nurse" is a double edge sword. They've gotten away with it for long enough. Now that they face real consequences let's see how insurance and malpractice coverage changes for them. I imagine it will get a lot more expensive. Or alternatively the insurance companies will start asking serious questions why just a nurse is allowed to practice unsupervised. When the bottom line is about the money this will raise eyebrows from hospital admin.

 

[GravelRider]

When "just a nurse" is a double edge sword. They've gotten away with it for long enough. Now that they face real consequences let's see how insurance and malpractice coverage changes for them. I imagine it will get a lot more expensive. Or alternatively the insurance companies will start asking serious questions why just a nurse is allowed to practice unsupervised. When the bottom line is about the money this will raise eyebrows from hospital admin.

Can mega-hospital systems self insure? If the CRNAs are employed by and insured by the mega-hospital, those insurance costs are not necessarily realized by the hospital. At that point it just becomes an accounting game for the hospital…does the cost savings on employing independent CRNAs outweigh the potential extra liability that a hospital might face for independent CRNAs?

 

[kidthor]

Can mega-hospital systems self insure? If the CRNAs are employed by and insured by the mega-hospital, those insurance costs are not necessarily realized by the hospital. At that point it just becomes an accounting game for the hospital…does the cost savings on employing independent CRNAs outweigh the potential extra liability that a hospital might face for independent CRNAs?

A lot of mega hospitals are semi self insured by risk pooling with other mega hospitals, and then reinsured on top of that.

 

[secretasianman]

Beat me to it. The low premiums have always seemed to me like this circuitous loophole to avoid legal consequences. Premiums are low so lawyers don’t target them, and by not being targeted, premiums stay low.

When "just a nurse" is a double edge sword. They've gotten away with it for long enough. Now that they face real consequences let's see how insurance and malpractice coverage changes for them. I imagine it will get a lot more expensive. Or alternatively the insurance companies will start asking serious questions why just a nurse is allowed to practice unsupervised. When the bottom line is about the money this will raise eyebrows from hospital admin.

 

[Agast]

I wonder if the CRNA in this case was sued as a stepping stone to be able to sue the hospital, where the deep pockets are. I

 

[Ashers]

Doctors and hospitals have deep pockets ... how deep are the midlevels' pockets? What's their usual malpractice coverage? If it's not very high (I have no idea?) then the lawyers may still just prefer to go after the physicians and facilities.

One independent CRNA (with 2 docs to put out fires) job I know of requires $200k/600k malpractice coverage. It's on gaswork where CRNAs took over my old job.

 

[HalO'Thane]

N.C. Supreme Court overrules 90-year-old precedent protecting nurses from legal liability

This is an interesting development. The case at the center of this argument is whether a CRNA can be held liable for poor outcomes, even while under the supervision of an attending physician.

Description of case

A 3-year-old had a mask induction with sevoflurane and suffered a cardiac arrest leading to hypoxic brain injury. If the plan was generated by the anesthesia attending, is the CRNA really at “fault” for method of induction? Also it’s been a while since I’ve done peds but I thought mask induction at that age is standard of care.

Without knowing the full details of the case and just by going off of that medical malpractice link above, maybe the kid had a bad heart to begin with; either due to congenital heart disease or the arrhythmia itself? In that case, it is possible that she didn't tolerate a bunch of Sevo during inhalation induction, especially if the CRNA had it cranked at 8% while the anesthesiologist was looking for an IV.

From what it sounds like, I don't think the CRNA was held liable for the method of induction but rather the improper administration of the drug.

 

[woopedazz]

Who wouldn't have induced this kid with sevo? From the scant info available... Can't see too much of a problem with that decision

 

[painstop]

I assume the decision in question would be that the CRNA did not turn off the gas and just use 100% oxygen but I would have to see the details of what happened.

 

[Status Sciaticus]

N.C. Supreme Court overrules 90-year-old precedent protecting nurses from legal liability

A split N.C. Supreme Court has voted to overturn a 90-year-old state court precedent that protected nurses from legal liability. Because the majority decision secured just three votes on the seven-member court, it’s unclear how the latest ruling will affect future cases.

www.carolinajournal.com

I must say I was ignorant of this before. They CAN’T even be sued, at least in NC.

Who wouldn't have induced this kid with sevo? From the scant info available... Can't see too much of a problem with that decision

maybe its not the induction that led to the cardiac arrest, but the management afterwards, especially if it was hypoxia induced cardiac arrest. Maybe couldn't tube or ventilate the kid. Too few details for anything but conjecture at this point.

 

[kidthor]

The NC court opinion goes over the details of the case. I think the care given was reasonable. Probably one of those unavoidable unexpected bad outcome things that end up being settled because of optics and financial reality, rather than a standard of care issue.

Also IMO I don’t think the crna breached standard of care (again, based on the brief info in the court opinion), but the issue was whether the crna could be liable in the first place. It’s a better defense for them to say they couldn’t ever be liable, thereby avoiding debate on the facts of the case. I’m not sure how Carolinas employs and insured the crnas, but certainly it could be a route for a plaintiff to get to hospital pockets if they employed crnas directly as many hospitals do.

The old NC case law suggested a nurse couldn’t be liable when following doctor’s orders. But back then there weren’t aprns all over, so this new court decision seems to reflect modern reality.

 

[IMGASMD]

maybe its not the induction that led to the cardiac arrest, but the management afterwards, especially if it was hypoxia induced cardiac arrest. Maybe couldn't tube or ventilate the kid. Too few details for anything but conjecture at this point.

I thought this was better kept in private. Don’t want to be out here and talking about CRNAs.

 

[jwk]

The key point on this case is not the clinical side. It’s the fact that the CRNA is being held responsible for their own actions, rather than automatically being shielded because they were being “supervised”. It overturns nearly a century of precedent in NC, and recognizes the changes in nursing practice over that time period. They want to brag about independence until everything goes to crap. Now they’ve got to put their money where there mouth is.

 

[GravelRider]

Nursing societies may now point to this ruling and say “see, we are being held to high standards legally and therefore we should be allowed to practice independently.”

 

[Fpg1245]

Nursing societies may now point to this ruling and say “see, we are being held to high standards legally and therefore we should be allowed to practice independently.”

That is precisely how it will be spun and now they’ll use it saying oh look now we need long nurse residency programs just like the doctors do!

 

[Southpaw]

The key point on this case is not the clinical side. It’s the fact that the CRNA is being held responsible for their own actions, rather than automatically being shielded because they were being “supervised”. It overturns nearly a century of precedent in NC, and recognizes the changes in nursing practice over that time period. They want to brag about independence until everything goes to crap. Now they’ve got to put their money where there mouth is.

Just want to point out that every supervising anesthesiologist, and the ASA, make the claim that nurses in fact need a shield and it is the physician who provides it. I’m not convinced this ruling is what most anesthesiologists wanted.

However, if we are saying nurses are fine to practice independently because that is how malpractice law will be followed, then fine.

But we can’t have it both ways.

 

[Arch Guillotti]

maybe its not the induction that led to the cardiac arrest, but the management afterwards, especially if it was hypoxia induced cardiac arrest. Maybe couldn't tube or ventilate the kid. Too few details for anything but conjecture at this point.

Mask induction and subsequent CV collapse.

 

[DrZzZz]

Just want to point out that every supervising anesthesiologist, and the ASA, make the claim that nurses in fact need a shield and it is the physician who provides it. I’m not convinced this ruling is what most anesthesiologists wanted.

However, if we are saying nurses are fine to practice independently because that is how malpractice law will be followed, then fine.

But we can’t have it both ways.

Disagree to a point. If I pick a bad anesthetic plan and the crna follows it as I instructed, I don't know how liable they should be for going along with that plan if it leads to a bad outcome. But if the crna gives a drug to a patient that they have a known anaphylactic reaction to and the patient suffers any harm from that, they absolutely should be liable, especially if I didn't explicitly instruct them to give that medication. If a crna never calls me for an induction, induces without me, and kills the patient, how are they not liable for that? There are many things a crna is expected to be able to manage without direct orders from a supervising anesthesiologist, and for those things, they ought to be held liable.

 

[calvnandhobbs68]

Nursing societies may now point to this ruling and say “see, we are being held to high standards legally and therefore we should be allowed to practice independently.”

Well yeah but they're basically doing it anyway. Even in states where there's "collaboration" it's pretty much in name only. There are literally "physician collaborator" services online where some doc trying to make a quick buck will "collaborate" with your entire office of NPs. It's really not a barrier in real life to NPs doing their own thing, especially on the outpatient side, so might as well start holding them legally accountable for this rather than hiding behind the "i'm just a nurse" shield still.

 

[IMGASMD]

Just want to point out that every supervising anesthesiologist, and the ASA, make the claim that nurses in fact need a shield and it is the physician who provides it. I’m not convinced this ruling is what most anesthesiologists wanted.

However, if we are saying nurses are fine to practice independently because that is how malpractice law will be followed, then fine.

But we can’t have it both ways.

I am not sure asa or supervising anesthesiologists necessarily have the best of the profession in mind.

There are people who would let them practice independently and just let it burn.

 

[Anesthesiageek]

The problem is 99.9% of anesthesia is really not that difficult and it doesn’t matter who does the case most patients do just fine

 

[Straight2eight]

The problem is 99.9% of anesthesia is really not that difficult and it doesn’t matter who does the case most patients do just fine

Incorrect. This is a shallow, nurse level view of the impact of anesthesia delivery on the peri-operative course. I take your point generally, and maybe no one cares if patients have non-lethal complications, but often “do just fine” means that they walked out the door but not in the same or better condition than when they arrived.

 

[Pappy Van Propofol]

The problem is 99.9% of anesthesia is really not that difficult and it doesn’t matter who does the case most patients do just fine

It doesn’t matter how difficult it is, the complications are catastrophic. I can’t understand how some anesthesiologists continue to undervalue themselves. It’s easy because we are good at it. Plumbers, electricians, pilots all probably think their job are easy too. It’s because they trained and to them it is easy.

 

[IMGASMD]

The problem is 99.9% of anesthesia is really not that difficult and it doesn’t matter who does the case most patients do just fine

I like how a ghost crna account pops up calling anesthesiologists and anesthetist, “providers” and spewing bs.

 

[IlDestriero]

I don’t do Cath lab cases in my current job, but in the past I would have placed a pre induction IV for this. Mask induction w/ sevo +/- N2O is routine, but anytime the spidey-sense starts tingling, they get an IV first, even if the family pushes back. An arrhythmia hx requiring ablation certainly qualifies in my mind. How often do you notice some strange non specific ECG changes or sinus arrhythmia in healthy kids with sevo that’s gone when the case is done and now <1/2 mac? Often enough.
Others may disagree, and I can’t say what the standard of care is.
Im not the biggest cowboy out there, and that helps me sleep well at night. The kid crying with IV placement for a couple minutes doesn’t outweigh the benefits.
Of course there may be a lot of important history and background we don’t know as well.
I think this idea that nearly all kids need a mask induction and IV placed under anesthesia is ridiculous and we probably should push back more than we do. It’s surgery not a stroll in the park.

 

[kidthor]

I think this idea that nearly all kids need a mask induction and IV placed under anesthesia is ridiculous and we probably should push back more than we do. It’s surgery not a stroll in the park.

Absolutely. Kids get admitted to the hospital and they get IVs placed magically without anesthesia. I think we go overboard with masking the kids down first.

I once had a nurse write a formal complaint about me because I put in an IV in the OR on a kid pre induction…. The kid had received versed and has trisomy 21 with a low grade congenital cardiac defect. This speaks to the cultural defect where it’s expected that everyone needs a mask induction first.

 

[IMGASMD]

Absolutely. Kids get admitted to the hospital and they get IVs placed magically without anesthesia. I think we go overboard with masking the kids down first.

I once had a nurse write a formal complaint about me because I put in an IV in the OR on a kid pre induction…. The kid had received versed and has trisomy 21 with a low grade congenital cardiac defect. This speaks to the cultural defect where it’s expected that everyone needs a mask induction first.

It also speaks to how we are there to “serve” the patients. Customer is always right, right?

 

[IMGASMD]

Read a little on the case. Apparently they had to do CPR twice. One right after induction for 12 mins. Another round after 2 hours of procedure.

Also
Plaintiffs alleged negligence against Drs. Sliz and Smith based on their advice that Amaya should undergo the heart procedure, as well as their actions during the procedure. (R pp 60, 71-78) Plaintiffs alleged negligence against Dr. Doyle and Mr. VanSoestbergen for their roles in Amaya’s anesthesia. (R pp 3, 60, 71-78) On the anesthesia-related issues, plaintiffs’ claims against the Hospital Authority derived entirely from their claims against Mr. VanSoestbergen.

So it seems like crna was employed by the hospital. So they’re trying to get through by suing crna and the hospital….

 

[Agast]

I’m surprised after the first round of CPR on induction they didn’t cancel the case….too easy to blame it on initiation of anesthesia but I feel like the kid is trying to tell you something

 

[HalO'Thane]

Read a little on the case. Apparently they had to do CPR twice. One right after induction for 12 mins. Another round after 2 hours of procedure.

Also
Plaintiffs alleged negligence against Drs. Sliz and Smith based on their advice that Amaya should undergo the heart procedure, as well as their actions during the procedure. (R pp 60, 71-78) Plaintiffs alleged negligence against Dr. Doyle and Mr. VanSoestbergen for their roles in Amaya’s anesthesia. (R pp 3, 60, 71-78) On the anesthesia-related issues, plaintiffs’ claims against the Hospital Authority derived entirely from their claims against Mr. VanSoestbergen.

So it seems like crna was employed by the hospital. So they’re trying to get through by suing crna and the hospital….

Do you have a link to that extended description of the case? I couldn’t find those details anywhere.

 

[IMGASMD]

Do you have a link to that extended description of the case? I couldn’t find those details anywhere.

https://www.ncha.org/wp-content/uploads/2021/07/Connette-Appellee-Brief.pdf

This is what I read.

 

[Ronin786]

The hope has got to be that the nursing body as a whole realizes the risk associated with being held liable for outcomes are not worth the ego boost of calling your own shots.

Reality is they'll probably just point to this as a reason to "practice to the top of their license" since they're held liable anyways. Might lead to a lot more disagreements with CRNAs wanting more of a say. Double-edged sword.

 

[epidural man]

This thread makes me really sad I’m part of this field and I really wish I could make a money doing something else I liked.

I can’t imagine doing anything else in medicine, but just wish I was a real estate guy, or sound engineer for a busy music studio, played saxophone for the San Diego Symphony.

It’s horrible because bad things happen when we try to manage things in a human body - it just does sometimes and the fact that people get to sue as if everything should always work out perfectly is Sad.

It’s horrible because we are in this mess were we are fighting with lesser trained individuals who are smart, independent thinkers, so we war with them - with no clear resolution in site.

It is horrible because the job we do is ALWAYS extremely dangerous, never simple or easy - yet boneheads continue too say stuff like “what we do is easy and safe 99.9%” of the time…”. It never is safe and never easy and it is always complicated. Risks are manageable and some can be anticipated and dealt with - with ease, but that does not make it “easy” or simple. If you really believe doing a colonoscopy on a healthy 50 y/o with propofol is easy, I would say you don’t really don’t understand anesthesia and the job at all. Is it easy for you to do? Probably. That isn’t the same thing. If you think it is easy, watch a med student try to place an LMA. Seems easy, right?

 

[thinkorswim]

It also speaks to how we are there to “serve” the patients. Customer is always right, right?

We are there to serve nurses, who always know best under the guise of being “advocates for their patients.” It’s sad at times.

I have found that most patients and families are quite reasonable when explained clearly that what’s being done may be uncomfortable, but ultimately is for their own benefit and safety. The nurses don’t like it outside of their comfort zone though.

 

[Ashers]

I can’t imagine doing anything else in medicine, but just wish I was a real estate guy, or sound engineer for a busy music studio, played saxophone for the San Diego Symphony.

Yesterday, at work, someone asked if I'd choose anesthesia again. I said I wouldn't choose medicine again, and I would do what I went to college to do... marine biology.

I don't like jobs being taken over by corporations, CRNAs, hospitals. I enjoy the day to day practice of anesthesiology, but it's getting frustrating dealing with the politics, hospitals making protocols they want you to follow for every patient, so it decreases thinking, etc. I also had a pharmacist block a really simple study I attempted to do because she didn't want to help and wanted me to buy her expensive equipment. The frustrations...

 

[IMGASMD]

The nurses don’t like it outside of their comfort zone though.

True on every level. The first thing crna says when a case is a little complicated, “cancel!”

I worked as a hospitalist at a rural hospital. On weekends if I had to admit anyone, the most important question in my head is, who is on to take over the patients. If it’s a NP, I would always transfer the “tougher” cases out.

Don’t get me on the newer PACU nurses, especially at Surgicenters. The ones that have never worked in a hospital PACU, you know who I am talking about…….

 

[kidthor]

also had a pharmacist block a really simple study I attempted to do because she didn't want to help and wanted me to buy her expensive equipment.

And yet everyone wants us to draw blood in the OR for their studies (and label tubes, put them on ice, call the coordinator, etc).

 

[martvubo]

And yet everyone wants us to draw blood in the OR for their studies (and label tubes, put them on ice, call the coordinator, etc).

Had a study person come into my room to chew me out the other day for not getting labs when I started the patient's IV even though this scolding was the very first time I heard about the study. Apparently the plastic bag with tubes was stapled to the back of their chart (which I did not pick up because their signed anesthesia consent was already on top of it) and the holding nurse (who I never saw) gestured to them and said "here, these" (not that those words would have conveyed "get labs" since I didn't know about the study, but also s/he certainly didn't say them to me).

 

[GassYous]

Had a study person come into my room to chew me out the other day for not getting labs when I started the patient's IV even though this scolding was the very first time I heard about the study. Apparently the plastic bag with tubes was stapled to the back of their chart (which I did not pick up because their signed anesthesia consent was already on top of it) and the holding nurse (who I never saw) gestured to them and said "here, these" (not that those words would have conveyed "get labs" since I didn't know about the study, but also s/he certainly didn't say them to me).

Lol what a joke

Did the nurses' hands fall off?

 

[OptionOffense]

The problem is 99.9% of anesthesia is really not that difficult and it doesn’t matter who does the case most patients do just fine

Lets try that on you. I will find the kookiest CRNA and let them try their experiments on you. Of course, I will supervise.

 

[OptionOffense]

Had a study person come into my room to chew me out the other day for not getting labs when I started the patient's IV even though this scolding was the very first time I heard about the study. Apparently the plastic bag with tubes was stapled to the back of their chart (which I did not pick up because their signed anesthesia consent was already on top of it) and the holding nurse (who I never saw) gestured to them and said "here, these" (not that those words would have conveyed "get labs" since I didn't know about the study, but also s/he certainly didn't say them to me).

I would have said something along the lines of... When I usually want something done, I do it myself. or at least come personally to make sure it gets done.. His/her study is not your problem. He could have even called you the night before to say heads up get labs when you place the iv.

 

[OptionOffense]

I would have said something along the lines of... When I usually want something done, I do it myself. or at least come personally to make sure it gets done.. His/her study is not your problem. He could have even called you the night before to say heads up get labs when you place the iv.

and at the end say "Im not your Bi tch"

 

[Zekchar]

I’m just waiting for the shtstorm of malpractice suits against midlevel mismanagement. There’s so much fxkery out there in primary care, derm, ER, etc that it must be a good time to be a trial lawyer. If that happens that could spur more change in our field.

already happening