Errors in medication administration are commonly occurring adverse events that result in patient harm. Many initiatives have been implemented in healthcare organizations to attempt to decrease the occurrence. However, errors in practice still exist at an alarming rate due to the complex and unpredictable environment in which nurses are working.^2,3

In addition, intrapartum nurses administer several high-alert medications routinely in practice. Often, these medications are at the center of allegations in a medical malpractice case. These include:

Registered nurses (RNs) are expected to adhere to professional standards and to advocate for and participate in activities to create safe medication systems within their practice setting. To safeguard against medication errors, here are some helpful tips:

Medication practice is much more than just the technical task of giving a pill or giving an injection. Assessment following medication administration or titration of a medication based on the woman’s assessment is an important aspect of nursing care. Reassessment following administration of a medication allows for the continued formation of the plan of care and other needed communication or intervention. The titration of oxytocin based on maternal and fetal assessments is a high liability area for obstetric nurses.

NOTE: Nurses have the educational preparation to make patient-specific range-related medication decisions.

The use of any piece of equipment with patient care requires the following:

NOTE: Be specific about your request and the time frame for response! Always clarify, confirm, and restate any orders given.

There is a legal duty to notify the appropriate physician and/or midwife in a timely manner of any significant, abnormal assessment data that does not respond to routine nursing intervention. Failure to notify of abnormal assessment findings may lead to poor outcomes and increase the chances for malpractice litigation. The Joint Commission has identified miscommunication among caregivers as a primary cause of perinatal events, including infant death and injury.^4,5 In the intrapartum setting, communication among all caregivers is essential to optimize outcomes. Communication occurs in the medical record and verbally. Common breakdowns in RN to physician/midwife communication may involve the following situations:

Effective communication techniques that nurses, nurse midwives, and physicians can use include the following^5,6,7,8:

NOTE: Be specific about your request and the time frame for response! Always clarify, confirm, and restate any orders given.

Ultimately, all care providers have the same goal: a healthy woman and baby. It is important to remember this goal in communicating and collaborating with members of the health care team. Using effective, standardized methods of communication such as SBAR (Situation, Background, Assessment, Recommendation) can enhance patient safety, improve outcomes, and reduce liability.⁹

The most common communication between nurses is report, hand-off, or hand-over, when care of the woman is transferred between providers, shifts, or units. The purpose of the hand-off is to pass along woman-specific information to ensure continuity of care and safety. Hand-off reports should be standardized to minimize gaps in information that could contribute to inappropriate care of the patient. The SBAR technique is one format that has been utilized for effective communication between nurses and between nurses and physicians or midwives. As an adjunct to the SBAR technique is bedside report. Participating in the hand-off at the woman’s bedside allows her and/or her family members to ask questions, clarify assessment parameters, and understand the plan of care. Display 20.2 is an example of SBAR.

NOTE: Being well prepared and organized to give a report during a hand-over or before making a call to the provider is important. If you are unsure of your assessment, discuss the situation with your charge nurse or preceptor. Avoid giving report on a woman for another nurse unless it is an emergent situation.

Every hospital should have a written chain of command policy/procedure for nurses to follow in order to properly escalate concerns. Nurses may become liable when a disagreement regarding clinical management occurs and they fail to initiate the defined chain of command. Chain of command activation is indicated when there is potential for the maternal and/or fetal condition to rapidly deteriorate causing harm, and discussions with the appropriate provider have failed to provoke a proper plan of care. Display 20.3 is an example chain of command.

NOTE: Prior to activating the chain of command, the nurse should discuss care concerns with the provider. If the concern is not addressed, then the nurse should inform the provider that she is activating the chain of command.

Provider orders should comply with hospital policy and be based on evidence or best practice recommendations. The nurse may be held liable if provider orders are not followed and injury occurs as a result of not following the orders. If there is concern regarding a specific provider order, the nurse should notify the provider and discuss the rationale for the order. Liability may also occur if the provider order is clearly contraindicated by normal practice and the nurse follows the order. Communication regarding the plan of care includes a clear understanding of provider orders.

Obtaining informed consent is required by law.^1,10 Providers are obligated, prior to delivering certain types of treatment, to inform the woman about the risks and benefits of the proposed treatment, along with the risks and benefits of forgoing treatment, and any alternatives. Only after the woman has voluntarily consented may the provider proceed. All states provide exceptions in the case of emergencies, or when the woman has been declared mentally incompetent by a court of law, or if the woman lacks physical capacity. Providers who fail to properly obtain informed consent are subject to legal actions for malpractice and/or criminal battery (unlawful contact). It is crucial to understand the necessary content, applicability, and the nurse’s role and responsibility in this area.

For valid informed consent, the woman must be legally and physically capable of making the decision, the proper information must be conveyed, and the consent must be given voluntarily. The question of whether a woman is legally able to make a treatment decision involves a number of factors. First, the woman must be of legal age. Eighteen is recognized as the legal age for decision making in most states, but a woman under 18 may be considered “emancipated” and thus legally able to make her own treatment decisions if she meets certain criteria set by state law. In many cases, emancipation requires a court order. Do not ever assume a woman under 18 years is emancipated based on your assessment of her situation without knowing the laws regarding emancipated minors in your state.

The next part of the assessment involves whether the woman is capable of comprehending the information presented such that she can meaningfully consent. You will hear this referred to
as “capacity” or “competence.” While the terms are used interchangeably, they are different. To distinguish, “capacity” is a medical term referring to the determination made by providers as to whether an individual is capable of making medical decisions. “Competence” is a legal term referring to judicial determination. Even though questions of competency are legal in nature, usually a provider makes the assessment in the process of deciding whether the woman is mentally able to assess and make choices about her own care. The inquiry is whether the individual understands the treatment choices, risks, and alternatives; and whether she understands the significance and consequences of her decision. If you have concerns about the woman’s ability to process information and make decisions, you should notify the treating provider.

The issue of meaningful consent does not present only with women who are underage, mentally ill, or mentally or physically challenged. Courts have invalidated a woman’s consent where certain conditions rendered the patient unable to meaningfully process the information; thus, the consent given was not legally binding. Some examples of situations where courts invalidated a patient’s informed consent are: being under great amounts of stress or in extreme pain (e.g., labor); being medicated/sedated; being intoxicated or under the influence of drugs; or being in a semiconscious state.

NOTE: States vary in the requirements for informed consent. It is the responsibility of the physician and nurse to know the laws regarding informed consent in their own state of practice.

Information refers to the content of the explanation given to the woman. Failure to provide reasonable and relevant information in language the woman can understand exposes providers to possible legal action. While states vary in their approaches to informed consent, the information given during an informed consent discussion should include the following:

Voluntariness refers to the circumstances under which the woman gives consent. All patients have the right to weigh decisions about their medical care after full disclosure of all relevant information, freely, and without being pressured or deceived. If fraud (deception), duress (forcing the woman to agree through the use of pressure, threats, coercion, violence, and restraints), or collusion (usually arises when family members work with providers in secret to direct treatment) is present, the consent is invalid. Remember that an individual can refuse further treatment or withdraw consent for a particular procedure at any time. Withdrawal can be given verbally, in writing, or by gesture (e.g., shaking head “no,” withdrawing arm from nurse’s hand). If the woman indicates a withdrawal of consent, the procedure should be discontinued as soon as safely possible. Extenuating circumstances in a life-threatening situation can negate the woman’s refusal of treatment.

NOTE: The patient may prevail in a malpractice lawsuit if the patient did not consent to a procedure or was poorly informed by the provider.

It is not absolutely necessary to obtain consent when delay will cause death or seriously jeopardize the patient’s health. Another exception of sorts is “therapeutic privilege,” which occurs
when a healthcare provider does not fully inform a patient about a treatment or procedure because the provider believes that complete disclosure would be harmful or extremely emotionally upsetting. Because in the United States all patients have the right to be informed about and make treatment decisions (including refusal of treatment), today’s courts almost never recognize this exception.

When an adult is mentally incompetent or physically unable to give consent (i.e., comatose), a legal guardian, conservator, a legally designated power of attorney for health care, or judge may provide consent. These are the only sources for such consent. Family members do not automatically have the right to give consent. The court can overrule a competent adult’s decision about a treatment, but such a judicial determination is made only when the state’s interest of preservation of life is counter to the woman’s wishes.

NOTE: The preservation of life concept is the basis for many court decisions involving the fetus and/or newborn after the age of viability has been achieved. EXAMPLE: A woman who refuses a cesarean birth when the fetus is at term and a placenta previa is evident.

Providers (physician, certified nurse midwife, or nurse practitioner) are responsible for obtaining informed consent for medical procedures or treatments because only a treating provider has the required training, expertise, and knowledge regarding the woman’s condition. In most instances, all treatment and care provided by a nurse is covered by a general consent to treatment. Nurses are often involved in the informed consent process, however.

Nurses are frequently requested to witness informed consent. In addition, in some settings, the provider might delegate the task of obtaining a woman’s signature on a consent form to nursing personnel. If this is the policy and procedure of the institution, prior informed consent must have been obtained by the provider during prenatal care. THE GUIDELINES FOR OBTAINING CONSENT IN THESE CASES MUST BE SPECIFICALLY WRITTEN FOR THE PROCEDURE, APPROVED, AND SIGNED BY MEDICAL AND NURSING ADMINISTRATION. If the woman questions the information provided, or she is unclear in her understanding, or refuses to sign the consent, you must not only refrain from trying to educate or persuade the woman, but are OBLIGATED, BOTH LEGALLY AND ETHICALLY, TO INFORM THE ATTENDING PROVIDER OF THE WOMAN’S INQUIRIES AND/OR REFUSAL TO SIGN. The provider is the only person legally responsible for giving additional information or answering the woman’s questions about treatment.

NOTE: Remember that a nurse simply obtaining a woman’s signature on a consent form does not transfer the legal liability for informed consent from the provider to the nurse.