NICU is a place where we treat newborns with health problems. In some, health issues are incredibly complicated and demand hospital stays lasting many months.
It is no surprise that these tiny patients will encounter numerous people who will be facilitating medical care on an administrative or medical level.
I will present the main NICU “actors” with their roles and potential medico-legal exposure.
Neonatologists
In the USA, neonatologists are medical doctors who have undergone three years of residency training in pediatrics and an additional three years of subspecialty training in neonatology. Doctors who passed their exams will be identified as “board certified,” you can verify their certification by following this link.
Although all doctors don’t need to pass their board exams, they are expected to do so. Most reputable hospitals will only grant doctors hospital privileges to treat patients if they obtain board certification within 2 to 4 years after completing their specialty or subspecialty training.
In other words, young doctors may be allowed to treat patients in NICU after their neonatal fellowship training, but if they don’t pass exams within 2-4 years, they will lose their privileges and go to work in less demanding hospitals (usually rural or underserved institutions).
Neonatologists are in charge of all patients hospitalized in the NICU, even when patients have had surgery or require subspecialty services such as pediatric cardiologists or nephrologists. A neonatologist is like a captain of the ship. Other NICU professionals help or advise him, but the final decision almost always belongs to the neonatologist and parents.
Given this presumed ultimate and holistic responsibility assigned to neonatologists, it is almost impossible for them to avoid legal troubles if something goes wrong with their patients.
My advice to younger doctors is always the same:
- Be diligent.
- Respond quickly to all concerns voiced by parents, nurses, or consultants.
- Always anticipate changes in the patient’s condition.
- Go to the bedside.
- Examine patients in person without relying on reports from younger doctors in training.
- Perform differential diagnosis and document everything in a timely manner.
- Finally, if everything is OK, go later to recheck the patient. The baby’s condition may change quickly; often, relying on overworked staff to be notified is a recipe for disaster.
You can review my full article on the most common diagnoses and errors that lead to malpractice suits in neonatology.
Pediatric subspecialists
As a neonatologist, I have often used in my practice other pediatric subspecialists. I used to call a cardiologist the most. That is because premature babies often develop a condition called PDA, and I needed to order an ultrasound of the heart and discuss the diagnosis and treatment of this condition with an appropriate specialist.
Pediatric specialists have a little less legal risk than their colleagues, neonatologists. They are only called for consultation after neonatologists identify the problem. Bad neonatal outcomes are more often due to delayed consultation requests rather than mismanagement by subspecialists.
Doctors in training
Since NICUs are usually located in large university centers or children’s hospitals, there will be doctors in training there.
Doctors who recently graduated will be learning their first or base specialty (pediatrics or internal medicine) and will be called residents. Doctors undergoing subspecialty training are named fellows, and their training fellowships (neonatal fellowships).
Doctors in training always work under the supervision of attending physicians. Sometimes, supervising doctors are off-site, and the trainees must promptly notify their supervisors about any patients’ condition changes.
Doctors in training who “do too much” on their own and do not frequently communicate with their supervisors about patients may jeopardize patients’ outcomes and create legal risks for themselves and their institutions.
All teaching hospitals should have strict policies and codes of conduct for their attendings and trainees regarding each individual’s responsibilities and scope of practice.
Medical students
Medical students are not doctors! Their direct education or supervision is often left to “green” doctors in training, such as residents or fellows.
As a medical student, you must ensure that experienced professionals always watch you during any procedure, even the easiest one.
Nurses
Neonatologists often care for 10-20 patients in the NICU and may be going to deliveries whenever needed. On the other hand, a typical nurse will care for 1-4 NICU babies during her shift.
The nurse’s responsibility is to draw blood, administer medications, and monitor the baby continuously. The nurse usually first spots changes in the baby’s condition and notifies the neonatologist about them.
Common reasons for a nurse to be part of a lawsuit are listed below:
- administration of the wrong medicine or dose (in cases where a nurse and not a pharmacy prepares the treatment)
- administration of a medication to the wrong patient
- failure to notify doctors about the patient’s condition change
- negligence, for example, leaving the patient to take care of her personal affairs
Charge nurses
A charge nurse is a temporary role for a nurse during her shift when she is in charge of other nurses in addition to caring for patients. She is responsible for assigning patients, ensuring sicker patients get more attention, and managing transfers and new bed assignments for freshly admitted babies.
Hospital administrators and medical directors of NICU
Hospital administrators run the hospital. They must ensure the NICU has sufficient resources: people, equipment, and medicines. They must comply with federal and state law and follow the most recent safety recommendations to facilitate optimal patient care.
Failure in their duties may expose them to litigation, particularly if it is associated with grave outcomes for the patients cared for in those institutions. Furthermore, the whole institution may end up being involved in a malpractice suit due to administrators’ failure to act diligently and responsibly (my post on hospitals’ responsibilities).
Medical directors (usually doctors or nurses) provide guidance and leadership regarding proper staffing levels, scheduling, policy development, education, and quality improvement. If they fail to follow the safest practices and evidence-based medicine, they risk litigation from dissatisfied patients or their family members. One example may be when directors allow nurses or neonatologists to work more than 24 hours. Literature shows that exhausted doctors and nurses make many more errors, resulting in unfavorable patient outcomes (source article).
Pharmacist
Many large level 3 and 4 NICUs have a pharmacist on-site. Their role is to monitor medication doses, ensure that we test certain drugs’ levels, and assist neonatologists in ordering intravenous fluids, including hyperalimentation. On the other hand, pharmacists located in the hospital pharmacies will be responsible for measuring and providing proper doses for each patient according to doctors’ orders.
They should also verify the appropriateness of the dose for each patient using demographic and medical information entered in the charts.
Due to the complex nature of choosing, preparing, and administering medications to neonates, there are numerous instances in which errors may occur. The pharmacist’s and director’s responsibility is to minimize those human errors.
Radiology technicians
Radiology technicians perform portable X-rays and ultrasounds in the NICU. All other radiological studies are done outside of the NICU. While conducting studies in the unit, radiologists only supervise technicians indirectly. Their liability exposure may be due to delayed response after being called urgently to the unit.
Not following the procedure policy may be another reason for litigation. There were cases in which the technician used too high a dose of irradiation to take an X-ray or did not put a marker to indicate the laterality of the image. These mistakes may lead to poor image quality and misdiagnosis or harm to the patient.
Respiratory technicians
Respiratory technicians provide respiratory support to newborns in the NICU. They are the ones who prepare a ventilator and connect a patient to it. Ventilators and oxygen therapy saved many lives but, unfortunately, also harmed or killed patients when inappropriately used.
I have heard of cases when a respiratory technician could not assemble a breathing machine to start therapy, forgot to connect the oxygen supply line to a ventilator, or set dangerously high inspiratory pressure. Many grave errors are possible, and whenever I review a neonatal chart, I request to see all notes from the respiratory therapists.
Front Desk Secretary
A unit secretary is a person who responds to parents’ calls and concerns and notifies nurses or doctors about them. She also controls access to entry doors for parents and visitors.
There were situations where strangers abducted children from the units, or parental concerns were not addressed promptly due to the secretary’s failure to notify the medical team about them.
Security personnel
Security personnel play a vital role in ensuring the safety of hospital staff, patients, and their families. In today’s society, unfortunately, we often hear about violent individuals, mentally sick people, and persons under the influence of alcohol or drugs attempting to harm people in the hospital.
In Summary:
All hospital employees and contractors must know their responsibilities and be familiar with hospital procedures and policies. As we can see, each individual’s role is essential to the smooth operation of health care facilities, in this case, NICU, and its patients’ outcomes.
Failure to follow policies, negligence, not applying evidence and safe practices, and human errors may create legal risks for individuals and institutions.
Recommended Articles:
Why are the NICU Levels of Care Essential in Medico-legal Cases?
A neonatal chart reviewer explains importance of levels of care in NICU
When hospital can be found liable in litigation involving newborns treated in the NICU?