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News: A woman alleged that a staff nurse failed to properly monitor and discontinue her intravenous (IV) line after she complained of pain and discomfort. IV fluid leaked into her tissue, resulting in full-thickness skin loss, requiring eight subsequent surgeries and eventual disfigurement. A jury awarded $800,000 in damages against the hospital.
Background: With 25 hospitalizations for renal disease behind her, the 24-year-old patient alleged that during a hospitalization the nurse overseeing her care failed to properly monitor her IV line. Shortly after the nurse placed the IV line, the patient said she told the nurse that she was experiencing minor discomfort, pain, and swelling at the site of insertion. The IV infusion contained a vesicant-like product that was known to cause severe burning if infiltration occurred. Over the next two hours, the patient’s hand swelled to double its normal size, and she suffered extreme extravasation before the nurse finally removed the line. As a result of the fluid entering her tissue rather than remaining in her blood vessels, the patient suffered full-thickness skin loss in her nondominant left hand. The injury to her hand required eight subsequent surgeries, including groin flap, skin grafts, and joint manipulation.
The plaintiff claimed the IV line should have been checked by the nurse every 20 minutes instead of every two hours based on the type of infusion material being administered. The plaintiff maintained that if the IV line had been properly monitored or if her had complaints been responded to in a timely manner that the line would have been removed sooner and the damage to her hand avoided or minimized.
The defendant hospital countered the allegations. The nurse testified that the patient had not complained about the IV line and that the site had been properly monitored. Nursing notes in the medical record indicated that the site had been monitored at least once per hour and that no problems had been detected until the infusion was complete. At trial, her kidney transplant surgeon testified that she could live a full and normal life.
The jury awarded the plaintiff $800,000.
What this means to you: "It stands to reason that any situation involving a high-risk transplant patient should be handled with increased vigilance, and that monitoring the IV line once per hour was simply not enough," says Ellen L. Barton, JD, CPCU, a Phoenix, MD-based risk management consultant. In this instance, you have a patient who has been hospitalized more times than her age receiving potentially caustic IV material. Using either factor and certainly the combination, it seems that the patient should have been deemed high risk and treated accordingly.
"While we will probably never return to the high nursing staff-to-patient ratios of the ’70s and ’80s, training, education, and documentation can be properly employed to cover some of the decrease in nurse-to-patient ratios. In this case, there seems to be an issue of clinical competence regarding both the initial placement of the IV line and subsequent monitoring of the site. Practice might address the issue of IV placement technique. However, even with poor placement, training and education on the need for sufficient monitoring would have likely mitigated the poor outcome. At $100,000 per additional surgery, a little more monitoring might have gone a long way to avoid the injury and the damages," says Barton.
While the patient testified that she reported her discomfort to the nurse, the medical record is completely absent of the patient’s comments.
"In general, to rely solely on the patient’s assessment of their condition will not necessarily give you the clinical evaluation needed to address their medical condition. First, any given patient might have a high tolerance or conversely low tolerance to pain. And second, the patient may not display the classic symptoms. This may make the clinician’s judgment equally, if not more, important to determining what has transpired with the patient.
"However, if the patient has a lengthy medical history, such as this transplant patient, their personal assessment may carry additional weight. Repeatedly hospitalized patients with chronic illnesses are more prone to be familiar with their own condition and more experienced with medical care. Regardless of what the patient’s background may be, the patient’s comments or
lack thereof should be noted in the medical record. Otherwise, one stands to create he-said/she-said’ situations between the patient and health care providers, and the jury tends to side with their patient peer," adds Barton.
"More often than not, one nurse is charged to cover all aspects of several patients’ care. This makes education, training, and experience with patients’ sensitivities and documentation of such essential. In this instance, the patient was probably very familiar with the setting and procedure, and it seems that she attempted to communicate her discomfort with the IV line. Based on the outcome and need for additional surgeries, she just might have been right, but it seems that no one was listening," notes Barton.
• Sherry Sinclair vs. Rush-Presbyterian-St. Luke’s Hospital, No. 95L-6274, Cook County (IL) Circuit Court.