'Be Nice' and Document to Prevent Malpractice Suits

Laura Arenschield

May 17, 2019

A jury ruled in favor of the patient in a malpractice lawsuit in Georgia, in part because the nursing staff updated the patient's care record late, Kelli Rosenthal, RN, CRNI, VA-BC, a longtime nurse and expert witness reported.

In Jackson vs Coffee Medical Center, a patient with diabetes, who was unable to work, was treated for pancreatitis. He was given intravenous (IV) promethazine and demerol, but the IV site allegedly leaked, infiltrating surrounding tissues. The thumb on the patient's nondominant hand had to be amputated.

The hospital argued that the vascular ischemia was from diabetes or an intravascular blood clot, and that the IV site was not infiltrated. But just 4 days after the Georgia Supreme Court struck down the state's $350,000 noneconomic damages cap in medical malpractice cases, a jury handed the patient a $1.5 million award.

"Nurses need strategies to minimize the risk of being a party to litigation," Rosenthal told Medscape Medical News. "As the saying goes: In God we trust; everyone else has to chart."

There shouldn't be a lot of late entries, she said, "and there shouldn't be gaps in the medical records."

But "there is not a huge amount of proactive education on these issues, and it's really not covered in school," said Rosenthal, who will speak about best practices and the legal issues associated with infusion at the upcoming Infusion Nurses Society (INS) 2019 Annual Conference in Baltimore.

"IV therapy is still a clinical specialty that gets very little attention in basic nursing preparation," explained Rosenthal, who is regional director of nursing at AccessRN in northeastern New Jersey. "Certainly things like ultrasound-guided peripheral infusion are not taught as part of someone's basic education."

The current standard is to use imaging techniques to prevent patient injury as much as possible. Knowing those standards, and knowing when you have a duty to intervene, are key, she explained.

Infusion lines can be pivotal to care, but they can also open the body up to infection, over- or underdosed medications, and nerve injury — all of which can lead to lawsuits. Typically, it is "not until after something has gone wrong" that nurses learn to protect themselves and their patients, she pointed out.

"Almost 100% of the time — because a nurse is such a powerful patient advocate — they have that duty to intervene," Rosenthal told Medscape Medical News. "The infusion nurse is expert in this field; the people who are actually ordering the lines may not have had as much experience."

"You really can't go wrong if you stick with your standards of practice," she said.

Wrong Drugs and Extravasation Injury

The risks associated with infusion lines can be serious for patients and costly for healthcare systems, and for providers if a malpractice suit is filed.

In one case, after the wrong drug was administered by IV, the patient developed pneumonia and had to be hospitalized for 4 additional weeks, Rosenthal reported. In another case, a catheter line fractured during a thoracotomy and the surgeons were unable to retrieve it. That resulted in a lawsuit that ended with a $1.1 million payout.

But "the number one theme of malpractice litigation against nurses related to infusion therapy" is extravasation injury, which can occur when medication leaks from the IV site to surrounding tissue, she explained.

"Know the risk of what can happen to your patient if that drug should extravasate before you give anything, and make sure you're giving it properly," she said.

Of course, that doesn't mean if something goes wrong, the nurse, doctor, or hospital are automatically responsible, said Lisa Gorski, RN, CRNI, a clinical nurse specialist at Wheaton Franciscan Healthcare in Mequon, Wisconsin, who has served as an expert witness in malpractice cases and is a former president of the INS.

Sometimes the nurse does everything right and bad things still happen.

"Adverse reactions to the infusion can and do happen, and sometimes they're preventable. But sometimes the nurse does everything right and bad things still happen," Gorski told Medscape Medical News.

Mitigating the risk comes down to education, she noted.

"Often, there isn't good education for nurses who are providing infusions or placing IV catheters in hospital settings," she said, and "they often underappreciate the risks."

"I've been asked to examine horrible outcomes," she explained, describing "patients who lost a limb or had to have extensive surgeries as a result of a complication related to that intravenous catheter."

"The majority of the time you don't end up with those types of problems, but they do occur," Gorski added.

Rosenthal has a list of tips for nurses placing infusion lines:

  • Carry your own professional liability insurance

  • Participate in and maintain proof of all ongoing training and continuing education

  • Document to reflect the whole picture

  • Maintain professional board certification in the infusion specialty

  • Keep up with new evidence for practice

  • Never make statements to family or patients admitting guilt

And one more, she added: "Be nice."

"Sometimes a bad outcome is just a bad outcome; it wasn't caused by anyone's negligence," Rosenthal said. "Despite our best efforts, in healthcare, there really aren't guarantees. You can't promise that everything is always going to work out perfectly."

Rosenthal is a speaker for Genentech and other medical-device manufacturers through Resource Nurse Continuing Education, her consulting company. Gorski has disclosed no relevant financial relationships.

Infusion Nurses Society (INS) 2019 Annual Conference. To be presented May 21, 2019.

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