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The Fine Line Between Advocating and Jeopardizing Patient Safety

Dana Rucereto

James Madison University

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Introduction

Humans are not perfect beings, with everything there comes a risk of error and it is

inevitable. According to Makary and Daniel (2016), CDC rankings suggests that medical error is

the third most common cause of death in the US. This is a tough concept to come terms with

especially in regard to the healthcare system because people depend on the healthcare system for

recovery and their wellbeing. Although it is impossible to eliminate, there are ways to better

monitor and be more mindful of when there is a risk and how to avoid unsafe patient care. This

topic is one that needs to be addressed rather than kept a secret amongst the internal roots of a

health care facility.

Background

Recently, I was exposed to a rather ethically difficult situation while at clinical. One of

the patients I provided care for was recovering from his multiple level laminectomy, which is a

rather invasive spinal procedure. As I looked over his chart, I soon understood that he had a

lengthy and complex medical history that could cause setbacks with a speedy recovery.

Throughout the day the patient complained of abdominal cramping, tenderness, and fullness. He

refused all his medications except for his laxative in hopes that it would help with his state.

However, this did not do the trick, instead doctors ordered for him to get a nasogastric tube

(NG), as it was evident he had a bowel obstruction. The nurse caring for him was notified and

then she told me, with excitement that I could do the procedure if it was OK with the patient.

Unfortunately, he wanted a registered nurse to perform the procedure and suddenly her demeanor

changed. As she set up the equipment at the patient’s bedside, she turned around and told me,

“I’m nervous. I have only done this one other time and I don’t really know what I am doing.”

She was able to tell me this in private because the patient was deaf. In a moment, the tube
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entered the patients left nostril and she began feeding it down, his eyes watered, but he did not

make a sound. Eventually, the other nurse gave him water and encouraged him to swallow.

Without delay, there was a return but instead of a green yellow bile it was blood and the nurses

questioned it, but continued to stabilize the NG tube. A few minutes passed and still no return of

bile and no order for a chest x-ray to ensure proper placement of the tube. I did not say anything

to either nurse, but told the others in my clinical group and my professor. If I were placed back in

this situation, I would have confronted the nurses in a respectful manner and asked why there

was not an instant return of bile and why they did not get a chest x-ray to ensure the tube was

placed correctly.

Looking back, this was a situation of moral distress because from the very start I knew

that the nurse performing the procedure did not have the level of experience the patient wanted.

He was at a disadvantage as well because he was unable to know her true confidence level and

the type of risk that comes alone with improper NG tube placement. Furthermore, the tube was

not properly placed the first time, and I later found out the nurses had to fix the placement by

going 10 cm deeper than the first time. I refrained from speaking up because I was the student in

the room, but it is also important to not forgot that patient advocacy is a priority.

Methods/Findings

Under these circumstances, it is important for all practicing and future healthcare

professionals to have a set of guidelines when faced with an ethical challenge. According to The

Madison Collaborative, there are Eight Key Questions that best reflect humane ethical reasoning

traditions. These questions allow for a flexible framework in decision making and include:

fairness, outcomes, responsibilities, character, liberty, empathy, authority, and rights.

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With this in mind, utilization of the eight key questions in regard to my situation could

have changed a variety of outcomes. To begin with, fairness is addressed by balancing legitimate

interests and to do so, it would have been important for me to speak up for the patient to value

his interests in the fact that he wanted an experienced nurse to perform the procedure. Thinking

about the best short-term outcomes, the patient comes first, and if I intervened the NG tube

would have been properly placed the first time rather than the second. Responsibility is a huge

factor and my obligation to the patient is his well-being and safety, and if I reiterated that to the

nurse she might think twice about her actions. In terms of character, I want to be the best

possible nurse I can and in order to do so, I need to be confident in my judgement and speak up

when I see any form of malpractice. Patient liberty, personal autonomy and consent is factored in

because he needs to fully understand the benefits and risks of the procedure, along with the level

of expertise the nurse has. This goes hand in hand with innate and legal rights as well as

authority because it is extremely important to treat the patient based on their terms, but also

following the law and facility protocol. Finally, empathy can be applied because if it were

someone I cared deeply about, I would question the nurse on how many times she has done this

before and how confident she is in the procedure. If she were to hesitate or appear to be second –

guessing herself I would ask if another nurse could do the procedure.

Equally important, there is an established code of nursing ethics developed by the

American Nurses Association. Provision 3 speaks volumes in regard to the ensuring patient

safety. It states, “The Nurse promotes, advocates for, and strives to protect the health, safety, and

rights of the patient.” This provision is elaborated on further and explains what to do in a

situation that requires acting on questionable practice stating, attention must be brought to the

possible detrimental effect upon the patient’s well-being or best interests and that when factors in
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the health care system threaten the welfare of the patient, similar action should be directed to the

responsible administrator. This can be used as guide in regard to my situation because patient

well-being is being jeopardized and an administrator needed to be notified. This is not only for

patient safety, but for the health care system’s integrity and limitation of financial costs.

According to Paul J. Gilbert, MD, FACEP, misguided tubes enter the lungs which causes

significant morbidity and mortality as well as, costing medical providers millions of dollars.

Conclusion

With all things considered, it is important to identify when an ethical situation is

occurring in the healthcare system. There is a fine line between what is best for the patient, but

also what is morally right for the patient. There are many factors to consider in almost every

decision when providing direct patient care. Looking back, I would have done a few things

differently such as, speaking with the nurse about the procedure and the possible negative

outcomes that could occur if in fact it was not done correctly. Second, addressing the fact that

they did not request a chest x-ray to confirm proper placement of the NG tube even after there

was poor return. For future, similar situations it is important to emphasize that nurses are the last

line of defense for the patient. With that being said, even if the indicated procedure is beneficial,

it will only be as beneficial as the healthcare professional providing the care. Knowledge based

practices are of great importance in reducing risks and increasing patient safety which is a

concept that is heavily emphasized on in this profession. It is important to never forget that and

to always ask questions when unsure about how to safely and effectively care for the patient.

Therefore, the interprofessional team must work together to provide the best care possible.
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References

James Madison University. (n.d.). The Madison collaborative: Ethical reasoning in

action. Retrieved from http://www.jmu.edu/mc/8-key-questions.shtml

Makary, M. A., & Daniel, M. (2016). Medical error-the third leading cause of death in the

US. BMJ : British Medical Journal (Online), 353http://dx.doi.org/10.1136/bmj.i2139

Retrieved from https://search.proquest.com/docview/1787070383?accountid=11667

Misplaced NG tubes a major patient safety risk. (2015, April 1). Retrieved March 19, 2018, from

https://www.ahcmedia.com/articles/135136-misplaced-ng-tubes-a-major-patient-safety-

risk

National Student Nurses’ Association, Inc. (2009). Code of Ethics: Part II, Code of academic

and clinical conduct and interpretative statements. Available from http://www.nsna.org