Professional Practice, Quality Improvement, and Legal/Ethical Issues
Practice inside the lines, then improve them
Professional practice means knowing your state nurse practice act, your institutional policy, and your certification standards, and recognizing the difference between delegation (transferring a task to a competent person) and assignment. Competency must be validated and documented, not assumed.
Legal: informed consent is the provider's duty; the nurse verifies, witnesses, and advocates. Know the exceptions - minors with guardians, emergency situations, and the patient's right to withdraw consent at any time. HIPAA requires minimum necessary disclosure, and documentation must be objective, timely, and factual. Late entries are labeled as such; never alter a record.
Ethical: autonomy, beneficence, nonmaleficence, justice, veracity, and confidentiality frame dilemmas such as a patient refusing premedication or a DNR order in the procedure suite. A DNR is not automatically suspended; it is reviewed with the team and the surrogate before the procedure.
Quality improvement: use PDSA for small tests of change, root cause analysis after a sentinel event, and failure mode and effects analysis prospectively. Incident reports go to the risk system, not the medical record, and exist to fix systems rather than blame individuals - the just-culture principle. Track National Patient Safety Goals: correct identification, handoff communication, medication safety, and alarm management.
Traps: documenting conclusions rather than observations; charting an incident report in the progress notes; accepting a verbal contrast order without a documented, authenticated order; and responding to an error by disciplining one nurse when the process allowed the error.
Worked example: two patients with similar names are nearly swapped. The near miss is reported through the safety system, and the team adopts a two-identifier verification at every handoff - a system fix rather than an individual sanction.
Rule of thumb: document what you assessed, did, and taught, not what you concluded.