Title: TERESA COX V FLINT BD OF HOSPITAL MANAGERS

State: michigan

Issuer: Michigan Supreme Court

Document:

____________________________________________________________________________________________ 
____________________________________________________________________________________________________________________________ 
____________________________________ 
Michigan Supreme Court 
Lansing, Michigan 48909 
C hief Justice 
Justices 
Maura D. Corrigan  
Michael F. Cavanagh 
Elizabeth A. Weaver 
Marilyn Kelly 
Clifford W. Taylor 
Robert P. Young, Jr. 
Opinion 
Stephen J. Markman 
FILED JULY 25, 2002  
TERESA COX, as a Next Friend of 
BRANDON COX, a Minor, TERESA COX 
and CAREY COX, Individually,  
Plaintiff-Appellees,  
v  
No. 118110  
BOARD OF HOSPITAL MANAGERS FOR  
THE CITY OF FLINT doing business 
as HURLEY MEDICAL CENTER, a Municipal 
Corporation,  
Defendant-Appellant.  
BEFORE THE ENTIRE BENCH  
CORRIGAN, C.J.  
In 
this 
medical 
malpractice case, we consider two issues:  
1) whether a court may instruct a jury that it may find a  
hospital vicariously liable for the negligence of a “unit” of  
the hospital, and 2) whether MCL 600.2912a sets forth the  
standard of care for nurses in malpractice actions and, if so,  
which standard applies.  
 
We hold that vicarious liability may not be premised on  
the negligence of a “unit” of a hospital and that substantial  
justice requires reversal.  The “unit” instruction relieved  
plaintiffs of their burden of proof and did not provide the  
jury with sufficient guidance.  For a hospital to be held  
liable on a vicarious liability theory, the jury must be  
instructed regarding the specific agents of the hospital  
against whom negligence is alleged and the standard of care  
applicable to each agent.  
Further, we hold that the plain language of MCL 600.2912a  
does not prescribe the standard of care for nurses because  
they do not engage in the practice of medicine.  Absent a  
statutory standard, the common-law standard of care applies.  
Under the common-law standard of care, nurses are held to the  
skill and care ordinarily possessed and exercised by  
practitioners of their profession in the same or similar  
localities.  
I  
FACTUAL BACKGROUND AND PROCEDURAL POSTURE  
On February 8, 1990, Brandon Cox was born at 26 or 27  
weeks gestation, weighing approximately 900 grams.  He was  
placed in the neonatal intensive care unit (NICU) of defendant  
hospital, and an umbilical arterial catheter (UAC) was  
inserted into his abdomen to monitor his blood gases, among  
other uses. 
At 4:00 p.m. on February 10, Nurse Martha  
2  
 
Plamondon drew blood from the UAC and repositioned Brandon. At  
4:20 p.m., it was discovered that the UAC had become  
dislodged, causing Brandon to bleed from his umbilical artery  
and lose approximately half his blood supply. No cardiac or  
respiratory alarm sounded.  The events that followed are in  
dispute.  Nurse Plamondon testified that she immediately  
applied pressure to stop the bleeding and summoned Dr. Robert  
Villegas, who ordered a push of 20cc of Plasmanate. Dr.  
Villegas did not recall the event.  Nurse Plamondon also  
testified that she paged Dr. Amy Sheeder, a resident in the  
NICU.  Dr. Sheeder ordered another 10cc of Plasmanate and 20cc  
of packed red blood cells. On February 11, Brandon was  
transferred to Children’s Hospital.  On February 13, a cranial  
ultrasound showed that Brandon had suffered intracranial  
bleeding. He was subsequently diagnosed with cerebral palsy  
as well as mild mental retardation.  
In 
1992, 
plaintiffs 
filed 
this 
medical 
malpractice 
action  
against defendant and one of its doctors, Dr. Edilberto  
Moreno.1  Plaintiffs presented expert testimony at trial that  
Nurse Plamondon and others had breached the applicable  
standard of care. 
Defendant offered expert testimony  
supporting 
a 
contrary view.  Defendants argued that plaintiffs  
1The parties stipulated to dismiss Dr. Moreno before
trial. 
3  
 
could not prove that the removal of the UAC caused Brandon’s  
injuries, as the injuries were not uncommon for infants born  
at 26 or 27 weeks’ gestation. The judge ruled, over defense  
objection, that a “national” standard of care applies to  
nurses and the other individuals alleged to have been  
negligent.  
The jury found in favor of plaintiffs and awarded  
$2,400,000 in damages. 
Defendant moved for judgment  
notwithstanding the verdict, a new trial, or remittitur.  The  
trial court found that little evidence of causation existed  
and ruled that it would grant a new trial unless plaintiffs  
accepted 
remittitur 
to $475,000.  Plaintiffs appealed, and the  
Court of Appeals ordered the trial court to produce a detailed  
opinion indicating the basis for remittitur.2  On remand, the  
trial court reversed the prior grant of remittitur and granted  
a judgment notwithstanding the verdict in favor of defendant,  
holding that plaintiff had  failed to establish negligence on  
the part of any particular nurse or doctor.  
Again plaintiffs appealed, and the Court of Appeals  
reversed and reinstated the original jury verdict.3  The Court  
held that sufficient circumstantial evidence of negligence  
2Unpublished order, entered December 14, 1994 (Docket No.
179366). 
3Unpublished opinion per curiam, issued November 22, 1996
(Docket No. 184859). 
4  
 
  
existed and that defendant had not preserved its arguments by  
filing a cross-appeal. Defendant then filed a cross-appeal,  
which was dismissed because defendant had not submitted a copy  
of the circuit court order.  The circuit court then vacated  
the order granting judgment notwithstanding the verdict and  
reinstated the jury verdict.  Defendant appealed, and the  
Court of Appeals held, over a dissent, that defendant’s  
appellate issues were not preserved because it had failed to  
file a cross-appeal from the original circuit court order.4  
Defendant appealed to this Court.  We vacated the  
decision 
of 
the 
Court 
of 
Appeals 
and 
remanded 
for  
consideration of defendant’s issues.5  On remand, the Court of  
Appeals again affirmed, over a dissent, in a published  
decision.6
 Defendant filed an application for leave to  
appeal to this Court.  We denied leave to appeal.7  We then  
granted defendant’s motion for reconsideration and granted  
leave to appeal.8  
4Unpublished opinion per curiam, issued April 6, 1999
(Docket No. 205025). 
5462 Mich 859; 613 NW2d 719 (2000). 
6243 Mich App 72; 620 NW2d 859 (2000). 
7464 Mich 877; 630 NW2d 625 (2001). 
8465 Mich 943; 639 NW2d 805 (2002). 
5 
II  
JURY INSTRUCTION  
A  
STANDARD OF REVIEW  
We review claims of instructional error de novo.  Jury  
instructions should include “all the elements of the  
plaintiff’s claims and should not omit material issues,  
defenses, or theories if the evidence supports them.”  Case v  
Consumers Power Co, 463 Mich 1, 6; 615 NW2d 17 (2000).  
Instructional error warrants reversal if the error “resulted  
in such unfair prejudice to the complaining party that the  
failure to vacate the jury verdict would be ‘inconsistent with  
substantial justice.’” Johnson v Corbet, 423 Mich 304, 327;  
377 NW2d 713 (1985); MCR 2.613(A).  
B  
DISCUSSION  
We hold that the trial court improperly modified SJI2d  
30.01 by substituting “hospital neonatal intensive care unit”  
for the specific profession or specialties at issue.  Further,  
we hold that the error requires reversal because failure to do  
so would be inconsistent with substantial justice.  
When 
the 
trial 
judge discussed the jury instructions with  
the parties, he indicated that he would phrase SJI2d 30.01 “in  
[his] own way.”9  The judge stated:  
9Unmodified, SJI2d 30.01 provides: 
6 
 
 
 
 
Well, I’m going to indicate that with respect 
to Defendant’s conduct, the failure to do something 
which a hospital with a neonatal intensive care 
unit would do or would not do. That’s the way I’m 
going to phrase this.  
Defendant 
objected, 
requesting 
that 
the 
instructions 
state 
the  
standard 
of 
care 
“with 
regard 
to 
a 
neonatal 
nurse  
practitioner[10] of ordinary learning or judgment or skill in  
this community or similar one.”  Defense counsel contended  
that the case had focused on Nurse Plamondon and her  
responsibility regarding the UAC and was not as broad as the  
entire unit. The judge overruled defendant’s objection.  
When he instructed the jury, the judge significantly  
When I use the words “professional negligence” 
or “malpractice” with respect to the defendant’s 
conduct, I mean the failure to do something which a 
[name profession] of ordinary learning, judgment or 
skill in [this community or a similar one/ name 
particular specialty] would do, or the doing of 
something which a [name profession] of ordinary 
learning, judgment or skill would not do, under the 
same or similar circumstances you find to exist in 
this case.  
It is for you to decide, based upon the 
evidence, what the ordinary [name profession] of 
ordinary learning, judgment or skill would do or 
not do under the same or similar circumstances.  
10No evidence in the record suggests that Nurse Plamondon
was a “nurse practitioner,” which is a specialized term used
in nursing that refers to a registered nurse who receives
advanced training and is qualified to undertake some of the
duties and responsibilities formerly assumed only by a
physician.  See Merriam-Webster’s Collegiate Dictionary.  The 
only evidence presented at trial indicated that Nurse 
Plamondon was a registered nurse. 
7  
 
modified SJI2d 30.01, stating:  
When I use the words professional negligence  
or malpractice with respect to the Defendant’s 
conduct, I mean the failure to do something which a 
hospital neonatal intensive care unit would do or 
the doing of something which a hospital neonatal 
intensive care unit would not do under the same or  
similar circumstances you find to exist in this 
case.  
It is for you to decide, based upon the 
evidence, what the hospital neonatal intensive care 
unit with the learning, judgment or skill of its 
people would do or would not do under the same or 
similar circumstances.  
In other words, the jury instruction as modified eliminated  
any reference to any particular profession, person, or  
specialty, 
substituting 
instead 
the 
phrase 
“neonatal 
intensive  
care unit.”  The modified jury instruction also failed to  
differentiate 
between 
the 
various 
standards 
of 
care 
applicable  
to different professions and specialties.  
The plaintiff in a medical malpractice action “bears the  
burden of proving: (1) the applicable standard of care, (2)  
breach of that standard by defendant, (3) injury, and (4)  
proximate 
causation 
between the alleged breach and the injury.  
Failure to prove any one of these elements is fatal.”  
Wischmeyer v Schanz, 449 Mich 469, 484; 536 NW2d 760 (1995).  
Crucial to any medical malpractice claim “is whether it is  
alleged that the negligence occurred within the course of a  
professional 
relationship.” 
 
Dorris 
v 
Detroit 
Osteopathic 
Hosp  
Corp, 460 Mich 26, 45; 594 NW2d 455 (1999), citing Bronson v  
8  
  
  
 
Sisters of Mercy Health Corp, 175 Mich App 647, 652; 438 NW2d  
276 (1989).  A hospital may be 1) directly liable for  
malpractice, through claims of negligence in supervision of  
staff physicians as well as selection and retention of medical  
staff, or 2) vicariously liable for the negligence of its  
agents. Id; Theophelis v Lansing Gen Hosp, 430 Mich 473, 478,  
n 3; 424 NW2d 478 (1988) (opinion by GRIFFIN, J.).  Here,  
plaintiffs have not advanced claims of direct negligence on  
the part of defendant hospital.  Therefore, defendant’s  
liability must rest on a theory of vicarious liability.11 Id.  
at 480.  
Vicarious liability is “indirect responsibility imposed  
by operation of law.”  Id. at 483.  As this Court stated in  
1871:  
[T]he master is bound to keep his servants 
within their proper bounds, and is responsible if 
he does not. The law contemplates that their acts  
are his acts, and that he is constructively present  
at them all. [Smith v Webster, 23 Mich 298, 299-300  
(1871) (emphasis added).]  
In other words, the principal “is only liable because the law  
creates a practical identity with his [agents], so that he is  
held to have done what they have done.” Id. at 300. See also  
Ducre v Sparrow-Kroll Lumber Co, 168 Mich 49, 52; 133 NW 938  
11Although plaintiffs’ first amended complaint contains
numerous charges of direct negligence by defendant hospital,
they offered no evidence of direct negligence at trial. 
9  
(1911).  
Applying this analysis, defendant hospital can be held  
vicariously liable for the negligence of its employees and  
agents only.  The “neonatal intensive care unit” is neither an  
employee nor an agent of defendant.  At most, it is an  
organizational subsection of the hospital, a geographic  
location within the hospital where neonates needing intensive  
care are treated.  No evidence in the record suggests that the  
neonatal intensive care unit acts independently or shoulders  
any independent responsibilities.  Therefore, because no  
evidence exists that the neonatal intensive care unit itself  
is capable of any independent actions, including negligence,  
it follows that the unit itself could not be the basis for  
defendant’s vicarious liability.  
The negligence of the agents working in the unit,  
however, could provide a basis for vicarious liability,  
provided plaintiffs met their burden of proving (1) the  
applicable standard of care, (2) breach of that standard, (3)  
injury, 
and 
(4) 
proximate causation between the alleged breach  
and the injury with respect to each agent alleged to have been  
negligent. The phrase “neonatal intensive care unit” is not  
mere shorthand for the individuals in that unit; rather,  
plaintiffs must prove the negligence of at least one agent of  
the hospital to give rise to vicarious liability.  Instructing  
10  
  
 
the jury that it must only find the “unit” negligent relieves  
plaintiffs of their burden of proof.  Such an instruction  
allows the jury to find defendant vicariously liable without  
specifying which employee or agent had caused the injury by  
breaching the applicable standard of care.12  
On this point, we agree with the Court of Appeals  
decision in Tobin v Providence Hosp, 244 Mich App 626; 624  
NW2d 548 (2001).  In Tobin, the trial court refused to modify  
SJI2d 30.01 to require the jury to determine whether each  
individual category of specialist who attended the decedent  
had violated the standard of care applicable to that  
specialty. Instead, the trial court instructed:  
When I use the words "professional negligence" 
or "malpractice" with respect to the defendant's 
conduct, I mean the failure to do something which a  
12Contrary to the dissent’s assertions, our holding does
not increase plaintiffs’ burden or insulate defendants from
liability.  Rather, our holding merely requires plaintiffs to
establish which agent committed the negligence for which the
principal is liable as required by agency principles and
medical malpractice law.  The dissent observes that no 
authority directly addresses the “unit” instruction given
here, but our analysis is well-grounded in undisputed agency
principles.  The dissent acknowledges that a plaintiff must
show that an agent of the hospital committed malpractice but
provides no authority for its conclusion that a “unit” is
considered an agent of a hospital. Further, the dissent cites
no authority for its assertion that plaintiffs who are unable
to establish which professional is negligent are somehow
relieved of the requirement of proving a violation of the
relevant standard of care by the particular agent for whom the
hospital is to be held vicariously liable.  No principle of
law provides that plaintiffs are required to prove every
element of their case unless is it “too difficult” to do so. 
11  
hospital's agents/servants/employees of ordinary 
learning, judgment or skill in this community or a 
similar one would do, or the doing of something 
which a hospital's agents/servants/employees of 
ordinary learning, judgment or skill would not do, 
under the same or similar circumstances you find to 
exist in this case.  
It is for you to decide, based upon the 
evidence, 
what 
the 
ordinary 
hospital's 
agents/servants/employees or [sic, of] ordinary 
learning, judgment or skill would do or would not 
do under the same or similar circumstances. [Id. at  
672.]  
The Court of Appeals found that the refusal to modify was  
error, stating:  
The unmodified standard instruction, under the 
circumstances of this case, was not specific 
enough; it permitted the jury to find that, for 
example, 
the 
nurse 
anesthetist 
violated 
the  
standard of care applicable to a critical care unit 
physician. The standard instruction is sufficient 
to 
inform 
the 
jury 
of 
the 
definitions 
of  
"professional negligence" and "malpractice" in the 
ordinary 
case 
involving 
one 
or 
two 
named  
defendants. However, in this case plaintiff chose 
to bring suit against the hospital and its  
(unnamed) agents, servants, or employees. Thus, it 
was incumbent on the trial court to ensure that the  
jurors 
clearly 
understood 
how 
they 
were 
to  
determine whether any of defendant's employees 
committed professional negligence or malpractice 
under 
the 
particular 
standard 
of 
practice 
applicable to their specialty. The unmodified  
standard instruction did not fulfill that function.  
[Id. at 673.]  
Similarly, in this case, plaintiffs did not name any  
specific agents of the hospital in their lawsuit at the time  
12  
 
 
of trial.13  Dr. Carolyn S. Crawford, an expert witness for  
plaintiffs, criticized the care of several agents of  
defendant, 
including 
a 
neonatologist, 
a 
respiratory 
therapist,  
a resident, and Nurse Plamondon.14  The trial court’s “unit”  
instruction did not specify the agents involved, nor did it  
ensure that the jurors understood the applicable standards of  
care.  The respiratory therapist, for example, may not be held  
to the standard of care of the neonatologist. The “unit”  
instruction failed to ensure that the jury clearly understood  
1) which agents were involved, and 2) that it could find  
professional negligence or malpractice only on the basis of  
the particular standard of care applicable to each employee’s  
profession or specialty.15  
13Originally, the suit named Dr. Moreno, but the parties
stipulated to his dismissal before trial. 
14Justice Markman correctly observes that much of the
evidence at trial focused on Nurse Plamondon, but plaintiffs
presented evidence that other individuals were negligent as
well. In fact, the trial court ruled that the “unit” 
instruction was proper because plaintiffs’ case included
evidence that individuals other than Nurse Plamondon were 
negligent.  Further, plaintiffs did not argue at trial that
the res ipsa loquitur doctrine applied. Because evidence of 
negligence on the part of several individuals was presented,
we cannot ascertain which individual the jury found to have
been negligent.  For this reason, the error was not harmless. 
15Plaintiffs did not present evidence regarding every
member 
of 
defendant’s 
NICU; 
therefore, 
the 
dissent’s 
assertions that every member of the NICU is a specialist and
had a provider-patient relationship with Brandon are pure
speculation. 
13  
We hold that, in order to find a hospital liable on a  
vicarious liability theory, the jury must be instructed  
regarding the specific agents against whom negligence is  
alleged and the standard of care applicable to each agent.  As  
stated above, a hospital’s vicarious liability arises because  
the hospital is held to have done what its agents have done.  
Here, the general “unit” instruction failed to specify which  
agents were involved or differentiate between the varying  
standards of care applicable to those agents.  The instruction  
effectively relieved plaintiffs of their burden of proof and  
was not specific enough to allow the jury to “decide the case  
intelligently, fairly, and impartially.”  Johnson, supra at  
327. Under these circumstances, failure to reverse would be  
inconsistent with substantial justice.  
III  
STANDARD OF CARE  
Although we have already held that the erroneous “unit”  
instruction requires reversal, we will also address the  
applicable standard of care for nurses to provide guidance on  
remand.  
A  
STANDARD OF REVIEW  
This issue requires an interpretation of MCL 600.2912a.  
Questions of statutory interpretation are reviewed de novo.  
Oade v Jackson Nat’l Life Ins Co, 465 Mich 244, 250; 632 NW2d  
14  
 
126 (2001).16  
B  
DISCUSSION  
In 1977, the Legislature enacted MCL 600.2912a, setting  
forth the standards of care for general practitioners and  
specialists. At the time of trial, MCL 600.2912a provided:  
In 
an 
action 
alleging 
malpractice 
the  
plaintiff shall have the burden of proving that in 
light of the state of the art existing at the time 
of the alleged malpractice:  
(a) The defendant, if a general practitioner, 
failed to provide the plaintiff the recognized 
standard of acceptable professional practice in the 
community in which the defendant practices or in a 
similar community, and that as a proximate result 
of the defendant failing to provide that standard, 
the plaintiff suffered an injury.  
(b) The defendant, if a specialist, failed to 
provide the recognized standard of care within that 
specialty as reasonably applied in light of the 
facilities available in the community or other 
facilities 
reasonably 
available 
under 
the  
circumstances, and as a proximate result of the 
defendant 
failing 
to 
provide 
that 
standard,  
16Further, we note that the applicable legal duty in a
negligence or malpractice action is a matter of law. Moning 
v Alfono, 400 Mich 425, 438; 254 NW2d 759 (1977). The Court 
of Appeals erred in holding that the standard of care was an
evidentiary matter reviewed for an abuse of discretion.  Once 
the correct standard of care is determined as a matter of law,
an appellate court reviews for an abuse of discretion a trial
court’s rulings regarding the qualifications of proposed
expert witnesses to testify regarding the specifics of the
standard of care and whether the standard has been breached. 
Bahr v Harper-Grace Hospitals, 448 Mich 135, 141; 528 NW2d 170
(1995). 
15  
plaintiff suffered an injury.[17]  
The trial court held that a “general” standard of care  
applied to Nurse Plamondon, ruling that because Nurse  
Plamondon was not a party, the “local standard” could not  
apply. The court stated:  
[I] still don’t consider that you look solely 
at the standard of care of the nurse, you look at 
the hospital’s standard of care which I consider a 
general standard.  
* * *  
[T]he standard of care of the hospital is 
always going to be an issue when the hospital is 
not a solely owned hospital owned by one doctor or 
by one person, and so it’s a general standard.  
Defendant objected, arguing that nurses were not specialists  
and that a local standard of care applied.  On remand, the  
Court of Appeals affirmed the trial court’s ruling, holding  
incorrectly that the issue was an evidentiary matter reviewed  
17The statutory standards of care set forth in MCL
600.2912a are often referred to as the “general” or “local”
standard of care for general practitioners and the “national”
standard of care for specialists. See, e.g., Bahr, supra at
138. The term “national,” however, is not an accurate 
description 
of 
the 
statutory standard of care for specialists. 
The plain language of subsection (b) states that the standard 
of care is that “within that specialty as reasonably applied 
in light of the facilities available in the community or other 
facilities 
reasonably 
available 
under 
the 
circumstances.” MCL  
600.2912a (emphasis added). Under the plain language of the 
statute, then, the standard of care for both general 
practitioners and specialists refers to the community.  
16  
 
 
 
 
for an abuse of discretion.18  
The question, then, is whether nurses are held to the  
standard of care of a general practitioner or a specialist  
under MCL 600.2912a.  We conclude that neither statutory  
standard applies.  MCL 600.2912a, by its plain language, does  
not apply to nurses.  The statute does not define “general  
practitioner” or “specialist.” When faced with questions of  
statutory interpretation, our obligation is to discern and  
give effect to the Legislature’s intent as expressed in the  
statutory language. DiBenedetto v West Shore Hosp, 461 Mich  
394, 402; 605 NW2d 300 (2000); Massey v Mandell, 462 Mich 375,  
18We note that before reaching the issue, the Court of
Appeals held that defendant had forfeited the issue by not
objecting until trial, relying on Greathouse v Rhodes, 242
Mich App 221; 618 NW2d 106 (2000).  This Court has since 
overruled Greathouse, 465 Mich 885; 636 NW2d 138 (2001),
holding that “[t]here is no statutory or case law basis for
ruling that a medical malpractice expert must be challenged
within a ‘reasonable time.’” 
Further, the Court of Appeals on remand again chastised 
defendant for failing to bring a cross-appeal, stating:  
Accordingly, even if we were to conclude that 
defendant’s issues on appeal provided grounds for 
relief, we would sua sponte apply the unclean hands 
maxim to allow the trial judgment to stand. [243 
Mich App 93.]  
As the dissenting Court of Appeals judge noted, we stated in 
our remand order, 462 Mich 859, that defendant has “properly 
and persistently raised” the issues in its appeal. 243 Mich  
App 94.  There is no merit to the Court of Appeals contention 
that defendant has “unclean hands” for failing to file a 
cross-appeal.  
17  
379-380; 614 NW2d 70 (2000). Undefined statutory terms must be  
given their plain and ordinary meanings.  Donajkowski v Alpena  
Power Co, 460 Mich 243, 248-249; 596 NW2d 574 (1999).  When  
confronted with undefined terms, it is proper to consult  
dictionary definitions. Id.  
Random House Webster’s College Dictionary (1997) defines  
“general practitioner” as “a medical practitioner whose  
practice is not limited to any specific branch of medicine.”  
“Specialist” is defined as “a medical practitioner who deals  
only with a particular class of diseases, conditions,  
patients, etc.”  “Practitioner” is defined as “a person  
engaged in the practice of a profession or occupation.”  
Therefore, for either subsection of MCL 600.2912a to apply, a  
person must be a “medical practitioner,” or engaged in the  
practice of medicine.  
Nurses do not engage in the practice of medicine.  MCL  
600.5838a(1) provides that a medical malpractice claim may be  
brought against any “licensed health care professional.”  MCL  
600.5838a(1)(b) 
defined 
“licensed 
health 
care 
professional” 
as  
“an individual licensed or registered under article 15 of the  
public health code . . . .”  Turning to the Public Health  
Code, MCL 333.17201(1)(c) defines “registered professional  
nurse” as  
an individual licensed under this article to engage 
in the practice of nursing which scope of practice  
18  
includes the teaching, direction, and supervision 
of less skilled personnel in the performance of 
delegated nursing activities.  
MCL 333.17201(1)(a) defines “practice of nursing” as  
the 
systematic 
application 
of 
substantial  
specialized knowledge and skill, derived from the 
biological, physical, and behavioral sciences, to 
the care, treatment, counsel, and health teaching 
of individuals who are experiencing changes in the 
normal health processes or who require assistance 
in the maintenance of health and the prevention or 
management of illness, injury, or disability.  
In contrast, MCL 333.17001(1)(c) defines “physician” as  
“an individual licensed under this article to engage in the  
practice of medicine.” “Practice of medicine” is defined in  
MCL 333.17001(1)(d) as  
the diagnosis, treatment, prevention, cure, or 
relieving of a human disease, ailment, defect, 
complaint, or other physical or mental condition, 
by attendance, advice, device, diagnostic test, or 
other means, or offering, undertaking, attempting 
to do, or holding oneself out as able to do, any of 
these acts.  
As the above definitions demonstrate, nurses do not  
engage in the practice of medicine. Therefore, by its plain  
terms, neither subsection of MCL 600.2912a applies to nurses.  
To determine the applicable standard of care for nurses, we  
must turn to the common law.  
Malpractice 
actions 
against 
nurses 
were 
not 
recognized 
at  
common law.  Adkins v Annapolis Hosp, 420 Mich 87, 94; 360  
NW2d 150 (1984); Kambas v St Joseph’s Mercy Hosp, 389 Mich  
249, 253; 205 NW2d 431 (1973). The Legislature has, however,  
19  
 
 
made malpractice actions available against nurses by statute.  
MCL 
600.5838a. 
 
Although the Legislature created a malpractice  
cause of action against nurses, it did not enact an applicable  
standard of care.  Therefore, we review the rules of the  
common law applicable to actions for medical malpractice for  
the standard of care.19  
A survey of our case law reveals that the standard of  
care at common law was the degree of skill and care ordinarily  
possessed and exercised by practitioners of the profession in  
similar localities.
 In 1896, this Court rejected a  
formulation of the standard of care that limited the scope to  
the individual’s neighborhood, holding instead that the  
standard of care would be the ordinary skill in the  
individual’s locality or similar localities. Pelky v Palmer,  
109 Mich 561, 563; 67 NW 561 (1896).  In 1915, this Court  
pronounced that “all the law demands is that [the defendant]  
bring and apply to the case in hand that degree of skill,  
19The dissent characterizes our analysis as “outcome­
determined.”
 On the contrary, we have endeavored to 
faithfully apply statutory rules of construction and the 
common law. 
Interestingly, the dissent itself cites no
authority whatsoever for its novel legal proposition that a
national standard of care applies to a “unit” of defendant’s
hospital.  No statutory or common-law basis for the dissent’s
assertion exists. The Legislature has prescribed the standard
of care for general practitioners and specialists, not for
“units.” The common law does not address the application of
a “national” standard of care for hospital “units.”  
The 
dissent appears to have created its preferred legal scheme out
of whole cloth. 
20  
 
care, knowledge, and attention ordinarily possessed and  
exercised by practitioners of the medical profession under  
like circumstances (Pelky, [supra]; Miller v Toles, 183 Mich  
252 [150 NW 118 (1914)]).”  Zoterell v Repp, 187 Mich 319,  
330; 153 NW 692 (1915).  In Ballance v Dunnington, 241 Mich  
383, 386-387; 217 NW 329 (1928), we held that the standard of  
care of an x-ray operator was set “by the care, skill, and  
diligence ordinarily possessed and exercised by others in the  
same line of practice and work in similar localities.”  See  
also Rubenstein v Purcell, 276 Mich 433, 437; 267 NW 646  
(1936).  In Rytkonen v Lojacono, 269 Mich 270, 274; 257 NW 703  
(1934), we held:  
The rule is firmly established that defendant 
was bound to use the degree of diligence and skill 
which is ordinarily possessed by the average 
members of the profession in similar localities.  
We 
conclude 
that this common-law standard of care applies  
to malpractice actions against nurses. 
Therefore, the  
applicable standard of care is the skill and care ordinarily  
possessed and exercised by practitioners of the profession in  
the same or similar localities.  The trial court on remand  
shall instruct the jury regarding this standard.  
IV  
CONCLUSION  
We conclude that to find a hospital liable on a vicarious  
liability theory, the jury must be instructed regarding the  
21  
 
 
specific agents against whom negligence is alleged and the  
standard of care applicable to each agent.  An instruction  
merely naming a unit of the hospital, without more, relieves  
plaintiffs of their burden of proof and does not comport with  
substantial justice.  Further, we hold that MCL 600.2912a, by  
its plain language, does not apply to nurses.  Instead, nurses  
are held to the common-law standard of care, i.e., the skill  
and care ordinarily possessed and exercised by practitioners  
of the same profession in the same or similar  communities.  
Accordingly, we reverse the judgment of the Court of Appeals  
and remand to the trial court for a new trial.  
WEAVER, 
TAYLOR, and YOUNG, 
JJ., concurred with CORRIGAN, C.J.  
22  
 
 
____________________________________ 
S T A T E 
O F 
M I C H I G A N  
SUPREME COURT  
TERESA COX, as a Next Friend of 
BRANDON COX, a minor, TERESA COX 
and CAREY COX, Individually,  
Plaintiffs-Appellees,  
v 
No. 118110  
BOARD OF HOSPITAL MANAGERS FOR  
THE CITY OF FLINT doing business as HURLEY 
MEDICAL CENTER, a Municipal 
Corporation,  
Defendant-Appellant.  
MARKMAN, J. (concurring in part and dissenting in part).  
I respectfully concur in part and dissent in part.  I  
fully concur with the majority’s legal determination that the  
trial court improperly modified SJI2d 30.01 by substituting  
“hospital neonatal intensive care unit” for the specific  
profession or specialties at issue. However, I dissent from  
the majority’s conclusion that this error requires reversal.  
Instead, I believe that the instruction, albeit flawed,  
adequately and fairly communicated the parties’ theories of  
liability so that failure to reverse would not be inconsistent  
with substantial justice.  
I 
also 
fully 
concur 
with 
the 
majority’s 
legal  
determination that MCL 600.2912a does not apply to nurses.  
 
  
 
Instead, as the majority correctly observes, nurses are held  
to the common-law standard of care, i.e., the skill and care  
ordinarily possessed and exercised by practitioners of the  
same profession in the same or similar localities. However,  
as with the instructional error issue, I do not believe that  
this error requires reversal.  Instead, because, under the  
facts of this case, the common-law standard of care and the  
“national” standard of care were the same, failure to reverse  
would not be inconsistent with substantial justice.  
Although, 
under 
different 
circumstances, 
these  
instructional errors might have been sufficient to warrant  
reversal, under the particular circumstances of this case, I  
do not believe that they can be so viewed.  
I. JURY INSTRUCTION  
A. STANDARD OF REVIEW  
This case concerns the trial court’s deviation from the  
standard instruction language set forth in SJI2d 30.01.  This  
Court reviews claims involving instructional errors by a de  
novo standard.  Case v Consumers Power Co, 463 Mich 1, 6; 615  
NW2d 17 (2000).  
In doing so, we examine the jury instructions 
as a whole to determine whether there is error  
requiring reversal. 
The instructions should  
include all the elements of the plaintiff’s claims 
and should not omit material issues, defenses, or 
theories 
if 
the 
evidence 
supports 
them.  
Instructions must not be extracted piecemeal to 
establish error. 
Even if somewhat imperfect, 
instructions do not create error requiring reversal 
if, on balance, the theories of the parties and the  
2  
applicable law are adequately and fairly presented 
to the jury. . . . We will only reverse for 
instructional error where failure to do so would be  
inconsistent 
with 
substantial 
justice. 
[Id.  
(citation omitted); see also MCR 2.613(A).]  
B. DISCUSSION  
The standard jury instruction at issue reads as follows:  
When I use the words “professional negligence” 
or “malpractice” with respect to the Defendant’s 
conduct, I mean the failure to do something which a 
________ (name profession) of ordinary learning, 
judgment or skill in [this community or a similar/ 
________ (name particular specialty)] would do, or 
the doing of something which a ________ (name 
profession) of ordinary learning, judgment or skill 
would 
not 
do, 
under 
the 
same 
or 
similar  
circumstances you find to exist in this case.  
[SJI2d 30.01]  
At trial, the court modified this standard instruction, and  
instead read the following instruction to the jury:  
When I use the words professional negligence  
or malpractice with respect to the Defendant’s 
conduct, I mean the failure to do something which a 
hospital neonatal intensive care unit would do or 
the doing of something which a hospital neonatal 
intensive care unit would not do under the same or  
similar circumstances you find to exist in this 
case.  
It is for you to decide, based upon the 
evidence, what the hospital neonatal intensive care 
unit with the learning, judgment or skill of its 
people would do or would not do under the same or 
similar circumstances.  
Comparing 
the 
standard 
instruction 
with 
the 
modified  
instruction, it is clear that the trial court: (1)  
substituted, in the first paragraph, “a hospital neonatal  
intensive care unit” in place of a “name[d] profession”; (2)  
omitted, in the first paragraph, the phrase “ordinary  
3  
  
  
 
  
 
  
learning, judgment or skill”; and (3) omitted, in the second  
paragraph, the word “ordinary” appearing before and modifying  
the clause “learning, judgment or skill.”1
 Defendant  
maintains that these modifications amounted to a “gross  
deviation” from the standard instruction, thus depriving  
defendant of a fair trial.  
Upon review of the first modification, i.e., the “unit”  
instruction, the majority finds that it was error requiring  
reversal for the trial court to insert “unit” in place of the  
specific profession or speciality at issue.2 
In support of  
its conclusion, the majority emphasizes that plaintiffs  
focused upon several members of the unit including a  
neonatologist, a respiratory therapist, a resident, and Nurse  
Plamondon–individuals who were subject to differing standards  
of care.3  Because of these differing standards:  
1 The dissenting justice states that “[c]onsideration of the [third omission] is 
inappropriate because defendant forfeited it.”  Slip op, p 8, n 6.  I respectfully disagree. 
Defendant, in its application for leave to appeal, asserted that the trial court’s “gross 
deviation from SJI2d 30.01 . . . deprived defendant of a fair trial.”  This “gross 
deviation” included, among other things, the omission of the word “ordinary” from the 
standard jury instruction.  In my view, analysis of this omission is a necessary part of 
an overall determination whether defendant here was truly deprived of a fair trial. 
2 Because the majority determined that the first modification amounted to error 
requiring reversal, it did not address the remaining two standard jury instruction 
modifications. 
3 
Specifically, the majority states, correctly in my judgment, that “[t]he 
respiratory therapist, for example, may not be held to the standard of care of the 
neonatologist.” Slip op at 13. 
4 
 
 
  
The “unit” instruction failed to ensure that  
the jury clearly understood 1) which agents were 
involved, and 2) that it could find professional 
negligence or malpractice only on the basis of the 
particular standard of care applicable to each 
employee’s profession or specialty. [Slip op at 
13.]  
Thus, the majority finds that the jury was undermined in its  
task of determining whether any of defendant’s agents  
individually fell below the appropriate standard of care and  
that, under these circumstances, substantial justice requires  
reversal. Id. at 14. I respectfully disagree. Although I am  
certainly not oblivious to the potential that the modified  
instruction had for confusing the jury, upon review of the  
whole record, I simply do not believe that this is what  
occurred here.  I do not believe that such potential for  
confusion reflects the reality of what transpired at this  
trial.  Rather, I believe that the jury clearly understood  
that the allegations of negligence were principally focused  
upon Nurse Plamondon, and that they understood Nurse  
Plamondon’s specific standard of care.  
In 
reviewing 
the particular instruction at issue, it must  
be emphasized that this instruction further clarified the  
“unit” reference by focusing on the “learning, judgment or  
skill of its people.”  When the trial court directed that the  
jury must examine the “learning, judgment or skill” of  
individual representatives of the defendant, the jury, based  
5  
  
upon the presentation of this case, almost certainly focused  
on the alleged negligence of a single person, Nurse Plamondon. 
    First, during opening arguments, plaintiff specifically  
and almost exclusively focused upon Nurse Plamondon’s alleged  
negligence in: (1) allowing the umbilical arterial catheter  
(UAC) to become dislodged from infant Brandon Cox,4 (2)  
failing to summon, in a timely manner, the assistance of an  
attending physician, and (3) medicating the infant without  
proper authorization from a physician.  
On the 10th at approximately four o’clock, a 
nurse, Nurse Plamondon, Martha Plamondon, attended 
to Brandon at four o’clock and she made a nursing 
note.
 She drew fluid out of this umbilical  
arterial catheter . . . and did other things to 
attend to the baby, and then she left.  
At 4:20 Brandon was found with the umbilical  
arterial catheter dislodged and he had lost . . . 
fifty-five to sixty percent of [his] blood.  And  
Plamondon noticed this at 4:20.  It happened some 
time between 4:00 and 4:20 that the catheter came  
out.  And that is just simply not supposed to 
happen under ordinary circumstances . . . . That 
only happens when somebody was inattentive.  
* * *  
So Plamondon arrives and does she call a  
physician right away, does a physician respond 
right away? No. She arrives at 4:20. It’s noted  
that this has happened to Brandon and nothing is 
done for him other than maybe some first aid to the 
umbilicus for fifteen minutes. . . .  
4 As explained in the majority opinion, Brandon Cox was born on February 8, 
1990 at 26 or 27 weeks gestation, weighing approximately 900 grams, and was admitted 
into defendant’s neonatal intensive care unit (NICU). 
6 
 
* * *  
Finally, he’s given Plasminate, which is a 
fluid replacement. It’ll bring blood pressure up, 
but it doesn’t really contribute to oxygenation.  
Consistently 
with 
opening 
arguments, 
plaintiffs’  
substantive evidence primarily focused on the alleged  
negligence of Nurse Plamondon.  Dr. Houchang Modanlou, an  
expert witness for plaintiff, testified that, upon review of  
Brandon’s 
chart, 
he 
had 
discovered 
essentially 
three  
“criticisms” concerning the care that Brandon received at  
defendant’s 
facility. 
Dr. 
Modanlou 
criticized 
Nurse  
Plamondon’s maintenance of the UAC, Nurse Plamondon’s delay  
in responding to the dislodgment of the UAC, and Nurse  
Plamondon’s decisions concerning appropriate emergency care.  
Dr. Modanlou’s testimony essentially excluded any other  
potential tortfeasors.  In particular, he stated that “from  
birth to the accident I did not have major criticism,” and  
affirmed that there was “no [significant] criticism of any of  
the care rendered to Brandon Cox until the 4:00 to 4:20 p.m.  
time period on February the 10th.”  
Dr. Carolyn S. Crawford, another expert witness for  
plaintiffs, also focused her testimony almost exclusively on  
Nurse Plamondon.  In part, she affirmed that “it [was]  
incumbent 
upon 
the 
reasonably 
prudent 
nurse 
after  
repositioning a baby to ascertain for certain that that  
7  
 
catheter’s in place and that the securing devices are still  
secure.”  With regard to the response pursuant to discovering  
the dislodged catheter, Dr. Crawford stated there was a breach  
in the standard of care “in not notifying the resident  
immediately, and in not calling for help . . . [i]t appeared  
that the nurse tried to handle the situation on her own for  
about fifteen minutes before she called for a doctor.”  
Plaintiff also labored to submit evidence discrediting  
Nurse Plamondon’s version of the events surrounding the  
dislodged catheter.  With regard to the administration of  
medication, Dr. Roberto Villegas, Jr., testified that, had he  
given Nurse Plamondon a medical order to administer  
Plasmanate, such an order would have been entered into  
Brandon’s medical record either by himself or the nurse.  
Further, he testified that he would not have ordered a full  
20cc of Plasmanate to be administered to Brandon, but instead  
would have ordered two separate 10cc dosages. Clearly, Dr.  
Villegas was called to testify solely for the purpose of  
proving that Nurse Plamondon had not received any medical  
orders 
for 
the 
administration of Plasmanate from Dr. Villegas,  
but instead administered it without proper authorization.  
Similarly, Richard Scott, a respiratory therapist, was called  
by plaintiffs to discredit Nurse Plamondon’s assertion that  
she immediately called for a physician or resident upon  
8  
  
 
discovering the dislodged UAC, as well as to emphasize that  
Brandon was inactive and, therefore, would have been unable to  
dislodge the UAC connection as defendant speculated.  
Indeed, defendant also made clear that the crux of this  
case focused upon Nurse Plamondon.  At opening argument,  
defendant stated that “their expert is pointing to a nurse,  
Nurse Martha Plamondon, who happened to be on that shift when  
this was discovered.”  Defendant’s subsequent proofs, not  
surprisingly as a result, sought principally to refute any  
negligence on the part of Nurse Plamondon.5  Further, on  
appeal to this Court, defendant in its brief recognized that  
the alleged negligent conduct was focused upon Nurse  
Plamondon—“[a]t the outset it must be clearly understood that  
plaintiffs’ 
experts’ 
testimony 
was 
restricted 
to 
criticisms 
of  
the hospital’s nurses, particularly Nurse Plamondon . . . .”  
On these bases, it seems reasonably clear, in my judgment,  
that virtually the entire thrust of this case focused on the  
negligence, or lack thereof, of one particular individual,  
Nurse Plamondon.  
Obviously, this conclusion is at odds with the  
majority’s, and Justice Kelly’s, positions that this case  
essentially involved the negligence of several agents.  While  
5 Defendant also sought to negate the causation element as part of its case in 
chief. 
9 
 
plaintiff, during closing argument, may have expressed  
concerns 
about 
individuals other 
than 
Nurse 
Plamondon, 
namely,  
Respiratory Therapist Richard Scott and Nurse Edith Krupp,  
reviewing the record in its entirety indicates to me that any  
potential negligent conduct on the part of these actors was an  
incidental inquiry here.  Indeed, the primary purpose of even  
eliciting testimony from these individuals was essentially to  
support or negate the theories of negligence concerning Nurse  
Plamondon.  For example, Scott’s testimony focused on his  
observations concerning movements on the part of Brandon  
before the dislodgment of the UAC, as well as Nurse  
Plamondon’s conduct after discovering the dislodged UAC.  
Plaintiffs primarily elicited this testimony in an effort to  
dispel defendant’s theory that Brandon pulled the UAC out with  
his hands or feet as well as discredit Nurse Plamondon’s  
testimony that she had immediately called out to Dr. Villegas  
upon discovering the dislodged UAC.  Further, the substance of  
Ms. 
Krupp’s 
testimony essentially focused 
on 
Brandon’s 
medical  
condition before the dislodgment of the UAC.
 Thus, this  
testimony essentially was relevant to negating or supporting  
the causation element.  Nurse Krupp also testified about an  
adjustment that she had made to the UAC the day before the  
incident involving Nurse Plamondon.  However, because of its  
fleeting appearance in the record, I do not believe that it  
10  
 
  
 
materially altered the posture of this case, i.e., that the  
focus was on Nurse Plamondon.6  
Because the record indicates that the gravamen of this  
dispute related to Nurse Plamondon, as opposed to other  
potential tortfeasors, I believe that the jury, when told to  
consider the “learning, judgment or skill” of defendant’s  
representatives, principally focused on whether, one person,  
Nurse Plamondon, committed malpractice when she (1) “allowed”  
the UAC to come out of Brandon’s umbilicus, (2) delayed in  
summoning the assistance of a physician, and (3) performed  
medical procedures without appropriate authorization. Thus,  
I believe that the instruction “adequately” and “fairly”  
communicated the theories of this case as presented by the  
parties to the jury, and that failure to reverse would not be  
inconsistent with substantial justice.  
With regard to the second and third modifications of the  
standard instruction—the court’s deletion of the phrase “of  
ordinary learning, judgement or skill” in the first paragraph  
and its deletion of the word “ordinary” before the qualifying  
phrase in the second paragraph, these modifications also, I  
believe, constituted instructional error.  
SJI2d 30.01 provides that an alleged tortfeasor must fail  
6 Nor, of course, would Nurse Krupp be subject to any different standard of care 
for purposes of jury consideration than Nurse Plamondon. 
11 
 
to do something that is normally required by such an  
individual “of ordinary learning, judgment or skill,” or else  
must do something which an individual “of ordinary learning,  
judgment or skill” would not do under the same or similar  
circumstances.  As Judge Griffin in dissent asserted, these  
phrases are contained within the standard jury instruction  
because 
this 
“ordinary” 
care 
standard 
constitutes 
a 
limitation  
upon a defendant’s duty.  For example, in the context of legal  
malpractice, this Court has stated:  
[A]ccording to SJI2d 30.01, all attorneys have 
a duty to behave as would an attorney “of ordinary 
learning, judgment, or skill . . . under the same or 
similar circumstances . . . .”  
[A]n attorney does not have a duty to insure or 
guarantee the most favorable outcome possible.  An  
attorney is never bound to exercise extraordinary 
diligence, or act beyond the knowledge, skill, and 
ability 
ordinarily possessed by 
members 
of 
the 
legal 
profession. [Simko v Blake, 448 Mich 648, 656; 532 
NW2d 842 (1995)]  
As indicated in Simko, the limitation on one’s standard of  
care is significant because it alerts the jury to the fact  
that a professional defendant need not conform his conduct to  
what is at a level above that of other members of his  
profession.  Instead, he needs only to conduct himself in way  
that is consistent with others in his profession.  For this  
reason, the trial court indeed erred when it deleted the  
phrase “of ordinary learning, judgement or skill” in the first  
paragraph of the instructions as well as when it deleted the  
12  
 
 
  
word “ordinary” before the qualifying phrase in the second  
paragraph.  However, as with the first instructional error, I  
am of the opinion that these errors were harmless, under the  
particular circumstances of this case.  
In reviewing the second modification, it is important to  
emphasize that a substantial portion of this clause did appear  
in the second paragraph.  In part, the second paragraph of the  
instruction stated that the jury must decide what a neonatal  
unit, “with the learning, judgment or skill of its people  
would do under the same or similar circumstances.”  Although  
this qualifying phrase was not stated twice within the  
instruction, as it should have been, the essential concept  
that a comparison must be had with others who are comparably  
situated was reasonably communicated to the jury.  
Further, a review of the record shows that both parties,  
in presenting their theories of the case, clearly communicated  
that Nurse Plamondon need not conduct herself in a way that  
exceeded the standards of other members of her profession.  
Instead, the parties exclusively focused on the conduct  
normally, 
or 
ordinarily, 
exhibited by other 
reasonably 
prudent  
nurses.  Thus, the jury well understood that Nurse Plamondon’s  
conduct need only be within the range of conduct exhibited by  
other members of her profession.  
In sum, while the instruction in this case was clearly in  
13  
 
error, I am not convinced that the correct instruction, one  
devoid of these errors, would have resulted in any different  
verdict.  Thus, in my view, failure to reverse would not be  
inconsistent with substantial justice.  
II. STANDARD OF CARE  
Finally, while I agree with the majority’s legal  
conclusion that nurses are held to the common-law standard of  
care, i.e., the skill and care ordinarily possessed and  
exercised by practitioners of the same profession in the same  
or similar localities, I believe that the trial court’s  
decision to permit testimony asserting a “national” standard  
of care was harmless under the circumstances of this case.  An  
error in a trial court’s ruling is “not ground for granting a  
new trial, for setting aside a verdict, or for vacating,  
modifying, or otherwise disturbing a judgment or order, unless  
refusal to take this action appears to the court inconsistent  
with substantial justice.” MCR 2.613(A).  
A review of the testimony shows that Nurse Plamondon had  
the duty to: (1) maintain and monitor the UAC, (2) summon a  
physician or resident in a timely fashion upon discovering the  
dislodgment of the UAC, and (3) provide medicinal treatment  
only under the direction of a physician or resident. These  
duties were apparently the same under either a “national”  
standard of care or a “common-law” standard of care.  Further,  
14  
 
 
 
and equally importantly, the applicable standards of care in  
this case were simply not in dispute here.  Instead, the  
parties only disputed whether Nurse Plamondon had breached the  
aforementioned 
duties 
and whether any 
resulting 
negligence 
was  
the cause of Brandon’s injuries.  Thus, because the duties of  
this nurse were apparently the same under either standard of  
care, and because the standards of care were not in dispute at  
trial, I believe that failure to grant a new trial or set  
aside the verdict would not be inconsistent with substantial  
justice.  
CONCLUSION  
In conclusion, I believe that the trial court erred in  
its instructions to the jury.  Specifically, I agree with the  
majority that the trial court improperly substituted the  
“unit” for the specific profession or specialities at issue.  
In addition, I believe that the trial court improperly deleted  
“ordinary learning, judgment or skill” from the first  
paragraph of SJI2d 30.01, and improperly deleted “ordinary,”  
from its second paragraph.  In a different circumstance, it is  
quite easy to imagine that such errors would require reversal.  
Indeed, it is not inconceivable that such instructions might  
have confused the jury in this case.  However, upon review of  
the whole record, I am convinced that the instructions  
“adequately” and “fairly” communicated the parties’ theories  
15  
so that failure to reverse would not be inconsistent with  
substantial justice.  The reality of this case is that the  
jury was presented with the alleged negligence of one person,  
Nurse Plamondon, and nothing in the jury instructions could  
reasonably have shifted this focus for the jury.  
For these reasons, I would affirm the Court of Appeals  
decision.  
16  
___________________________________ 
v 
S T A T E O F M I C H I G A N  
SUPREME COURT  
TERESA COX, as next friend of 
BRANDON COX, a minor, TERESA COX 
and CAREY COX, individually,  
Plaintiffs-Appellees,  
No. 118110  
BOARD OF HOSPITAL MANAGERS FOR THE  
CITY OF FLINT, doing business as 
HURLEY MEDICAL CENTER, a municipal 
corporation,  
Defendant-Appellant.  
KELLY, J. (dissenting).  
I disagree with the majority's conclusions (1) that a  
medical 
malpractice 
plaintiff 
must 
always 
allege 
the  
negligence of a specific individual in an action for vicarious  
liability and that jury instructions must reflect such  
allegations, and (2) that nurses are not subject to the  
standard 
of 
care 
for 
medical malpractice defendants as defined  
by the Legislature in MCL 600.2912a.  I would hold that, in  
such cases, vicarious liability can be premised on proof that  
 
an unidentified member or members of a discrete unit in a  
hospital were professionally negligent.  
I would hold also that the trial court did not err when  
it applied a national standard of care to this case.  
Moreover, nurses practicing advanced care that requires  
special training are specialists within the meaning of MCL  
600.2912a and therefore are subject to a national standard of  
care. Thus, I would affirm the Court of Appeals decision to  
uphold the jury verdict.  
I. Factual and Procedural History  
Plaintiffs' son Brandon was born at defendant Hurley  
Medical 
Center 
extremely 
premature 
and 
underweight.  
Immediately after birth, Brandon was placed in level three  
neonatal intensive care.  That neonatal intensive care unit  
(NICU) is reserved for the most seriously ill newborn  
patients.
 In the NICU, a doctor inserted an umbilical  
arterial catheter (UAC) into Brandon's abdomen to monitor his  
blood gas levels.  The UAC was secured to Brandon with tape  
and sutures. Later, the UAC was adjusted by the NICU nurses  
and retaped.  
Two days after Brandon's birth, Nurse Martha Plamondon  
drew blood from the UAC to test Brandon's blood gases and  
repositioned the baby.  Twenty minutes later, at 4:20 p.m., a  
respiratory therapist discovered that Brandon was bleeding.  
2  
 
Brandon's UAC had become dislodged and he was suffering the  
effects of blood loss.  He had lost approximately 40cc of  
blood, or about half of his total blood volume. By at least  
one account, Brandon had likely been bleeding the entire  
twenty minutes. However, no alarm had sounded.  
The events that followed are in dispute.  Nurse Plamondon  
testified that she applied pressure to stop the bleeding and  
administered a 20cc push of Plasmanate at the order of Dr.  
Robert Villegas. Dr. Villegas did not recall giving such an  
order.  Although the hospital's procedures require that the  
physician who orders treatment be noted on a patient's chart,  
no doctor's name appears on Brandon's chart authorizing the  
20cc push of Plasmanate.  The 20cc push is recorded at 4:40  
p.m., twenty minutes after Brandon was discovered bleeding.  
Dr. Villegas testified that he would have ordered two separate  
pushes of 10cc of Plasmanate had he done anything at all.  
A resident doctor, Dr. Amy Sheeder, arrived in answer to  
a page from Nurse Plamondon.  Dr. Sheeder ordered another push  
of 10cc of Plasmanate, as well as 20cc of packed blood cells.  
Brandon was also given additional oxygen through an increase  
in his respirator rate and "bagging." The following day, he  
was transferred to Children's Hospital, where an ultrasound  
revealed that he had suffered intercranial bleeding, and he  
was diagnosed as having cerebral palsy. Brandon has ongoing  
3  
mental and physical disabilities.  
Plaintiffs filed a medical malpractice claim against  
defendant and one of its doctors, Dr. Edilberto Moreno. Dr.  
Moreno was dismissed by stipulation before trial, leaving no  
member of defendant's hospital staff named as a defendant.  
Plaintiffs alleged that the defendant medical center was  
vicariously liable for the active and passive negligence of  
the NICU staff (1) in allowing the UAC to become dislodged,  
and (2) in failing to respond properly once the UAC became  
dislodged.  They claimed that the resulting blood loss and  
treatment caused Brandon's mental and physical disabilities.  
Plaintiffs were awarded $475,000 in mediation.  They  
accepted the award, but defendant rejected it.  At trial,  
defendant challenged plaintiffs' expert witnesses, Dr.  
Houchang Modanlou and Dr. Carolyn Crawford.  Each testified  
about the standard of care in an NICU and each concluded that  
defendant's NICU staff breached the standard of care.  
Defendant argued that the doctors were unfamiliar with the  
standard of care in the locality.  The trial judge rejected  
defendant's argument that a local standard of care applied to  
the case.  
Both of plaintiffs' expert doctors were permitted to  
testify 
that 
members 
of defendant's NICU breached the standard  
of care in their treatment of Brandon.  Their testimony  
4  
established, 
also, 
that 
NICU 
staff 
negligence 
caused 
Brandon's  
injuries.  As the trial progressed, at times plaintiffs  
focused on the negligence of Nurse Plamondon at times and at  
other times advanced a broader theory of liability against the  
entire NICU.  
By closing argument, plaintiffs settled on the broader  
theory that substandard basic care in the NICU caused  
Brandon's 
injuries. 
 
Although 
plaintiffs 
named 
Nurse 
Plamondon  
in the closing argument, they left it to the jury to determine  
whether anyone in the NICU committed malpractice.  At the very  
least, 
these 
were 
alternate 
theories 
of 
defendant's 
liability.  
Defendant 
offered 
expert 
testimony 
supporting 
a 
contrary 
view,  
arguing that Brandon, born at just twenty-six or twenty-seven  
weeks' gestation and 900 grams, was likely to have mental and  
physical disabilities without an intervening cause.  
Defendant requested jury instructions confining the  
negligence issue to an evaluation of a neonatal nurse  
practitioner in the same or similar circumstances.  Defendant  
argued 
that 
plaintiffs' case was confined to allegations about  
Nurse Plamondon.  The trial court rejected the argument,  
concluding that plaintiffs' case was not limited to Nurse  
Plamondon.
 On its own initiative and over defendant's  
objection, the trial judge modified the standard jury  
instructions.  SJI2d 30.01. He instructed the jury that it  
5  
should consider whether the NICU failed to do what an NICU  
would do under the same or similar circumstances.  The jury  
found in plaintiffs' favor and awarded $2,400,000.  
Defendant 
moved 
for 
judgment 
notwithstanding 
the 
verdict,  
a new trial, or remittitur.  The trial judge granted  
remittitur, ordering a new trial unless plaintiffs accepted  
the $475,000 awarded at mediation.  Plaintiffs appealed to the  
Court of Appeals, which remanded the case to the trial court  
for a detailed opinion supporting the remittitur amount.1  On  
remand, a different judge reversed the remittitur and granted  
JNOV for defendant. Plaintiffs appealed again, and the Court  
of Appeals reversed and reinstated the jury verdict, which the  
panel found was supported by sufficient evidence.2  The panel  
refused to reach issues raised by defendant because it had not  
properly filed its cross appeal.  
Rather 
than 
appeal 
from 
that 
decision, 
defendant 
returned  
to the trial court where, over plaintiffs' objection, the  
judge entered a new order on the jury verdict.  When defendant  
sought review of that order, the Court of Appeals affirmed the  
original judgment on procedural grounds. It held in a split  
decision that the trial court lacked the authority to issue a  
1Unpublished order, entered December 14, 1994 (Docket No.
179366). 
2Unpublished opinion per curiam, issued November 22, 1996
(Docket No. 184859). 
6  
new order and that the law of the case barred defendant's  
appeal.3  
Defendant sought leave to appeal here and, in a split  
decision, this Court vacated the most recent Court of Appeals  
decision and remanded for consideration of defendant's  
arguments.4  On remand, the Court of Appeals resolved the  
issues against defendant and again upheld the jury verdict in  
a split decision.5  Defendant again filed an application for  
leave to appeal to this Court.  After initially denying leave,  
a majority of this Court granted defendant's motion for  
reconsideration and granted leave to appeal.  465 Mich 943  
(2002).  
II. Jury Instruction  
We review claims of instructional error de novo.  Case v  
Consumer Powers Co, 463 Mich 1, 6; 615 NW2d 17 (2000).  
However, to the extent that the review requires an inquiry  
into the facts, we review the trial court's decision on  
underlying factual issues for an abuse of discretion.  See  
Hilgendorf v St John Hosp & Medical Center, 245 Mich App 670,  
694-695; 630 NW2d 356 (2001); Isagholian v Transamerica Ins  
3Unpublished opinion per curiam, issued April 6, 1999
(Docket No. 205025). 
4462 Mich 859 (2000). 
5243 Mich App 72; 620 NW2d 859 (2000). 
7 
 
Corp, 208 Mich App 9, 16; 527 NW2d 13 (1994).  
The trial court did not abuse its discretion in this case  
when it rejected defendant's argument that plaintiffs' case  
was confined to allegations of Nurse Plamondon's negligence.  
It was correct to modify the standard jury instructions to  
reflect plaintiffs' theory of the case, rather than deliver  
defendant's 
requested 
instructions 
focusing 
on 
Nurse  
Plamondon.6  
A trial court is permitted, in fact required, to modify  
the standard jury instructions to fit the facts of a  
particular case.  See Case, supra at 6; see also Tobin v  
Providence Hospital, 244 Mich App 626, 672-673; 624 NW2d 548  
(2001).  This case is unusual in that every member of the NICU  
is a specialist, subject to a national standard of care.  See  
part III.  Moreover, plaintiffs did not allege a highly  
technical failure that could be a breach of the standard of  
care for one member of the NICU and not another.  
The evidence here was that, in an NICU, a UAC should not  
6In his dissenting and concurring opinion, Justice
Markman discusses the trial court's omission of the word 
"ordinary" from the jury instructions.  Slip op, pp 12-14.
Consideration of the issue is inappropriate because defendant
forfeited it.  Defendant did not raise it until, six years
after the jury verdict, the dissenting judge on the Court of
Appeals 
panel 
identified the omission as grounds for reversal.
See 243 Mich App 96-98.  The issue had not been brought before
that Court, was not raised in the trial court, and is only now
argued by defendant for the first time. 
8  
become dislodged.  A baby should not bleed for twenty minutes.  
And a baby of Brandon's size should not be given a single push  
of 20cc of Plasmanate, let alone a total volume of 50cc  
Plasmanate and blood within one hour and twenty minutes.  
Moreover, 
there 
was 
evidence that Brandon's respirator was set  
too high, causing his lungs to rupture and contributing to a  
diminished oxygen supply.  Regardless of whether it was a  
nurse or doctor responsible for these errors, there was  
evidence of a breach of the general standard of care  
appropriate for a level three NICU.  
In many if not the majority of medical malpractice cases,  
the instructions modeled after SJI2d 30.01 must specify the  
individual medical professionals alleged negligent and  
articulate a standard of care for each professional.  However,  
the negligence alleged in this case mingles the culpability of  
several members of defendant's NICU staff.  Plaintiffs were  
not able to determine which member of the staff was  
responsible for certain actions because the hospital records  
were incomplete and the NICU staff members implicated one  
another.  
Considering all the circumstances, it was permissible to  
instruct the jury regarding the negligence of the discrete  
hospital unit.  The trial court did not err when it instructed  
the jury:  
9  
 
 
When I use the words professional negligence  
or malpractice with respect to the Defendant's 
conduct, I mean the failure to do something which a 
hospital neonatal intensive care unit would do or 
the doing of something which a hospital neonatal 
intensive care unit would not do under the same or  
similar circumstances you find to exist in this 
case.  
It is for you to decide, based upon the 
evidence, what the hospital neonatal intensive care 
unit with the learning, judgment or skill of its 
people would do or would not do under the same or 
similar circumstances. . . .[7]  
To 
establish 
medical 
malpractice, 
a 
plaintiff 
must 
prove:  
"(1) the applicable standard of care, (2) breach of that  
standard 
by 
defendant, (3) injury, and (4) proximate causation  
between the alleged breach and the injury."  Wischmeyer v  
Schanz, 449 Mich 469, 484; 536 NW2d 760 (1995).  To establish  
vicarious liability against a hospital, a plaintiff must show  
7I recognize that the instructions are a significant
departure from the standard jury instructions, SJI2d 30.01, 
which, when unmodified, provide:  
When I use the words "professional negligence" 
or "malpractice" with respect to the Defendant's 
conduct, I mean the failure to do something which a 
[name profession] of ordinary learning, judgment or 
skill in [this community or a similar community/ 
name particular specialty] would do, or the doing 
of something which a [name profession] of ordinary 
learning, judgment or skill would not do, under the 
same or similar circumstances you find to exist in 
this case.  
It is for you to decide, based upon the 
evidence, what the ordinary [name profession] of 
ordinary learning, judgment or skill would do or 
not do under the same or similar circumstances.  
10  
 
that an agent of the hospital committed malpractice.  The  
principal is held to have done what the agent did.  Smith v  
Webster, 23 Mich 298, 299-300 (1871); see also Ducre v  
Sparrow-Kroll Lumber Co, 168 Mich 49, 52; 133 NW 938 (1911).  
As is true in any malpractice claim, the individual or  
individuals alleged to be negligent must have breached the  
standard of care within the course of the physician-patient  
relationship.  See Dorris v Detroit Osteopathic Hosp Corp, 460  
Mich 26, 45; 594 NW2d 455 (1999); Bronson v Sisters of Mercy  
Health Corp, 175 Mich App 647, 652; 438 NW2d 276 (1989).  
The 
majority 
adopts 
defendant's 
position 
that 
a 
plaintiff  
has not proven a case of medical malpractice vicarious  
liability until the plaintiff has (1) identified the specific  
individual professional or professionals who breached the  
standard of care and (2) proven that the individual breached  
the applicable standard of care.  It asserts that the unit  
instructions in this case improperly limited the burden of  
proof for plaintiffs.  
However, neither defendant nor the majority identifies  
any authority for the proposition that a medical malpractice  
plaintiff must always allege the negligence of a specifically  
named individual.  This is because there is no such authority.  
Whether unit liability instructions, such as were given in  
this case, are ever permissible is an issue of first  
11  
 
impression.8  
Where a plaintiff alleges the discrete negligent act of  
a hospital's agent, the jury must be instructed on that  
individual's obligation to meet a specific standard of care.  
Here, plaintiffs alleged that the NICU staff failed to  
properly maintain a UAC as a level three NICU should.  
Where no unit member can be shown negligent, but  
negligence 
is 
established, plaintiffs need not prove which one  
breached the generally applicable standard of care to find the  
principal vicariously liable. 
In this unusual case,  
plaintiffs shouldered and satisfied the burden of proving  
malpractice supporting their vicarious liability claim using  
the unit theory.  
A medical malpractice plaintiff must prove (1) duty,  
though a physician-patient relationship, (2) breach of duty,  
through a breach of the standard of care, (3) proximate  
causation, and (4) harm.  A plaintiff does not escape this  
burden when, as in this case, the jury is instructed  
concerning the liability of a discrete hospital unit.  
8The majority criticizes my position as unsupported by
authority. Slip op at 11, n 12. However, it also offers no
authority for the notion that an individual agent of a
hospital must be named and proven negligent in every case of
vicarious 
liability. 
 Tobin, supra, 
stands for the proposition
that jury instructions must be modified to fit the facts of
the case.  It does not hold that they must always identify
specific individuals and different standards of care. 
12  
Here, evidence was presented that supported the jury's  
conclusion that (1) every member of the NICU had a physician­
patient relationship with Brandon, and therefore a duty to  
meet the standard of care, (2) the care Brandon received in  
the NICU was sub-standard, under the established standard for  
basic care given in an NICU, (3) the breach of care caused  
prolonged oxygen deprivation and an intercranial bleed, and  
(4) the oxygen deprivation and bleed permanently harmed  
Brandon.  Under the circumstances of this case, the unit  
theory of liability did not relieve plaintiff of any burden  
whatsoever.  
The rule of law adopted by the majority actually  
increases a plaintiff's burden in vicarious liability medical  
malpractice cases.  In this case, evidence supports the jury's  
conclusion that the patient's care was mishandled by a  
discrete hospital unit.  It shows that an agent of the  
hospital committed malpractice, either alone or as part of a  
system's mismanagement.  In such a case, it should not be  
necessary for the plaintiff to prove which individual is  
culpable.  A rule requiring such a showing allows hospitals to  
benefit from their employees' fingerpointing and poor record  
keeping.  
The dissenting Court of Appeals judge believed that,  
because a hospital must render treatment through its  
13  
physicians and nurses, a plaintiff must specifically identify  
the individuals who are negligent, citing Danner v Holy Cross  
Hosp, 189 Mich App 397, 398-399; 474 NW2d 124 (1991).  I do  
not dispute that it is the doctors and nurses in the NICU that  
are alleged to be negligent in this case. 
However, to  
conclude that, because there is no specifically named  
individual, there is no physician-patient relationship to  
support plaintiffs' claim against defendant is fatuous.  
In this case, every member of defendant's NICU had a  
provider-patient relationship with Brandon. Thus, no matter  
which individual was named, that requirement would be  
satisfied.  It would have been satisfied if plaintiffs and the  
trial court had listed each member of the NICU and it was  
satisfied by referring to those individuals collectively as  
"the hospital neonatal intensive care unit."9  
9The majority tries to paint the NICU as only a physical
thing, "a geographic location within the hospital," rather
than 
a 
discrete 
collection of defendant's employees or agents.
Slip op at 10.  While I would agree that a physical unit
itself cannot form the basis of defendant's vicarious 
liability, the term was an apt description of a group of
individuals.  It is the group that breached the standard of
care in this case.  It distorts reason to conjecture that the
jury 
understood 
"the 
hospital neonatal intensive care unit" to
be a physical thing and not a descriptive term encompassing
those employees of defendant responsible for Brandon's care. 
Moreover, defendant argued that Nurse Plamondon was the 
sole member of its staff that plaintiffs claimed to be 
negligent.  The trial court was justified in rejecting that 
argument on the basis of evidence.  I agree with the Court of 
(continued...) 
14  
 
 
My view is consistent with the Court of Appeals holding  
in Tobin, supra.  There, the panel held that SJI2d 30.01 must  
be modified to fit the facts of the case at hand.  It  
concluded that the trial court erred when it delivered the  
following generalized instructions:  
When I use the words "professional negligence" 
or "malpractice" with respect to the defendant's 
conduct, I mean the failure to do something which a 
hospital's agents/servants/employees of ordinary 
learning, judgment or skill in this community or a 
similar one would do, or the doing of something 
which a hospital's agents/servants/employees of 
ordinary learning, judgment or skill would not do, 
under the same or similar circumstances you find to 
exist in this case.  
It is for you to decide, based upon the 
evidence, 
what 
the 
ordinary 
hospital's 
agents/servants/employees or [sic, of] ordinary 
learning, judgment or skill would do or would not 
do under the same or similar circumstances. [Id. at  
672.]  
Tobin 
correctly 
determined 
that 
the 
standard 
instructions  
were too nonspecific to allow the jury to determine whether  
any of the defendant's employees breached the standard of  
care. Id. at 673. As in this case, the alleged malpractice  
in Tobin was limited to the vicarious liability of a hospital  
defendant.  However, in sharp contrast to the case at hand,  
the allegations of medical negligence in Tobin were complex.  
9(...continued) 
Appeals that defendant should have requested more specific 
instructions naming the people within the NICU if it objected 
to identifying the wrongdoer as the unit. It did not do so.  
15  
Also, each of the individuals alleged to be negligent was  
subject to a different standard of care.  The plaintiff in  
Tobin essentially alleged that a nurse anaesthetist, medical  
technician, emergency room surgeon, and critical care  
physician, or a combination of them, breached the applicable  
standards of care.  See id. at 660. She claimed that those  
breaches caused her husband to receive an unauthorized blood  
transfusion 
and 
that 
the blood was contaminated with bacteria,  
causing her husband's death. Id. at 631.  
Whereas 
the 
instructions 
modeled 
after 
SJI2d 
30.01 
needed  
to be specific in Tobin, they were more appropriately general  
in this case.  A trial court must consider the facts of every  
case and deliver instructions that best convey the applicable  
legal theories to the jury.  Accordingly, I would endorse the  
Court of Appeals clear directive to trial courts in Tobin:  
"[I]nstruct the jury using a modification of SJI2d 30.01 that  
accurately delineates the standards of care applicable to the  
various medical personnel who plaintiff contends committed  
malpractice . . . ." Id. at 675.  
This is not a case of res ipsa loquitur, even as that  
doctrine has been loosely construed in Michigan.10
 In a  
10Michigan courts do not apply true res ipsa loquitur in
medical malpractice cases.  Strictly applied, res ipsa
loquitur relieves a plaintiff of proving the exact negligent
act that caused an injury, looking only to the result when the
(continued...) 
16  
  
  
medical malpractice case, a plaintiff may present expert  
testimony that, but for a breach of the standard of care, the  
result in the case would not have occurred. 
This is  
sufficient evidence of the breach to go to a jury.  See Jones  
v Poretta, 428 Mich 132, 154-155; 405 NW2d 863 (1987).  Res  
ipsa loquitur refers to circumstantial evidence of negligence  
where the specific incidence of negligence cannot be  
identified. Id. at 150, citing Mitcham v Detroit, 355 Mich  
182, 186; 94 NW2d 388 (1959).  Here, the incidents of  
negligence were identified, but the specific actor was not.  
This is a stronger case for liability than the ordinary  
claim of res ipsa loquitur.  It is not necessary to speculate  
that someone must have been negligent on the basis that there  
is direct evidence of negligence. This case does not rely on  
expert testimony that, but for someone's negligence, Brandon  
would not be impaired, a conclusion unsupported by the  
evidence. Here, there was expert testimony that a UAC would  
not become and remain dislodged for twenty minutes in a level  
10(...continued)
plaintiff's condition must have happened through some 
negligence. Jones v Poretta, 428 Mich 132, 150; 405 NW2d 863
(1987); See Prosser, Torts (4th ed), § 39, p 222-224.  In 
contrast, the Michigan rule requires that the plaintiff prove
the breach of the standard of care, or "more than a bad
result." This is accomplished in a medical malpractice case
with expert testimony that the result would not have happened
had the plaintiff been treated in accordance with the standard
of care. Jones, supra 151-156. 
17  
three NICU if the staff had complied with the standard of  
care. That was direct evidence that the staff breached that  
standard.  
Moreover, this is not a case of the discrete negligence  
of an individual caregiver.  Rather, what the evidence  
established was a systemic failure of the NICU.  Several  
errors were made related to the maintenance of the UAC.  
First, there was evidence that the UAC should not have become  
dislodged.  This could have happened because it was improperly  
inserted by one of the physicians or it could have happened  
because 
Nurse 
Plamondon dislodged it when she checked Brandon.  
Second, 
once 
the UAC became dislodged, there was evidence  
that someone in the NICU should have noticed sooner that  
Brandon was in distress.  Both Nurse Plamondon and Dr.  
Villegas were present.  Third, there was evidence that either  
Nurse Plamondon or both she and Dr. Sheeder gave Brandon too  
great a volume of Plasmanate and red blood cells within too  
short a time.  
Finally, 
there 
was 
evidence 
that 
Brandon's 
respirator 
was  
set too high in response to his blood loss, causing ruptured  
alveoli in his lungs and contributing to his depleted oxygen  
level.
 This, like the administering of Plasmanate, was a  
medical decision that should not have been made by Nurse  
Plamondon.  
18  
The evidence does not reveal with certainty which member  
of the NICU staff was responsible for each of these failures.  
It does establish that the members of the NICU as a group  
breached the standard of care for a NICU. Had the jury been  
instructed 
on 
the 
negligence of Nurse Plamondon, Dr. Villegas,  
or Dr. Sheeder, individually, it might not have been able to  
identify which was negligent.  Evidence of who was responsible  
for the negligent acts was much more readily accessible to  
defendant than to plaintiffs.  For that reason and because  
this is a case of vicarious liability, plaintiffs did not need  
to specify which members of the NICU staff breached the  
general standard of care.  
The unit negligence instruction does not relieve  
plaintiffs of their burden of proof under the circumstances of  
this case.  On the contrary, the majority's blanket rule  
oversimplifies the case and increases the burden on  
plaintiffs.  Although the majority's holding would be sound if  
the 
responsible 
individual 
or 
individuals 
could 
be 
identified,  
in this case it was not possible. The hospital staff failed  
to record who took what action.  The effect of the holding,  
rather than reduce plaintiff's burden, is to insulate the  
malpractice defendants from vicarious liability.  
There was evidence here of substandard care given by a  
hospital unit.
 The trial court's modified instructions  
19  
 
properly conveyed a legitimate legal theory to the jury  
without risk of added confusion. It was correct.  
III. Standard of Care  
Defendant argues that because (1) the only negligence  
alleged in this case was that of Nurse Plamondon, and (2) all  
nurses are subject to a local standard of care, the trial  
court erred when it concluded that a national standard of care  
applied in this case.  As the majority notes, the Court of  
Appeals did not address this issue.  Instead, it focused on  
whether the trial court abused its discretion when it admitted  
Dr. Modanlou's expert testimony concerning the national  
standard of care.  This is understandable, as defendant has  
consistently fused two distinct issues.  Even in its brief  
before this Court, defendant asserts the standard of review  
for an evidentiary error.  It does not identify what standard  
of care applies to the alleged malpractice, a legal question.  
Hence, the majority reaches an issue that was never clearly  
argued or properly raised.  
Whether all nurses are subject to a local standard of  
care 
is 
a 
legal 
question 
that 
requires 
statutory  
interpretation, which this Court reviews de novo.  See  
Cardinal Mooney High School v Michigan High School Athletic  
Ass'n, 437 Mich 75, 80; 467 NW2d 21 (1991). It is an issue of  
first impression.  
20  
Defendant relies on cases that do not reach whether  
nurses can ever be considered specialists.  I would reject its  
argument for two additional reasons: First, the trial court  
correctly 
determined 
that 
plaintiffs 
alleged 
the 
negligence 
of  
more people than just Nurse Plamondon. Because I believe it  
was permissible to allege the negligence of the NICU, the  
standard of care here should be that applicable to the NICU as  
a whole, a national standard of care. See part II.  
This is not to be confused with the standard of care for  
an NICU physician, a neonatologist, or an NICU nurse.  In a  
medical malpractice case where a plaintiff alleges a more  
technical breach, the more specific standard of care for the  
individual alleged to have been negligent must be applied.  In  
this case, only the standard of basic care was at issue.  
Second,  even if Nurse Plamondon were the only individual  
alleged to be negligent, a nurse who is specially trained to  
give advanced care is a specialist under MCL 600.2912a,  
subject to a national standard of care.  Therefore, I disagree  
with the "guidance" the majority offers to the trial court.  
Here, every member of the NICU staff, both doctors and nurses,  
had been specially trained to care for critically ill newborn  
infants.  Therefore, every individual and the unit as a whole  
were subject to the national standard of care for maintaining  
a UAC in a level three NICU.  
21  
 
It has been established that healthcare providers are  
subject either to a national or a local standard of care.  In  
1975, faced with the argument that the locality rule should be  
abandoned for a more national standard,11 the Legislature  
codified the two different standards of care for medical  
malpractice defendants.  MCL 600.2912a. The local standard  
was 
designated 
for 
the "general practitioner" and the national  
for the "specialist."  It falls to this Court to determine  
which medical caregivers fit into the category of "general  
practitioner" and which are "specialists." On the basis of  
the 
Legislature's 
directive in MCL 600.2912a, I would conclude  
that a nurse may be either, depending on the level of training  
and expertise the job requires.  
MCL 600.2912a(1) provides, in relevant part:  
[I]n an action alleging malpractice, the  
plaintiff has the burden of proving that in light 
of the state of the art existing at the time of the 
alleged malpractice:  
(a) The defendant, if a general practitioner, 
failed to provide the plaintiff the recognized 
standard of acceptable professional practice or 
care in the community in which the defendant 
practices or in a similar community, and that as a 
proximate result of the defendant failing to  
provide that standard, the plaintiff suffered an 
injury.  
11In his concurring opinion in Siirila v Barrios, 398 Mich 576, 625-630; 248 NW2d 
171 (1976), Justice Williams argued for abandonment of the locality rule in favor of a 
national standard of care for all medical caregivers.  He urged local practice as but one 
consideration in evaluating the standard of care. 
22  
 
 
(b) The defendant, if a specialist, failed to 
provide the recognized standard of practice or care 
within that specialty as reasonably applied in 
light of the facilities available in the community 
or other facilities reasonably available under the 
circumstances, and as a proximate result of the 
defendant failing to provide that standard, the 
plaintiff suffered an injury.  
Therefore, general practitioners usually are subject to a  
local standard of care and specialists are held to a national  
standard.  The language of MCL 600.2912a quite clearly does  
not distinguish between physicians and nurses when it  
classifies "the defendant" in a medical malpractice case as a  
specialist or general practitioner.  There is no reason to  
depart from the statute and treat physicians and nurses  
differently, where the relevant issue is the level of the  
defendant's training and knowledge.  
The majority, in an analysis that has the appearance of  
being outcome determined, departs from the Legislature's  
directive when it concludes that MCL 600.2912a does not apply  
to nurses.  It claims to rely on the plain language of MCL  
600.2912a 
in 
concluding 
that 
the 
specialist-general  
practitioner dichotomy does not apply to nurses.12  However,  
after disregarding the obvious scope of MCL 600.2912a, the  
majority bases its conclusion solely on the definitions of  
"general 
practitioner," 
"specialist," 
"practitioner," 
"medical  
12Slip op at 17. 
23  
 
practitioner," 
"licensed 
health 
care 
professional,"  
"registered 
professional 
nurse," 
"physician," 
and 
"practice 
of  
medicine." In so doing, it looks far afield of the statute,  
which plainly and unambiguously applies to every defendant in  
a medical malpractice action.  
Next, given that all medical malpractice defendants are  
subject to MCL 600.2912a, one must determine whether a nurse  
may ever be considered a specialist for the purposes of the  
statute.  A specialist is "a person devoted to one subject or  
to one particular branch of a subject or pursuit," or "a  
medical practitioner who deals only with a particular class of  
diseases, conditions, patients, etc."  Random House Webster’s  
College Dictionary (1997).  
It is well established that one engaging in the prenatal  
care of an infant is generally considered a specialist,  
subject to a national standard of care. See, e.g., Thomas v  
McPherson Community Health Center, 155 Mich App 700, 708; 400  
NW2d 629 (1986); Swanek v Hutzel Hosp, 115 Mich App 254, 257;  
320 NW2d 234 (1982); McCullough v Hutzel Hosp, 88 Mich App  
235, 241; 276 NW2d 569 (1979).  However, a specialist is  
classified as such by virtue of advanced training, not merely  
by having concentrated in a specific area of practice.  See  
Jalaba v Borovoy, 206 Mich App 17, 21-22; 520 NW2d 349 (1994);  
Dunn v Nundkumar, 186 Mich App 51, 53; 463 NW2d 435 (1990).  
24  
Applying the facts of this case to that law, a nurse can  
specialize in an area of care that requires advanced training  
particular to a type of practice.  For example, Nurse  
Plamondon specialized in neonatal intensive care. 
She  
received intensive training before she could work in the NICU.  
There was evidence that she was able to perform procedures  
necessary for the needs of an infant in the level three NICU,  
for which even the resident doctor was untrained. All staff  
members specially trained to care for patients in a  
specialized hospital unit, including nurses, must be subject  
to a national standard of care for their individual roles.  
Thus, if the only issue were Nurse Plamondon's negligence, the  
national standard of care would apply to this case.  
Even if the majority were correct that MCL 600.2912a  
applies only to physicians, a local standard of care should  
not apply.  Plaintiffs alleged that the NICU as a unit failed  
to give Brandon the care he should have received there. The  
evidence supported plaintiffs' theory that Brandon's UAC  
should not have been dislodged long enough to spill half his  
blood volume, and the NICU should not have responded as it  
did.  Where the care given in a unit is specialized, all of it  
should be measured against the national standard for the basic  
care offered to patients in such a unit.  
It is apparent to me that defendant is employing smoke  
25  
and mirrors when asking for a new trial because a national  
rather than a local standard of care was applied. Defendant  
never articulated, either before the trial court or here, how  
the two standards are different.  Upon examination, it is  
apparent that the local and national standards for a  
practitioner in an NICU are one and the same.  If, on remand,  
the trial court were to conclude that plaintiffs advanced a  
claim against only Nurse Plamondon, her care of Brandon would  
be measured by the same standard applied earlier.  Merely the  
name, "local standard of care," would be changed.  
IV. Conclusion  
I would affirm the Court of Appeals decision to uphold  
the jury verdict against defendant. On the particular facts  
of this case, I cannot conclude that it was error to instruct  
the jury regarding the negligence of the hospital unit. The  
instructions properly conveyed a valid legal theory of  
vicarious liability to the jury without additional risk of  
confusion. Moreover, the trial court was correct to apply a  
national standard of care to this case. Plaintiffs advanced  
a claim against more than just Nurse Plamondon.  
Also, I would hold that nurses who (1) have received  
specialized training to give advanced care and (2) practice  
exclusively within an area of medicine recognized as a  
specialty 
are 
specialists within the meaning of MCL 600.2912a.  
26  
 
Thus, even if plaintiffs' medical malpractice claim were  
premised only on Nurse Plamondon's actions, the care she gave  
Brandon should be weighed on a national standard.  
CAVANAGH, J., concurred with KELLY, J.  
27