ED Liability Exposed: Common Nursing Practices That Put You at Risk

ED Liability Exposed: Common Nursing Practices That Put You at Risk

Disclaimer 

This article contains information based on my education, professional knowledge, and clinical experience. I am not an attorney; this content is for informational purposes only and should not be construed as legal advice.

Introduction

The emergency department is controlled chaos. You see multiple patients in a shift. Some arrive with clear emergencies. Others present with vague complaints that could mean anything. Everyone is sick or injured or worried they might be.

In this environment, it is easy to fall into patterns. Easy to rush through assessments. Easy to implement orders without thinking about why. Easy to document minimally. Easy to assume everything will be caught by the next person.

This is where liability begins.

Many ED nurses practice in ways that expose them significantly. Not because they are bad nurses. Not because they do not care. Rather, the ED environment encourages speed over thoroughness. It rewards getting through the shift, not getting through it defensively.

I want to walk you through the common practices I see that create liability. Some of them are obvious. Some are subtle. All of them matter.

The Triage Note - Your First Impression and Your Foundation

Your triage note is arguably the most important note a nurse will write in the ED.

Every person who touches that patient afterward reads the triage note. The provider reads it. The next nurse reads it. The consultant reads it. The intensivist in the ICU reads it. Years later, if there is a lawsuit, the attorney reads it.

Your triage note tells the story. It is the first impression. It shapes how everyone thinks about that patient for the rest of their stay.

Many triage notes read like stick figures. Patient presents with chest pain. Vital signs documented. Chief complaint written. That is it. Nothing that paints a picture of who this person is or what you found.

This is dangerous.

A complete triage note should describe what you observe upon examining the patient. Is the patient anxious or calm? Diaphoretic or dry? In obvious distress or comfortable? These observations matter. They tell the story of acuity.

A complete triage note includes your assessment findings. What did you find on your initial assessment? Any obvious signs of trauma or illness? Any unexpected physical findings? Is the patient confused or alert? Can they tell you their story, or are they too sick?

A complete triage note includes context. When did symptoms start? What was the patient doing when it happened? Are there relevant past medical conditions? Any recent surgeries or procedures? Any medications that matter to this presentation?

Many nurses skip this. They think triage is just vitals and chief complaint. They think a detailed assessment comes later. This thinking is wrong.

Your triage assessment is your first impression. If it is shallow, everyone assumes the patient is stable. If it is thorough, everyone understands the actual clinical picture.

When something goes wrong, the attorney looks at your triage note. If you documented a detailed assessment and clear clinical findings, you look professional. You look thorough. If you documented minimal information, you look rushed. You look superficial. You may have initiated a chain of failures in recognizing an emergent medical condition.

Take time on triage. Paint a picture with your words. Describe what you see and what you find. This note protects you from the moment the patient walks in.

Vital Signs Without Trending

You take vital signs. You document them. You move to the next patient.

This is an incomplete nursing practice.

Vital signs tell a story. Alone, they are data points. Together, they are a narrative. They show a trajectory. They reveal whether your patient is improving or deteriorating.

A patient with a heart rate of 110 is not critically concerning. A patient whose heart rate was 85 three hours ago and is now 110 is a story. The trend tells you something is changing.

Many nurses see vital signs spike and do nothing. The systolic blood pressure goes from 140 to 200. They document it and continue. They do not recognize that this trend requires attention.

Trending vital signs means comparing them over time. It means asking what the pattern shows. It means acting when the pattern is concerning.

When vital signs trend in the wrong direction, the patient is usually telling you something. The fever is rising. The heart rate is climbing. The blood pressure is dropping. These trends are your early warning system.

I see case after case where vital signs were documented but never trended. The patient deteriorated over hours. The vital signs showed it clearly. The nurse did not see it because they were not looking at the pattern. The provider was never notified. The patient was allowed to decompensate without intervention.

Documentation should reflect that you are trending. Write that you note the increasing heart rate. Write that you recognize the rising temperature. Write that you understand what the pattern means. Write that you discussed the trend with the provider. This documentation shows you are thinking clinically.

More importantly, trending vital signs catches problems early. The patient whose blood pressure is slowly dropping needs intervention before they crash. The patient whose fever is rising needs attention before they become septic. Trending is not busy work. It is an early warning.

Interventions Implemented Without Follow-Up

You get an order. You implement it. You move to the next task.

This is incomplete care.

Every intervention you implement deserves a follow-up assessment. Did it work the way you expected? Did the patient tolerate it? Did anything unexpected happen?

A patient with severe pain gets IV pain medication. You give the medication. Did the pain improve? Did anything unexpected happen? Is the patient sedated appropriately or too much? Is there nausea? Did the patient become hypotensive?

Many nurses give medications and never check back. They assume the medication worked. They assume the patient is fine. They do not actually assess the response.

This is nursing practice without the evaluation phase. Assessment, diagnosis, planning, intervention, evaluation. That is the process. You cannot skip the evaluation.

When something goes wrong, the attorney asks what happened after the intervention. Did you assess the response? Did you document it? If you did not, it looks like you implemented the order and forgot about the patient.

Your documentation should show your follow-up. I assessed pain 30 minutes after medication administration. I found the patient with even and unlabored respirations. The patient had no questions or concerns, and he/she rated his/her pain at 2/10. Per the patient, this is a tolerable level of pain. I assessed again at the one-hour mark. Pain remained controlled. These notes show you are thinking about the patient's response to your care.

Interventions include more than medications. You place a urinary catheter. Did you verify placement? Did you ensure adequate urine output? You apply oxygen. Did oxygen saturation improve? Is the patient tolerating the oxygen? You start an IV. Did the IV work, or did you need to restart it? Did it infiltrate? Interventions require follow-up. It may seem inconsequential in the moment, but when the chart is being reviewed to assess liability, that mole hill just became a mountain.

Follow-up assessment after interventions is your responsibility.

Critical Lab Results Not Communicated

A critical lab result comes back. It may be called to you, or you see it on the computer.

Did you report it to the provider? I often hear nurses state they thought someone else would see it. They assume the provider will look at all results. They failed to communicate critical results in a timely manner, resulting in delayed care.

Critical results are results that represent a significant threat to patient health. A potassium level of 7.5 is critical. A glucose level of 25 is critical. A hemoglobin of 6 is critical. These results do not wait for the provider to check the computer. These results require immediate notification. Although these values are used to demonstrate the point, many lab results would be considered critical findings.

When you see a critical result, your responsibility is clear. You notify the provider immediately. You do not wait. You do not assume they will see it. You call, page them, or notify them in person.

Documentation of this communication is essential. Write that you reported the critical potassium to the provider at 1400. Write that the provider was notified and acknowledged the result. Write what the provider ordered in response.

I see many cases where critical results were in the chart but never communicated. The patient deteriorated. The critical result explained why. The nurse saw the result in the computer but never told anyone. This is a major liability exposure.

Your responsibility includes knowing what constitutes a critical result. Know your lab's critical value list. Know what thresholds trigger immediate notification. Do not assume a mildly abnormal result is not critical. This can be contextual, considering the patient’s presentation. Do not ignore a result because it seems unexpected. It may very well be reality.

Some results look benign but matter. A patient on digoxin with a digoxin level of 3.5 may seem like a low number. It is critical. It means toxicity. A patient with a glucose of 248 seems manageable. But a patient with a blood glucose of 248, a pH of 7.0, and ketones in the urine is in critical condition.

Know your patient's context. Know what results matter for your patient's specific situation. A normal result for one patient might be critical for another.

When in doubt, communicate. If you think it might be important, notify the provider. They can decide if it is critical.

Unexpected Findings Not Reported

You assess a patient. You find something unexpected. You document it in the chart.

You do not tell the provider.

This is a critical gap in your practice.

Documentation is not the same as reporting. Documenting that you found something is not the same as communicating that finding to the provider. The provider cannot respond to something they do not know about.

Many nurses think documentation is enough. They think that if they write it in the chart, the provider will see it. They fail to understand that the provider needs to be notified of significant findings.

A patient comes in with chest pain. You assess them. You note that they are diaphoretic and anxious. You document this. Does the provider know? Only if they read your note. Many providers do not read every single nursing note. This is a reality. They need you to tell them what you found.

A postoperative patient reports increasing pain. You assess the surgical site. You find warmth and redness. You document it. Does the provider know about the possible infection developing? What if the provider is at home? They only know if you tell them.

Your responsibility includes reporting unexpected findings to the provider. New symptoms. Changes in condition. Abnormal assessment findings. Signs of deterioration. These findings require communication.

When you find something concerning, communicate directly. Use clear language. Describe exactly what you found. Let the provider decide if it requires action. Do not wait and hope they notice. Do not assume someone else will tell them.

A patient who is usually alert becomes confused. This is unexpected. Report it. A patient's oxygen saturation drops despite oxygen therapy. This is unexpected. Report it. A patient develops a new rash. This is unexpected. Report it.

Documentation of your communication matters. Write that you reported the worsening mental status to the provider at 1500. Write the provider’s response. Write what they ordered. This documentation shows that you recognized the problem and escalated it appropriately.

Many adverse outcomes in the ED could have been prevented if someone had communicated an unexpected finding. The delay between discovering the problem and reporting it

can sometimes determine whether the patient survives.

Not Understanding Why Orders Are Placed

You get an order. You implement it. You do not actually know why the provider ordered it.

This is dangerous.

When you understand why an order was placed, you understand what the intervention is supposed to accomplish. You understand what response you should expect. You understand when something is not working correctly.

A patient gets an order for oxygen. Why did the provider order it? Is the oxygen saturation low? Is the patient short of breath? Is the provider concerned about oxygenation? If you understand the reason, you will assess oxygen saturation after you start it. You will evaluate whether it improved.

A patient gets an order for a chest X-ray. Why did the provider order it? What findings are they looking for? Are they concerned about pneumonia? About heart failure? About pneumothorax? If you understand the reason, you can communicate with radiology about what findings matter. You can understand what results you should expect.

A patient gets an order for blood cultures. Why did the provider order them? Is there concern about infection? About sepsis? If you understand the reason, you will recognize if the patient's clinical picture supports that concern. You will know why the results matter.

When you do not understand why an order was placed, you blindly implement it. You do not know what response to expect. You do not know if something is wrong when the expected response does not happen.

In a lawsuit, the attorney will likely ask what you expected from the intervention. If you cannot articulate why the order was placed, it looks like you were just following directions. It looks like you were not thinking clinically.

Taking thirty seconds to understand an order changes your entire approach to that patient. Ask the provider why they ordered it. Read the provider's note to understand their thinking. Use clinical judgment to understand what response you should expect.

Then assess that response. Did it happen the way you expected? If not, why? This clinical thinking protects you.

The Nursing Process - Your Defense Against Liability

The nursing process is not something you learn in nursing school and then forget. The nursing process is your entire practice.

Assessment. You assess the patient thoroughly. You do not just take vitals. You actually assess. You look at the patient. You listen to their story. You perform a physical exam. You gather information from multiple sources. You utilize the tools you were trained to use in nursing school to gain a clinical picture.

Nursing diagnosis. Based on your assessment, what is going on with this patient? What are their problems? What are their risks? It is important to note that nurses do not assign medical diagnoses. However, certain nursing diagnoses can be assigned. Most importantly, be able to articulate your patient’s current condition.

Planning. Based on your diagnosis, what do you need to do? What interventions will address their problems?

Intervention. You implement your plan. You provide nursing care based on your clinical thinking.

Evaluation. You assess whether your interventions worked. Did the patient improve? Did something unexpected happen?

Many ED nurses skip steps. They take vitals and implement orders without really assessing. They do not think about what is actually going on. They just move through the checklist.

In a high-liability case, the attorney reviews the nursing record to see if the nurse followed the nursing process. Did the nurse thoroughly assess the patient? Did the nurse think about the patient's actual problems? Did the nurse plan interventions based on the assessment? Did the nurse follow up to see if interventions worked?

When you follow the process, your documentation shows clinical thinking. When you skip steps, your documentation appears to show task completion.

The nursing process takes time. It requires mental engagement. It is harder than just doing what you are told. Sure, it takes work, but it protects you legally. It also improves patient outcomes.

Commit to the process. Assess thoroughly. Diagnose clearly. Plan thoughtfully. Intervene

purposefully. Evaluate honestly. This is how you practice defensively.

The Cost of Complacency

The ED is a fast environment. You see many patients. You manage many problems simultaneously. You hear the same presentations repeatedly.

This repetition breeds complacency.

After you have seen thirty patients with chest pain, patient thirty-one feels familiar. You think you know what this presentation means. You do not assess as thoroughly as you did for patient one.

After you have placed fifty IV catheters, the technique becomes automatic. You do not think about what you are doing. Your hands move without conscious thought.

After you have documented fifty times, the documentation becomes rote. You use the same phrases. You do not really describe the patient. You simply fill in the template.

Complacency makes you faster. It makes the shift feel more manageable. It also makes you careless.

When complacency sets in, assessment becomes superficial. You miss findings that a thorough assessment would have caught. You do not ask the right questions. You do not look closely.

When complacency sets in, documentation becomes minimal. You write just enough to move on. You do not paint a picture. You do not describe what you found.

When complacency sets in, follow-up becomes inconsistent. You implement orders but do not assess the response carefully. You assume things are fine because you are busy.

The patient who deteriorated during your shift had vital signs that worsened. But you were not trending them. The patient had a finding you should have reported. But you did not notice it because you were rushing. The patient had an order that was not working. But you did not follow up to check.

One complacent shift can cost a patient's life. It can also cost you your license.

The antidote to complacency is vigilance. Vigilance means staying mentally present. Vigilance means treating each patient like they matter. Vigilance means assessing thoroughly, even when busy. Vigilance means documenting as if someone will read it in a lawsuit.

Vigilance is not extra work. Vigilance is the standard you should be maintaining all along.

Defensive ED Nursing

Defensive nursing sounds like you are protecting yourself. You are. But defensive nursing also protects your patients.

Defensive nursing means thorough assessment. You take time to assess. You do not rush through. You look for findings. You ask the right questions. You document what you find.

Defensive nursing means documenting thoroughly. You describe what you see. You explain your clinical thinking. You show that you are assessing the patient, not just completing tasks.

Defensive nursing means trending vital signs. You compare them over time. You recognize patterns. You act when something changes.

Defensive nursing means follow-up after interventions. You assess the response. You document what you found. You escalate if something is wrong.

Defensive nursing means reporting findings to the provider. You do not assume they will notice. You tell them directly. You document the communication.

Defensive nursing means understanding why orders are placed. You ask. You think about what response you should expect. You assess that response.

Defensive nursing means escalating concerns. You do not stay silent when something does not seem right. You communicate up the chain of command.

Defensive nursing means continuous learning. You stay current with ED protocols. You ask questions when you do not understand something. You learn from interactions and cases.

When you practice defensively, you protect yourself legally. You also provide better care. The practices that protect you in court also protect your patients.

Building and Maintaining Competence

Competence is not something you achieve once and then maintain automatically. Competence is active. It requires continuous attention.

Competence means understanding your practice. You do not just go through the motions. You understand why you do what you do. You understand the evidence behind protocols. You understand how your actions affect patients.

Competence means staying current. Medicine changes. Protocols change. You need to stay updated. You need to know what has changed from what you learned in nursing school.

Competence means recognizing your limitations. You do not assume you know the answer to everything. You ask for help when you need it. You ask for clarification when something is unclear. You do not implement an order you do not understand.

Competence means learning from cases. When something goes wrong, you think about why. You think about what you could have done differently. You do not repeat the same mistakes.

Competence means continuous assessment of your own practice. Are your assessments as thorough as they should be? Is your documentation adequate? Are you trending vital signs? Are you following up appropriately?

In the ED, it is easy to slip into complacency and call it competence. You have done this a thousand times. You must be competent. But have you really assessed your current practice recently, or are you operating on autopilot?

The ED nurses who maintain true competence are the ones who stay engaged. They question. They assess. They document thoroughly. They continue learning.

These are the nurses who are rarely named in lawsuits. Not because they never have bad outcomes. Rather, because they practiced defensively. They documented thoroughly. They thought clinically.

The Reality of ED Liability

Many ED cases end up in litigation. Some cases involve something bad happening, and the patient or family is looking for answers. Some cases involve genuine negligence.

When these cases get litigated, the attorney reviews the ED record. They look at the documentation. They look at the care that was provided. They ask whether the nurse met the standard of care. A legal nurse often looks at your documentation. They scrutinize everything that you did and compare it to the standard of care.

Poor documentation is a common finding in lost cases. The nurse did not document what they assessed. The nurse did not show clinical thinking. The nurse did not document communication with providers. Sure, we should retire the old phrase, “If it wasn’t documented, it wasn’t completed.” That is not clinical reality. Yet it is often the case. Just because it was not documented does not mean it did not happen, but it does make it incredibly difficult to prove it did.

Lack of trending and follow-up is a common finding. The vital signs were documented, but the nurse did not trend. The intervention was implemented, but the nurse never followed up. The patient deteriorated, but the nurse did not notice.

Failure to report findings is common, but dangerous. The nurse found something concerning but did not communicate it to the provider.

The ED environment does not excuse inadequate practice. The attorney will not say, "Well, the ED is busy, so we understand why this nurse did not assess the patient thoroughly." They will ask why the nurse did not practice defensively despite the busy environment.

Liability follows nurses who practice complacency. It follows the nurses who rush through assessments. It follows the nurses who document minimally. It follows the nurses who do not report findings or follow up on interventions.

The cost of a single lawsuit can permanently affect your career. It can affect your ability to practice. It can affect your reputation. It can affect your finances.

Practicing defensively now prevents these consequences later.

Moving From Complacency to Vigilance

If you recognize that your practice has slipped toward complacency, you can change it.

Start by honestly assessing your current practice. How thorough are your assessments really? Are you assessing, or are you going through a checklist? How detailed is your documentation? Are you painting a picture or just documenting vitals and chief complaint?

Are you trending vital signs or just documenting them? Are you following up after interventions, or are you assuming everything is fine? Are you reporting findings to providers, or are you assuming they will notice?

Be honest with yourself. Most ED nurses have areas for improvement.

Then commit to change. Commit to a more thorough assessment. Commit to better documentation. Commit to trending vital signs. Commit to follow-up. Commit to reporting findings. Commit to understanding why orders are placed.

This requires slowing down. This requires mental engagement. This requires taking time on tasks you have been rushing through.

Sustaining vigilance long-term is the harder part. After you have changed your practice, you need to keep practicing this way.

The way to sustain vigilance is to remember why you are doing this. You are protecting yourself. You are protecting your patients. You are practicing the standard of care. You are thinking clinically instead of moving on autopilot.

Every patient who comes into the ED deserves a thorough assessment. Every note you write might be read in court. Every vital sign is data that matters. Every intervention deserves follow-up. Every finding that concerns you deserves communication.

This is not extra work. This is the standard you should be maintaining.

Conclusion

The ED is challenging. Complacency is understandable but unacceptable. When you are running from patient to patient, it is natural to fall into patterns. It is natural to rush.

Complacency is dangerous. It exposes you to liability. It also compromises patient care.

The common practices I described in this article create liability because they are incomplete. Inadequate triage documentation leaves others without the foundation they need. Vital signs without trending miss early warning signs. Interventions without follow-up show incomplete nursing care. Unreported findings allow problems to progress unchecked. Not understanding why orders are placed prevents clinical thinking.

All of these practices are fixable. You can change how you practice. You can become more defensive. You can maintain the nursing process in everything you do.

Your triage note can paint a picture rather than just draw a stick figure. Your vital signs can be trended to show the patient's trajectory. Your interventions can be followed up to assess response. Your findings can be reported to providers immediately. Your orders can be understood, so you know what response to expect.

The nursing process should be your foundation. Assessment leads to diagnosis. Diagnosis leads to planning. Planning leads to intervention. Intervention leads to evaluation.

Vigilance is not optional in ED nursing. It is essential. You deserve to practice in a way that protects you. Your patients deserve to receive a thorough assessment and appropriate follow-up.

The practice changes I described are not complicated. They are not unrealistic. They are just more intentional than what you might be doing now.

Your license deserves protection. Your patients deserve your best practice. Your career deserves your commitment to vigilance.

Practice defensively. Stay engaged. Think clinically. Document thoroughly. Your future self will thank you.

Visit www.garveyces.com to learn more about my consulting and mentorship services or contact me directly at matthew.garvey@garveyces.com to discuss your case.

AI Assistance Disclosure

This article was developed, in part, with the assistance of artificial intelligence tools. The author has reviewed and edited all content to ensure accuracy and alignment with the author's professional expertise and opinions.