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Case Study A8: Severe Hemolytic Transfusion Reaction Involving a Student 

Discussion - Part 4 (Supervision of Students)

Supervision of students is a key part of Case A8. The discussion below will focus on supervising medical laboratory technology students but is applicable to other health professionals

BACKGROUND 

The TS laboratory in Case A8, like all clinical laboratories that train medical laboratory technology/science students in Canada, is an accredited clinical site. Accreditation of clinical sites occurs under the umbrella of accreditation of the overall education program by the Canadian Medical Association (CMA) Conjoint Committee on Accreditation of Allied Health Services. The accreditation process is rigorous with defined criteria.

Accreditation requires that students are trained using a system of formal competency assessment:

LEGAL STANDARD OF CONDUCT FOR STUDENTS

Negligence Primer. 

Disclaimer: The author of this case is not a lawyer - I am one of you. What is written here is the best information that I've gleaned so far and is presented solely for the interest of readers. Legal content has been derived from many sources and readers are advised to consult the resources in Further Reading, which are provided as aids to identify more information on this complex topic.

Negligence is often defined as

(1) not doing something which a reasonable person would do, or
(2) doing something which a reasonable person would not do.

Thus negligence can involve acts of commission and acts of omission. In order to succeed in a negligence case, the plaintiff, or person suing, must generally satisfy the court of the following four elements:

  1. Duty of care
  2. Breach of standard of care
  3. Injury or loss
  4. Causation - breach must be the proximate cause of the harm (the causal link between the defendant's act and the injury or loss)

1. Duty of care. A person who practices in a health profession owes the patient a duty. The duty of care involves applying skill, knowledge, diligence and caution when caring for patients.

2. Breach of standard of care. The standard of care is primarily determined by the general practice of the profession. The practitioner does not need to live up to the highest standards but rather the reasonable, accepted standards set for the profession. Standards of care are determined by consulting experts,  and relevant practice guidelines and standards (such as blood safety standards).

Patients also have the right to expect a reasonable standard of care from healthcare students who treat them. Therefore, students should be supervised at all times. They should perform only those patient-related tasks for which they have been adequately trained and have met a reasonable standard of competence. If treating a patient under indirect supervision (i.e., not constant observation), their skills should meet the standard of a reasonably competent professional.

3. Injury or loss. For negligence to occur, the patient must have experienced injury or loss of some kind due to the negligent act.

4. Causation. The most common test is the "but for" test. That is, if the accident would not have occurred but for the defendant's negligence, then the conduct is the cause of the injury. There must be a clear direct connection between the negligent act and the harm caused to the patient.

Also see 

Standard of care is referred to as "standard of conduct" in a legal setting. Today, healthcare students are held by the courts to the same standard of conduct as practicing professionals, including a national standard of care. 

As well, case law shows that supervising faculty have a parallel duty to patients to provide adequate levels of supervision to ensure that such a standard be met, as well as to ensure that the care comply with relevant policies and regulatory standards. A important reason that students are held by the courts to the same standard of conduct as practicing professionals is that they are providing care under the supervision of qualified, experienced faculty. See

Delegation and supervision are important elements of clinical education. There must be a designated person to supervise students in the clinical setting and the supervising practitioner must delegate appropriately. Failure to delegate and supervise appropriately could result in a finding of negligence against the practitioner. See 

SUPERVISION IN PRACTICE 

How TS laboratories train and supervise students (and new employees) varies greatly. Some examples to illustrate the spectrum of policies:

Initially restricted to specimens that are already resulted (or "cooked"); gradually progress to working on untested patients Work on real untested patients from the start
Supervised by 'dedicated' technologist whose sole task is student supervision Supervised by technologist who also performs routine work concurrently
Level of observation remains high - students are watched at all times Level of observation decreases over time -  students may go unwatched with tasks they have shown they can perform
Students never do bulk or batch testing Students progress to bulk and  batch testing
Technologist supervises only one student at a time Technologist may supervises one or two students at a time
Students are not allowed to use LIS Students can perform certain functions in LIS 

Regardless of policies used, TS laboratories, like all training facilities, require that results of student tests be read and confirmed by a qualified practitioner. Student test results are documented under the technologist's name. Similarly, non-test related student competencies such as blood product manipulations and communication with wards are closely monitored and verified.

THIS CASE 

Student. In Case A8, the student who made the pipetting error was in the second week of training in the transfusion service and, prior to the unobserved error,  had successfully performed batch testing under constant observation. Subsequent to the error, she was closely observed for the remainder of the internship and passed her clinical rotation. 

Special treatment (constant observation) tends to help students who may otherwise struggle.  Extra attention by concerned staff tends to prevent students from making errors that may otherwise occur with less supervision. In extreme cases, supervision may be so smothering as to prevent an incompetent student from failing. 

Technologist. The supervising medical technologist had acted within the framework of training in the department, i.e, gradually allowing the student to perform with less supervision but always reading test results. 

Missing the abnormal volume in the gel card  was deemed an error. Management concluded that it was an oversight that could happen to anyone when busy or distracted. The technologist in question was experienced, universally considered to be an excellent teaching technologist, and had a record of exemplary performance evaluations.

TS laboratory ("the system"). As discussed under risk management, the TS laboratory maintained existing supervisory policies and held in-service training sessions for staff to share and improve supervising strategies when also working on the bench, as well as sessions on technical tips for organizing work such as batch testing. 

The hospital's risk management office was asked to review the laboratory's policies for student training and to provide guidance. Risk management also presented an in-service on the legal concepts and issues related to student training. 

TraQ self study questions  

1. Is it sufficient for students who work on patients to meet the 

  1. Highest standard of care or reasonable standard of care?
  2. Same standard of care as fellow students or same standard as practicing professionals?

answer

2. In Case A8, if the family had decided to sue, assess whether the 4 elements needed to succeed in a negligence case would be met.

 answer

MORE DISCUSSION...

FURTHER READING

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