Here's How a Court Ruling in North Carolina Could Affect Liability for Nurses

Nurses in North Carolina can now be held liable for patient harm even if they were following doctors' orders, according to a state Supreme Court ruling last month.

In a 3-2 opinion issued August 19, the court noted how much the practice of medicine has changed in striking down precedent established by a legal case from the early 1900s, Byrd v. Marion General Hospital, which shielded nurses from liability when working under a physician's supervision.

"Due to the evolution of the medical profession's recognition of the increased specialization and independence of nurses in the treatment of patients over the course of the ensuing ninety years since this court's issuance of the Byrd opinion, we determine that it is timely and appropriate to overrule Byrd as it is applied to the facts of this case," Justice Michael Morgan wrote.

The ruling stems from a legal case brought on behalf of a young child who suffered permanent brain damage following the administration of anesthesia for a 2010 ablation procedure.

An anesthesiologist involved in the child's care ultimately settled the case against him and his practice out of court, according to facts detailed in the state Supreme Court's opinion. And in 2018, there was a jury verdict in favor of an involved nurse anesthetist (CRNA) and his hospital employer.

However, the child's guardians appealed the 2018 verdict, arguing in part that expert testimony that was excluded by the trial court would have showed the CRNA's involvement in the determination and implementation of an allegedly negligent anesthesia plan. In 2020, an appellate court affirmed the trial court's exclusion of the evidence. And that decision was then put before the state Supreme Court last year.

In the August ruling by the state Supreme Court, Justice Morgan wrote the following: "While the application of Byrd has previously operated to prevent the admission into evidence of such testimony pursuant to this court's announced principle in Byrd that nurses cannot be held liable for the discharge of their duties when obeying and diligently executing the orders of a supervising physician due to the physician's sole responsibility for the diagnosis and treatment of the patient, our reversal of this principle, as espoused in Byrd, compels a new trial."

"Accordingly, the trial court's exclusion of plaintiffs' expert testimony is reversed, and this case is remanded to the Court of Appeals for further remand to the trial court for a new trial," Morgan added.

The North Carolina Association of Nurse Anesthetists (NCANA) has been paying close attention to the case, its president, Stacy Yancey, MSNA, CRNA, told MedPage Today.

"There is so much about CRNA practice in North Carolina that can be unclear," Yancey said. "I think it needs to be addressed by the legislature. I don't think it is a good thing for North Carolina that these justices are having to look at 90-year-old precedent because there's nothing in state statute about CRNA practice."

Better defining CRNAs' scope of practice in North Carolina could be achieved through passage of the SAVE Act bill, she said, which passed the state Senate back in June and would grant full practice authority for advanced practice registered nurses.

Overall, Yancey said it's very difficult for medical providers to go into work every day without clear guidelines on their scope of practice. She noted that there are currently some 3,600 nurse anesthetists in North Carolina, representing a relatively small, but highly trained and specialized field.

In terms of greater autonomy of practice, Yancey noted that many rural hospitals in the state employ CRNAs alone. If those providers aren't getting reimbursed for their services because an insurance company doesn't know whether something is within a CRNA's scope of practice, that could hurt both the hospital and patients, she said.

"In this time of the labor shortage and people having trouble accessing healthcare, everyone needs to be able to do everything that they are trained and educated to do," Yancey said.

She said that she has seen some nurse anesthetists graduate in North Carolina and decamp to other states that have fewer restrictions on CRNAs' scope of practice.

Regarding the state Supreme Court ruling, Yancey said she has had both CRNAs and registered nurses reach out to her and express concern regarding the potential for increased liability. However, she said that she is not sure how much the ruling will change liability for CRNAs, who have historically carried their own malpractice insurance.

She did say that she believes the ruling shows that an outdated physician supervision model no longer provides a veil of malpractice protection for hospitals. Physician supervision comes down to patient care and healthcare economics, she said.

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