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Professional Issues in Imaging

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During World War I, the demand for x-ray technicians in military hospitals was so great that a shortage of technical workers became acute at home. The value of the well-trained technician was emphasized, and the radiologist was no longer satisfied with someone who knew only how to throw the switch and develop films.

Margaret Hoing, The First Lady of Radiologic Technology

A History of the American Society of X-Ray Technicians, 1952

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The field of radiologic technology began on November 8, 1895, when Wilhelm Conrad Röntgen, a German physicist, was working in his laboratory at the University of Wurzburg. Röntgen had been experimenting with cathode rays and was exploring their properties outside glass tubes. He had covered the glass tube to prevent any visible light from escaping. During this work, Röntgen observed that a screen that had been painted with barium platinocyanide was emitting light (fluorescing). This effect had to be caused by invisible rays being emitted from the tube. During the next several weeks, Röntgen investigated these invisible rays. During his investigation, he saw the very first radiographic image, his own skeleton. Röntgen became the first radiographer when he produced a series of photographs of radiographic images, most notably the image of his wife's hand . He termed these invisible rays x-rays because x is the symbol for an unknown variable

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Radiologic technology is the technical science that deals with the use of x-rays or radioactive substances for diagnostic or therapeutic purposes in medicine. Radiologic technologist is a general term applied to persons qualified to use x-rays (radiography) or radioactive substances (nuclear medicine) to produce images of the internal parts of the body for interpretation by a physician known as a radiologist. Radiologic technology also involves the use of x-rays or radioactive substances in the treatment of disease (radiation therapy).

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A radiologic technologist specializing in the use of x-rays to create images of the body is known as a radiographer . Radiographers perform a wide variety of diagnostic x-ray procedures, including examinations of the skeletal system, the chest, and the abdomen.

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To become a registered radiographer, an accredited radiography program must be completed. Programs are most commonly sponsored by hospitals, community colleges, and universities. Approximately 600 radiography programs are available in the United States. On successful completion of an accredited program, individuals are awarded a certificate, an associate degree, or a baccalaureate degree and are eligible to take the national examination in radiography offered by the American Registry of Radiologic Technologists (ARRT). A registered radiographer uses the initials RT(R) after his or her name. This abbreviation means registered technologist (radiography).

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Accreditation is a voluntary peer-review process. Although accreditation is voluntary, few programs choose not to undergo the accreditation process. Nearly all schools value their accreditation status highly and work hard to maintain standards that meet all the accreditation recommendations

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The Criteria for a Profession

Radiologic technology has evolved from an undereducated workforce of x-ray technicians in the early 1900s to the continued advances as a profession in the 21st century. This progression took place over a number of years with the efforts and dedication of the persons who worked in this field. The term profession implies a body of work that requires extensive training and the mastery of study by its members who have specialized skills, has a professional organization and ethical code of conduct, and serves a specific social need.

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Radiography is considered to be the fifth oldest allied health profession because the first Essentials document was established in 1944, after occupational therapy, medical technology, physical therapy, and medical records administration. Not until 1969 was the Joint Review Committee on Education in Radiologic Technology (JRCERT) established. The JRCERT board is currently nominated by the American College of Radiology, the American Society of Radiologic Technologists, the Association of Educators in Radiological Sciences, and the American Healthcare Radiology Administrators. The JRCERT accredits approximately 600 radiography programs (more than any other allied health profession), as well as approximately 80 radiation therapy technology programs (web site:

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Professionalcertification is a process through which an agency grants recognition to an individual on demonstration, usually by examination, of specialized professional skills. It is a voluntary process and is the responsibility of the person, not of the person's school or employer. Each certification organization sets requirements for the recognition of professionals through registration, certification, or other recognition of skills by examination.

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Actually, a registry is simply a listing of individuals holding a particular certification. The term registry is commonly applied to the agency that carries out the certification function and maintains the registry list

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The American Registry of Radiologic Technologists (ARRT) was founded in 1922 by the Radiological Society of North America (RSNA), with the support of the American Roentgen Ray Society (ARRS) and the cooperation of the Canadian Association of Radiologists and the American Society of X-Ray Technicians (now known as the American Society of Radiologic Technologists [ASRT]

The purposes of the ARRT include encouraging the study and elevating the standards of radiologic technology, examining and certifying eligible candidates, and periodically publishing a listing of registrants. This mission is accomplished through voluntary certification by examination. Once an individual has passed the appropriate examination, he or she is listed in the registry and granted the right to use an appropriate professional title. These designations are registered technologist (RT), with a specialty designation for radiographer (R),

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The ASRT was founded in 1920. As the most prominent national professional voice for radiologic technologists, the ASRT represents individual practitioners, educators, managers and administrators, and students in radiography, radiation therapy, and nuclear medicine, as well as the many specialties within each modality. The ASRT has approximately 115,000 members (nearly one half of the registered technologists in the United States).

The goals of the ASRT are to advance the professions of radiologic technology and imaging specialties, to maintain high standards of education, to enhance the quality of patient care, and to further the welfare and socioeconomics of radiologic technologists. The ASRT publishes a peer-reviewed, refereed journal (Radiologic Technology), conducts regional and national conferences, and produces educational programs of all types

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The criteria for a group of practitioners:

A vital human service is provided to the society by the profession.

Professions possess a special body of knowledge that is continuously enlarged through research.

Practitioners are expected to be accountable and responsible.

The education of professionals takes place in institutions for higher education.

Practitioners have an independent function and control their own practice.

Professionals are committed to their work and are motivated by doing well.

A code of ethics guides professional decisions and conduct.

A professional organization oversees and supports standards of practice

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The radiographer will interact on a daily basis with his peers in diagnostic imaging and with other members of the health care team :

  • Physician

  • Nurse

  • Physical and occupational therapist

  • Pharmacist

  • Lab Technologist

  • Social worker

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Imaging and radiation science professionals face a variety of ethical challenges within medical imaging services. Because of their differing diagnostic applications, individual modalities present specific ethical dilemmas. Imaging professionals should consider these dilemmas to be challenges and opportunities for growth. When faced with such challenges, imaging professionals and radiation science practitioners must apply professional standards and exercise personal integrity to respond correctly to the situation. A firm grounding in ethics may help imaging professionals, radiation therapy specialists, and other health care professionals respond positively to the dilemmas they encounter in the workplace

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Ethics is the system or code of conduct and morals advocated by a particular individual or group.

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The child's parents are afraid their son will outlive them if he has the surgery. A vascular imaging technologist who assisted with the cardiac catheterization is horrified when she finds out the young child will not be operated on because of low IQ and quality-of-life decisions made for the child by others. She wonders whose good the parents and physician are considering and in what way they arrived at such a decision.

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To resolve ethical dilemmas, one may apply this established set of principles to decision making:

  • Autonomy

  • Beneficience

  • Confidentiality

  • Fidelity

  • Justice

  • Nonmaleficence

  • Paternalism

  • Sanctity of life

  • Veracity

  • Respect for property

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Autonomy: Refers to the right of all persons to make rational decisions free from external pressures.

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Beneficience: Performance of good acts.

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Confidentiality: Refers to the concept of privacy

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Fidelity: Refers to the duty to fulfill one's commitments and applies to keeping promises both stated and implied

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Justice: Refers to all persons being treated equally or receiving equal benefits according to need.

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Nonmaleficence: Refers to the duty to abstain from inflicting harm and also the duty to prevent harm.

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Paternalism: Refers to the attitude that sometimes prompts health care workers to make decisions regarding a person's care without consulting the person affected

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Sanctity of life: Refers to the belief that life is the highest good and nobody has the right to judge that another person's quality of life is so poor that his or her life is not of value and should be terminated.

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Veracity: Refers to honesty in all aspects of one's professional life. One must be honest with patients, co-workers, and oneself

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Respect for property: Refers to keeping the patients' belongings safe and taking care not to intentionally damage or waste equipment or supplies with which one works

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Double Effect: Refers to the fact that some actions may produce both a good and a bad effect

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Conflicts among beneficence, nonmaleficence, and autonomy (the state of independent self-government) may arise during consideration of principles of justice. The general belief in the right to health care brings beneficence and nonmaleficence into conflict with autonomy and justice. Although most people believe that the good of health care should be available to all, health care resources are limited and hard decisions must be made about their allocation. Limited resources reduce the overall quality of care and may lead to less avoidance of evil. When quality of health care is reduced, the patient's autonomy suffers from loss of freedom of choices. When choices are limited, the obligations of the patient and health care giver may conflict with resources and justice for the patient

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A female patient is scheduled for a lumbar spine imaging series. The imaging professional in charge of the examination is interrupted and called to the emergency room to care for victims of a massive accident. Another imaging professional arrives to take over the examination before the initial exposure is taken. When asked if everything is ready, the first technologist says yes and hurries to the emergency room. The second imaging technologist surveys the patient, who is covered with a sheet, introduces himself, and performs the lumbar spine series. The processed images reveal that the woman is in her first trimester of pregnancy. Obviously, an injustice has been done, and a lawsuit may possibly result

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Was the injustice active, that is, did the first or second imaging professional deliberately not shield the patient and ask about possible pregnancy? Or was the injustice an unintentional error of omission resulting from the confusion caused by the first technologist's leaving to attend to accident victims in the emergency room?

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We don't receive wisdom; we must discover it for ourselves after a journey that no one can take for us or spare us.


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Professionalism is an awareness of the conduct, aims, and qualities defining a given profession, familiarity with professional codes of ethics, and understanding of ethical schools of thought, patient-professional interaction models, and patient rights

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Ethics may be divided into three broad schools of thought:



3.Virtue ethics

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Consequentialism, deontology, and virtue ethics are ways of establishing a value hierarchy in ethical decisions. Each school of thought offers different guidelines for ethical problem solving. No one school is better than the others; imaging professionals must choose the one that best serves individual, professional, and institutional goals

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Consequentialism, or teleology, bases decisions on the consequences or outcomes of a given act. It evaluates the good of an activity by assessing whether immediate harm is balanced with future benefit. For example, a patient undergoing radiation therapy for cancer may experience some discomfort now, but the palliation or cure of the cancer is the desired beneficial consequence of the therapy. Consequentialism advocates providing the greatest good for the greatest number

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Deontology bases decision making on individual motives and morals rather than consequences. It is therefore the opposite of teleology. Deontology examines the significance of actions themselves. For example, members of certain religious groups refuse blood transfusions because they believe the act is morally wrong. Although they may be concerned about the consequences of this refusal, they are making the choice based on their religious beliefs regarding blood transfusions. Personal rules of right and wrong derived from individual actions, duties, relationships of all kinds, and society are used for reasoning and problem solving in the deontologic school of thought.

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Virtue ethics is a relatively new school of thought. It focuses on the use of practical wisdom and moral character for emotional and intellectual problem solving. Virtue ethics incorporates elements of teleology and deontology to provide a more holistic approach to solving ethical dilemmas. Careful analysis and consideration of consequences, rules established by society, and short-term effects play significant roles in decision making in virtue ethics.

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Law: the principles and regulations established in a community by some authority and applicable to its people, whether in the form of legislation or of custom and policies recognized and enforced by judicial decision.

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Practice Standards

The Professional Performance Standards define the activities of the practitioner in the areas of education, interpersonal relationships, personal and professional self-assessment, and ethical behavior.

The Clinical Performance Standards define the activities of the practitioner in the care of patients and the delivery of diagnostic or therapeutic procedures and treatment. The section incorporates patient assessment and management with procedural analysis, performance, and evaluation.

The Quality Performance Standards define the activities of the practitioner in the technical areas of performance including equipment and material assessment, safety standards, and total quality management

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Statutory laws are derived from legislative enactments.

Common law usually results from judicial decisions

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Civil law has been broken if another person's private legal rights have been violated. The person who is found guilty of this type of offense is usually expected to pay a sum of money to repair the damage done.

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Certain terms in law come from Latin. The term tort comes from Latin, meaning “to twist, be twisted, or to wrest aside.” Tort is a private or civil wrong or injury, and not a breach of contract, for which the court provides a remedy for damages. There must always be a violation of some duty owed to the plaintiff, and generally such duty must arise by operation of law and not by mere agreement of the parties.

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Respondeat superior means “let the master answer.” If a nursing assistant is sued for actions that harm a patient, her employer can also be sued. The employer can be sued on the basis that the employer had control, or should have had control, over the actions of the nursing assistant and that the nursing assistant was working in the course and scope of her employment

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Res ipsa loquiturmeans “the thing speaks for itself.” For example, a person has surgery to correct a hernia, but when he awakes, his arm is paralyzed. Because he had no control over his actions during the surgery and a paralyzed arm is not an expected outcome or even a possible adverse reaction, then the law presumes that the paralysis had to be caused by the negligence of the surgical technician, operating room nurse, surgeon, and/or anesthesiologist. This presumption means that the plaintiff does not have to prove that negligence occurred in order to recover from the defendant.

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Stare decisismeans “to stand by things decided.” This prevents multiple suits on the same facts with the same parties. It allows courts to refer to previously decided similar cases and to apply the same rules and principles. The courts can follow prior decisions or those of courts of higher jurisdiction

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Negligence is a tort. It is the cornerstone of a malpractice case. Negligence does not require a specific plan to harm someone. There are four elements in a negligence action: duty, breach of duty, proximate harm or causal connection, and harm/damages

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A tort may be committed intentionally or unintentionally. An intentional tort is a purposeful deed committed with the intention of producing the consequences of the deed

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The degree of intent necessary to commit an intentional tort is broader than having a desire to bring about harm or injury to a person. If a person is or should be substantially certain that given circumstances will follow from his actions, then there exists the requisite intent. For example, if you walk behind a healthcare provider in the hospital just as he pulls a tray from the dinner cart and hits you, there is no intent to harm you, and no intentional tort is committed. But if a healthcare provider takes the tray and throws it across the room at a patient's bed so that it hits the patient, then he knew or should have known that the action of throwing a tray was likely to hit someone and cause injury. That knowledge is sufficient to form the intent necessary to commit an intentional tort of assault and battery in this case.

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Facts: A 75-year-old patient at a licensed healthcare provider care center suffered from diabetes, dementia, coronary artery disease, immobile decubitus ulcers (bedsores), and was unable to walk, talk, or feed herself.

Her physician prescribed a daily whirlpool bath as a medical treatment for the decubitus ulcers. The facility did not have a whirlpool so she was given a regular daily bath. A certified nursing assistant prepared a bath for the patient and placed her in hot water that was 138 degrees and that subsequently caused severe burns from which she died three days later.

A wrongful death action was brought. Parties settled before trial for $1.5 million.

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Intent may also be transferred. For example, you intend to shoot person A, but you miss and shoot person B instead. Even though you have no intent to harm person B, your intent to harm person A is transferred, and the law deems that you had the intent to harm person B. It is a rule of law that “intent follows the bullet.” While transferred intent does not often occur in the medical setting, if a healthcare provider gives the wrong patient an injection, she can be liable for battery and negligence even though she has no intent to harm that patient or any conscious desire to administer the injection to the wrong patient.

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An assault means placing someone in immediate fear or apprehension of a harmful or noxious touching without the patient's consent. To commit an assault, the person must be aware that you are about to touch him or her

For example, a patient is in bed crying and becomes hysterical. The home health aide caring for the patient becomes increasingly anxious and upset as a result of the patient's behavior. The aide raises her hand over her head and threatens to strike the patient. (The aide does not have to tell the patient anything; raising the hand as if to strike is enough.) If the patient sees the aide raising her hand and cringes to protect herself, then the patient is put in imminent fear of a battery, and the aide commits an assault

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Battery is harmful or offensive touching of another without his or her consent or without a legally justifiable reason. Without the consent of the patient, or absent an emergency, any touching of a patient can be a battery.

A battery does not mean you must try to maliciously hurt or strike a person. Any touching, such as inserting an intravenous device, may be a battery if done without the consent of the person or without a legally justifiable reason. Also, hitting, spitting at, kicking, and slapping a patient can all be batteries. In addition, you do not need to touch the patient to commit a battery

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A batteryis any offensive touching without permission or in the absence of an emergency situation. All patients admitted to a hospital are required to sign a general consent. This general consent is for medical care and treatment for other employees of the hospital to “touch” the patient, even in a therapeutic manner. Do not confuse this general consentwith an informed consentto surgery or to other invasive procedures. While the failure to obtain an informed consent may give rise to an action in medical negligence, the consent necessary to avoid a battery is the permission to touch the person.

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A medical batterycan be committed in specific situations where there is consent to perform some procedure but you perform another. At the cornerstone of this theory is the decision of the brilliant jurist Justice Benjamin Cardozo, who wrote in 1914: “Every human being of adult years and sound mind has a right to determine what shall be done with his own body, and a surgeon who performs an operation without his patient's consent commits an assault for which he is liable in damages

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While you may think that no person would perform a procedure other than the one authorized, several cases are instructive. In Pizzaloto v. Wilson, the patient gave consent for the surgeon to perform exploratory surgery to accomplish lysis of adhesions and fulguration of endometriosis [2]. During the abdominal surgery, the physician noted that the plaintiff's reproductive organs had sustained severe damage. He determined that she was in fact sterile and proceeded to perform a total hysterectomy and bilateral salpingo-oophorectomy.

When the plaintiff awoke from surgery, she was upset with what the physician had done. In ruling in her favor, the court ruled that the plaintiff was entitled to recover damages because there was no emergency present and the surgeon committed a battery. The court awarded her $10,000. See also Guin v. Sison, where the court awarded $1000 to a postmenopausal women who had her left fallopian tube and ovary removed without consent during the course of a colectomy

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There are limited situations in which the courts imply consent on behalf of the plaintiff. In one of the oldest cases of implied consent, the plaintiff, an employee of defendant, spoke no English. He was standing in line with other employees to be vaccinated. He asked no questions. He watched others being vaccinated, and when it was his turn, he held up his arm to the physician who proceeded with the vaccination. When plaintiff filed suit against the company and others alleging battery, the court stated the plaintiff's action clearly indicated implied consent or implied permissionto touch him. The court dismissed the battery claim [6]. It is highly unlikely that any similar situation would arise in medicine today, but there are circumstances when consent will be implied

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In modern medicine, consent is implied in emergency situations. The situation must be life threatening or pose a risk of significant physical injury to the patient if the procedures are not performed. Only those procedures absolutely necessary are authorized, and as soon as possible competent consent should be obtained. Only a physician can make the determination that a true emergency exists that necessitates proceeding without consent.

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If the religious prohibitions are known, then consent is not implied, even in the case of a minor. In Novak v. Cobb County Kennestone Hospital Authority, the hospital obtained a court order to administer blood to a 16-year-old Jehovah's Witness [7]. The order was entered despite the protest of the boy and his mother. Even though the mother and child brought suit after the boy had recovered, the court dismissed all claims. Without the court order, however, the hospital and physicians could not have proceeded with the blood transfusions. Keep in mind that a court will only order procedures in the case of a minor. If a competent adult refuses life-saving treatment, the courts will not interfere, nor will they imply consent.

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To prevent allegations of battery, always have your patient's written consent to perform a procedure. Only perform the procedure authorized, and do not exceed the scope of the consent. In emergency situations, have at least two physicians certify that an emergency exists, document the certification in the patient's record, and perform only those procedures that are necessary to save a person's life or to prevent significant injury or harm. As soon as possible, obtain competent consent for the performance of additional procedures

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False imprisonment is the unlawful detention of a person. The person is deprived of his personal liberty of movement against his will and without any authority to detain. To be falsely imprisoned, a person must be confined within a specific area against his will; he must be confined by means of physical barriers and/or by physical force or threat of physical force, and he must be aware of the confinement.

Issues of false imprisonment generally arise in three circumstances: first, in the psychiatric setting with involuntary commitments; second, with the use of restraints, either physical or chemical; and third, in situations where a patient attempts to leave the hospital against medical advice.

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Use of restraints is not limited to the psychiatric setting. In many hospitals and nursing homes, patients are restrained to prevent injury. Even putting up side rails on a bed is a form of restraint. The reasons that, for example, side rails are up should be documented in the record. If the patient refuses to allow the side rails to be put up, then have her sign a release from liability in the event of a fall. Even though it is probably not worth the paper it is written on in a court of law, a release gives the patient the opportunity to appreciate the gravity of her decision to refuse the side rails. Use of any other type of restraint, such as sheets to hold patients in wheelchairs, belts, or any other form of physical restraint, should be used only as a last resort and must be used only as approved by hospital policy and the physician

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Quasi-intentional torts include defamation, invasion of privacy, and breach of confidentiality. Quasi means “resembling.” These types of torts resemble intentional torts but are different because they are based on speech

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Defamationwrongfully damages the reputation of another person. Libel is written defamatory statements, and slanderis spoken defamatory statements. To be liable for defamation, you must make a defamatory statement that is published to third parties, and the speaker must have known or should have known that the statements were false

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An example of a defamation per se case is Schlesser v. Keck [20]. Plaintiff was a cook and caterer who tested false-positive for syphilis when she was in the army. She sought treatment for the false-positive. Defendant was the doctor's nurse who was administering the treatments. Despite the defendant's knowledge that the tests were false-positive and the defendant's knowledge that plaintiff did not have syphilis, defendant announced at a party that the plaintiff had syphilis and should not be allowed to cater or prepare food.

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Truth is an absolute defense to defamation. Even if a true statement damages a person's reputation, it is not actionable as defamation. Certain individuals, such as public officials, must prove actual malice on the part of the defendant before they are allowed to succeed.

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The computer age is creating even more problems for breach of confidentiality. While allowing practitioners to have easier access to their patient records and allowing information to be relayed more quickly, computerized medical records allow too many people access

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Whether a healthcare provider has access to the traditional written medical record or to computerized records, the responsibility to keep information confidential does not change. Any information that a healthcare provider learns while taking care of a patient is confidential, even if it does not relate directly to the treatment of the patient

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Invasion of privacyis the tort of unjustifiably intruding upon another's right of privacy by:

1. Appropriating his or her name or likeness

2. Unreasonably interfering with his or her seclusion

3. Publishing private facts

4. Placing a person in a false light

Invasion of privacy differs from defamation. In most instances, the information is true but is information that a person wants to keep private. While defamation causes injury to reputation, invasion of privacy causes injury to feelings.

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Good samaritan in legal terms refers to someone who renders aid in an emergency to an injured person on a voluntary basis. Usually, if a volunteer comes to the aid of an injured or ill person who is a stranger, the person giving the aid owes the stranger a duty of being reasonably careful. A person is not obligated by law to do first aid in most states, not unless it's part of a job description. However, some states will consider it an act of negligence though, if a person doesn't at least call for help. Generally, where an unconscious victim cannot respond, a good samaritan can help them on the grounds of implied consent. However, if the victim is conscious and can respond, a person should ask their permission to help them first

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Some states offer immunity to good samaritans, but sometimes negligence could result in a claim of negligent care if the injuries or illness were made worse by the volunteer's negligence. Statutes typically don't exempt a good samaritan who acts in a willful and wanton or reckless manner in providing the care, advice, or assistance. Good samaritan laws often don't apply to a person rendering emergency care, advice, or assistance during the course or regular employment, such as services rendered by a health care provider to a patient in a health care facility

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  • Under the good samaritan laws which grant immunity, if the good samaritan makes an error while rendering emergency medical care, he or she cannot be held legally liable for damages in court. However, two conditions usually must be met:

  • the aid must be given at the scene of the emergency, and.

  • 2) if the "volunteer" has other motives, such as the hope of being paid a fee or reward, then the law will not apply

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1 To successfully pursue a lawsuit for an intentional tort, the plaintiff must prove that the defendant had the requisite intent, that the injury resulted from the defendant's action, and that no defense was present.

2 If a defendant can prove that the plaintiff gave consent, then the defendant did not commit an intentional tort.

3 The defendant must stay within the boundaries of the consent given by the plaintiff. If the defendant exceeds the scope of the consent, then it is as though there was no consent.

4 Forcing treatment on an unwilling patient is assault and battery.

5 If procedures for involuntary admissions are not followed, then false imprisonment may occur. If force is used to detain a patient, then false imprisonment has occurred. No matter how noble a healthcare worker's motives may be, he has no right to forcibly detain a patient who is competent and not a danger to himself or others.

6 Invasion of privacy is likely to occur in the healthcare setting if healthcare professionals do not maintain the confidentiality of patient records.

7 All patients have the right to expect that healthcare professionals will maintain the confidentiality of medical records.

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