5.5 Protecting Your Nursing License

You have worked hard to obtain a nursing license and it will be your livelihood. See Figure 5.8[1] for an illustration of a nursing license. Protecting your nursing license is vital.

 

Illustration of a hand holding a State of Michigan nursing license
Figure 5.8 Nursing License

Actions to Protect Your License

There are several actions that nurses can take to protect their nursing license, avoid liability, and promote patient safety. See Table 5.5 for a summary of recommendations.

Table 5.5 Risk Management Recommendations to Protect Your Nursing License

Legal Issues Recommendations to Protect Your License
Practicing outside one’s scope of practice
  • Practice within the requirements of your state’s Nurse Practice Act, in compliance with organizational policies and procedures, and within the national standard of care.[2]
  • Maintain basic clinical and specialty competencies by proactively obtaining the professional information, education, and training needed to remain current regarding nursing techniques, clinical practice, biologics, and equipment.[3]
  • Only accept patient care assignments you are trained and competent to perform. Ask for additional training as needed.
  • Recognize one’s limitations and ask for assistance when needed.
  • If necessary, utilize the chain of command or the risk management or legal departments regarding concerns about patient care or practice issues and pursue concerns to resolution.[4]
Documentation
  • Document patient care assessments, observations, communications, and actions in an objective, timely, accurate, complete, and appropriate manner.
  • Document in a manner that permits accurate reconstruction of patient assessments, notification of others, and the sequence of events.[5]
  • Document as close to the time of care provision as possible. (In court, if it is not documented, it is considered not done.)
  • Provide an accurate documentation of a patient’s change in patient condition, care provided, and providers notified.
  • Document specific times of interventions provided during emergency situations.
  • When notifying a provider about a patient, document the name of the provider notified, the time of the notification, and the provider’s response. Follow through with any nursing actions taken and the patient’s response.
  • Never alter, delete, or falsify information.
  • If there is information that should have been charted but was not, document “late entry,” noting the time the charting occurred and the specific time the assessment or intervention actually took place.[6]
  • When describing a patient problem, include the nursing actions taken and the patient’s response.[7]
  • Use medical terminology.
  • Avoid abbreviations.
  • Review notes from other health care team members to ensure coordination of efforts is occurring.[8]
  • Maintain your own personal files that can be helpful with respect to your character, such as letters of recommendation, performance evaluations, and continuing education certificates.[9]
Medication errors
  • Avoid workarounds.
  • Always check medication rights x 3, even when using barcode scanners and other equipment. (Read more details about checking medication rights in the “Administration of Enteral Medications” chapter in Open RN Nursing Skills.)
  • Be aware of look alike/sound alike medications.
  • Double-check dosage calculations, Follow agency policies and procedures related to medication administration and documentation. especially for pediatric patients.
  • Clarify prescriptions with prescribing providers if they are unclear or you have concerns. For example, if acetaminophen is prescribed for fever and the patient is experiencing pain, clarify the indications in the order before administering it for pain.
  • Avoid distractions while preparing and administering medications. (Read more information about preventing medication errors in the “Legal/Ethical” chapter in Open RN Nursing Pharmacology.)
  • Maintain a chain of possession when administering medications. Never administer a medication for which you have not personally done the medication checks.
  • Never leave medication unattended.
  • If a medication error occurs, follow agency policy regarding notification and submitting an incident report.
Substance abuse and drug diversion
  • Waste controlled substances and document wasting according to agency policy.
  • Perform accurate counting and documentation of controlled substances per agency policy.
  • Seek assistance if you are experiencing challenges with substance use. Report impaired professionals regarding suspected substance abuse. (Read more about drug diversion and support for nurses with substance use disorder in the “Legal/Ethical” chapter in Open RN Nursing Pharmacology.)
  • Report convictions such as drug possession, driving under the influence (DUI), or operating under the influence (OWI) to your State Board of Nursing as required.
Acts that may result in potential or actual client harm
  • Participate in accurate and thorough handoff reports according to agency policy. (Read more about handoff reports in the “Communication” chapter of Open RN Nursing Fundamentals.)
  • Communicate with other members of the health care team using ISBARR format. (Read more about ISBARR format in the “Communication” chapter of Open RN Nursing Fundamentals.)
  • Follow the nursing care plan. Assess appropriateness of interventions according to the client’s current condition before implementing them.
  • Conduct thorough nursing assessments, especially for skin breakdown or pressure injuries. (Read more about assessing skin breakdown and pressure injuries in the “Integumentary” chapter of Open RN Nursing Fundamentals.)
  • Advocate for quality client care and speak up regarding concerns about patient safety.
  • Educate clients and encourage them to actively participate in their care and make informed decisions.
  • Follow National Patient Safety Goals. Implement fall prevention interventions according to agency policy. Report unsafe equipment. (Read more about promoting patient safety in the “Safety” chapter in Open RN Nursing Fundamentals.)
  • Document and report unsafe staffing or other workplace safety concerns per agency policy, state policy, or OSHA.
Safe-guarding client possessions & valuables
  • Encourage client valuables to be sent home.
  • Document all client possessions upon admission to inpatient facilities and obtain client or family signature or acknowledgement.
  • Lock valuables per agency policy.
  • Follow agency policy regarding receipt of gifts from clients or family.
Adherence to mandatory reporting responsibilities
  • Report suspected abuse of children, elders, and other vulnerable populations. (Read more about mandatory reporting in the subsection of this chapter.)
  • Report gunshot wounds, dog bites, and communicable disease per agency and state policy.

Culture of Safety

It  can be frightening to think about entering the nursing profession after becoming aware of potential legal actions and risks to your nursing license, especially when realizing even an unintentional error could result in disciplinary or legal action. When seeking employment, it is helpful for nurses to ask questions during the interview process regarding organizational commitment to a culture of safety to reduce errors and enhance patient safety.

Many health care agencies have adopted a culture of safety that embraces error reporting by employees with the goal of identifying root causes of problems so they may be addressed to improve patient safety. According to The Joint Commission, components of a culture of safety include the following:[10]

  • Just Culture: A culture where people feel safe raising questions and concerns and report safety events in an environment that emphasizes a nonpunitive response to errors and near misses. Clear lines are drawn between human error, at-risk, and reckless behaviors.
  • Reporting Culture: People realize errors are inevitable and are encouraged to speak up for patient safety by reporting errors and near misses. For example, nurses complete an “incident report” when a medication error occurs or a client falls according to agency policy. Reporting errors also assists the agency in performing risk management actions to reduce potential liability.
  • Learning Culture: People regularly collect information and learn from errors and successes while openly sharing data and information and applying best evidence to improve work processes and patient outcomes.

Just Culture

The American Nurses Association (ANA) officially endorses the Just Culture model. See Figure 5.9[11] for an illustration of Just Culture. In 2019 the ANA published a position statement on Just Culture. They stated that while our traditional health care culture held individuals accountable for all errors and accidents that happened to patients under their care, the Just Culture model recognizes that individual practitioners should not be held accountable for system failings over which they have no control. The Just Culture model also recognizes that many errors represent predictable interactions between human operators and the systems in which they work. However, the Just Culture model does not tolerate conscious disregard of clear risks to patients or gross misconduct (e.g., falsifying a record or performing professional duties while intoxicated).[12]

Illustration demonstrating just culture components
Figure 5.9 Just Culture

The Just Culture model categorizes human behavior into three categories of errors. Consequences of errors are based on whether the error is a simple human error or caused by at-risk or reckless behavior:[13]

  • Simple human error: A simple human error occurs when an individual inadvertently does something other than what should have been done. Most medical errors are the result of human error due to poor processes, programs, education, environmental issues, or situations. These errors are managed by correcting the cause, looking at the process, and fixing the deviation. For example, a nurse appropriately checks the rights of medication administration three times, but due to the similar appearance and names of two different medications stored next to each other in the medication dispensing system, administers the incorrect medication to a patient. In this example, a root cause analysis reveals a system issue that must be modified to prevent future patient errors (e.g., change the labelling and storage of look alike-sound alike medications).[14]
  • At-risk behavior: An error due to at-risk behavior occurs when a behavioral choice is made that increases risk where the risk is not recognized or is mistakenly believed to be justified. For example, a nurse scans a patient’s medication with a barcode scanner prior to administration, but an error message appears on the scanner. The nurse mistakenly interprets the error to be a technology problem and proceeds to administer the medication instead of stopping the process and further investigating the error message, resulting in the wrong dosage of a medication being administered to the patient. In this case, ignoring the error message on the scanner can be considered “at-risk behavior” because the behavioral choice was considered justified by the nurse at the time.[15]
  • Reckless behavior: Reckless behavior is an error that occurs when an action is taken with conscious disregard for a substantial and unjustifiable risk. For example, a nurse arrives at work intoxicated and administers the wrong medication to the wrong patient. This error is considered due to reckless behavior because the decision to arrive intoxicated was made with conscious disregard for substantial risk.[16]

These categories of errors result in different consequences to the employee based on the Just Culture model:

  • If an individual commits a simple human error, managers console the individual and consider changes in training, procedures, and processes.[17] In the “simple human error” example above, system-wide changes would be made to change the label and location of the medications to prevent future errors from occurring with the same medications.
  • Individuals committing at-risk behavior are held accountable for their behavioral choices and often require coaching with incentives for less risky behaviors and situational awareness.[18]In the “at-risk behavior” example above, when the nurse chose to ignore an error message on the barcode scanner, mandatory training on using barcode scanners and responding to errors would likely be implemented, and the manager would track the employee’s correct usage of the barcode scanner for several months following training.
  • If an individual demonstrates reckless behavior, remedial action and/or punitive action is taken.[19] In the “reckless behavior” example above, the manager would report the nurse’s behavior to the State Board of Nursing for disciplinary action. The SBON would likely mandate substance abuse counseling for the nurse to maintain their nursing license. However, employment may be terminated and/or the nursing license revoked if continued patterns of reckless behavior occur.

When seeking employment, it is helpful for nurses to determine how an agency implements a culture of safety because of its potential impact on one’s professional liability and licensure.

  1. “aid9688616-v4-728px-Get-a-California-Endorsement-for-Your-Nursing-License-Step-11.jpg” by unknown is licensed under CC BY-NC-SA 3.0 ↵
  2. Nurses Service Organization and CAN Financial. (2020, June). Nurse spotlight: Defending your license. https://aonaffinity-blob-cdn.azureedge.net/affinitytemplate-dev/media/nso/claim-reports/cna_cls_nurse20_sl_061120p3_cf_prod_asize_online_sec.pdf ↵
  3. Nurses Service Organization and CAN Financial. (2020, June). Nurse professional liability exposure claim report (4th ed.). https://www.nso.com/Learning/Artifacts/Claim-Reports/Minimizing-Risk-Achieving-Excellence ↵
  4. Nurses Service Organization and CAN Financial. (2020, June). Nurse professional liability exposure claim report (4th ed.). https://www.nso.com/Learning/Artifacts/Claim-Reports/Minimizing-Risk-Achieving-Excellence ↵
  5. Nurses Service Organization and CAN Financial. (2020, June). Nurse spotlight: Defending your license. https://aonaffinity-blob-cdn.azureedge.net/affinitytemplate-dev/media/nso/claim-reports/cna_cls_nurse20_sl_061120p3_cf_prod_asize_online_sec.pdf ↵
  6. Brous, E. (2019). The elements of a nursing malpractice case, Part 1: Duty. American Journal of Nursing, 119(7), 64–67. https://doi.org/10.1097/01.NAJ.0000569476.17357.f5 ↵
  7. Brous, E. (2019). The elements of a nursing malpractice case, Part 1: Duty. American Journal of Nursing, 119(7), 64–67. https://doi.org/10.1097/01.NAJ.0000569476.17357.f5 ↵
  8. Brous, E. (2019). The elements of a nursing malpractice case, Part 1: Duty. American Journal of Nursing, 119(7), 64–67. https://doi.org/10.1097/01.NAJ.0000569476.17357.f5 ↵
  9. Nurses Service Organization and CAN Financial. (2020, June). Nurse professional liability exposure claim report (4th ed.). https://www.nso.com/Learning/Artifacts/Claim-Reports/Minimizing-Risk-Achieving-Excellence ↵
  10. The Joint Commission. (2017, March 1). The essential role of leadership in developing a safety culture. Sentinel event alert, Issue 57. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sea_57_safety_culture_leadership_0317pdf.pdf ↵
  11. "Just Culture Infographic.png" by Valeria Palarski 2020. Used with permission. ↵
  12. American Nursing Association. (2010). Position statement: Just culture. https://www.nursingworld.org/~4afe07/globalassets/practiceandpolicy/health-and-safety/just_culture.pdf ↵
  13. American Nursing Association. (2010). Position statement: Just culture. https://www.nursingworld.org/~4afe07/globalassets/practiceandpolicy/health-and-safety/just_culture.pdf ↵
  14. American Nursing Association. (2010). Position statement: Just culture. https://www.nursingworld.org/~4afe07/globalassets/practiceandpolicy/health-and-safety/just_culture.pdf ↵
  15. American Nursing Association. (2010). Position statement: Just culture. https://www.nursingworld.org/~4afe07/globalassets/practiceandpolicy/health-and-safety/just_culture.pdf ↵
  16. American Nursing Association. (2010). Position statement: Just culture. https://www.nursingworld.org/~4afe07/globalassets/practiceandpolicy/health-and-safety/just_culture.pdf ↵
  17. American Nursing Association. (2010). Position statement: Just culture. https://www.nursingworld.org/~4afe07/globalassets/practiceandpolicy/health-and-safety/just_culture.pdf ↵
  18. American Nursing Association. (2010). Position statement: Just culture. https://www.nursingworld.org/~4afe07/globalassets/practiceandpolicy/health-and-safety/just_culture.pdf ↵
  19. American Nursing Association. (2010). Position statement: Just culture. https://www.nursingworld.org/~4afe07/globalassets/practiceandpolicy/health-and-safety/just_culture.pdf ↵
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Leadership and Management of Nursing Care Copyright © 2022 by Kim Belcik and Open Resources for Nursing is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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