Clinical Nursing Malpractice Case Studies, January 29, 2002 Coleman v. East Jefferson General Hosp., 747 So.

2d 1044- LA (1999) Summary: Starting Intravenous Lines and Performing Venipunctures are basic nursing skills in the Acute Care or Hospital settings. In this case, a female patient would accuse a male nurse of negligence and causing a resulting injury when he needed three attempts to successfully start an intravenous catheter. The female patient came to the hospital with vague complaints of abdominal pain and was evaluated in the Emergency Department. The physicians orders for treatment included intravenous medications for which a line would need to be started. Up to 90% of patients who require health care services need some form of I.V. therapy. Unfortunately, many hospitals have done away with I.V. teams, so you may be responsible for inserting and maintaining I.V. lines even if you're inexperienced or have limited opportunities to keep your skills sharp.2 ************************* Sidebar: Venipuncture and the insertion of intravenous catheters are basic nursing skills. If a nurse has not learned these skills in Nursing School, it will be often be learned on the job in the early months of orientation at an acute care facility. As with most nursing skills, it is one that improves with practice. The prudent nurse will attempt once or twice and then ask another nurse to give it a try. In rare cases, you will come across patients that are a difficult stick. In this case, if there simply are no veins the physician should be notified or an expert nurse should be called in. ************************* A male nurse was assigned to the patient when the Intravenous Catheter was to be placed. The nurse was having difficulty finding veins in the womans arms. He then attempted twice to start a line in her hand and was successful on the third attempt. It was the policy of the hospital at that time, that a nurse may attempt an intravenous catheter insertion no more than two times before calling for assistance. For the remainder of the patients treatment at the hospital, it would be documented that the patient complained of discomfort at the IV site and tolerated it poorly. Pain or discomfort at the site of an IV insertion should present a red flag to an experienced nurse. When combined with redness, swelling, puss or exudates at an IV site, pain can signal one of many potential complications of Intravenous Therapy including extravasation of IV fluids/medication, infection of the site or a dislodging of the catheter.

When pain or potential complications are reported, the site should be thoroughly evaluated for signs of a problem. If symptoms persist, the placement of another line at an alternate site should be offered for continued Intravenous Therapy. There was no indication in the hospital record, that other signs/symptoms of a complication existed other than the pain/discomfort. This may have been positional due to the location of the IV site in the patients hand. There was no indication that placement of another line was either offered to, or refused by the patient. When an I.V. lawsuit is argued in court, top-notch I.V. skills don't mean much unless they're backed up by appropriate, accurate, and concise documentation. Unfortunately, documentation is where many nurses fall short.2 Following her discharge, the patient would file a suit alleging negligence on the part of the nurse and hospital. Specifically, she claimed a poorly performed catheter insertion caused her to develop Reflex Sympathetic Dystrophy in her right hand. What is Reflex Sympathetic Dystrophy Syndrome? Reflex sympathetic dystrophy syndrome (RSDS) is a chronic condition characterized by severe burning pain, pathological changes in bone and skin, excessive sweating, tissue swelling, and extreme sensitivity to touch. The syndrome is a nerve disorder that occurs at the site of an injury (most often to the arms or legs). It occurs especially after injuries from high-velocity impacts such as those from bullets or shrapnel. However, it may occur without apparent injury.3 Summary judgment was entered for the hospital finding that no negligence was evident. The patient appealed. Questions to be answered: 1. Was the nurse negligent in his catheter insertion technique? Were certifications and hospital policies/procedures adhered to? 2. Were standards of care, specific to Intravenous Catheter Insertions adhered to. 3. Was it plausible, that the patients Reflex Sympathetic Dystrophy may have resulted from the multiple catheter insertion attempts that day? On review of the chart and following expert testimony, no deficiencies in technique could be found in the placement of the catheter. By his employment record and training, he was fully qualified to place intravenous catheters as a part of his scope of practice as a licensed nurse. It was noted that the hospitals standards, allowed for a maximum of two attempts before calling for assistance. The nurse in question, attempted three times.

On further review, the community standards, which was the measure used for this case, allowed four insertion attempts. By this standard of care, the nurse was within reasonable limits by trying three times. Expert Testimony addressed the issue of causation of the patients Reflex Sympathetic Dystrophy. In statements made, no direct causative link could be established between the starting of an intravenous catheter, and a diagnosis of Reflex Sympathetic Dystrophy. At best, the plaintiffs expert stated that it was a slim possibility, that a link could be made. The physician offered no support to the claim that the plaintiffs alleged injuries were caused by the catheter insertion. The appeals court affirmed the judgment of the lower court. It should be noted that Intravenous Therapy, while a basic part of nursing practice, is extremely prone to complications and resulting malpractice & negligence actions. Related clinincal Nursing (Malpractice) Case Studies: