Improper administration and monitoring of Mitomycin

The defendant in this case is a nurse.

Medical malpractice claims can be asserted against any healthcare provider, including nurses. Although there may be a perception that physicians are held responsible for the majority of lawsuits, the reality is that nurses are more frequently finding themselves defending the care they provide to patients. In fact, over $83 million was paid for malpractice claims involving nursing professionals, according to the most recent CNA HealthPro 5-year study*.

Improper insertion of intravenous access; Failure to properly administer intravenous Mitomycin; Failure to properly monitor Mitomycin infusion resulting in injury, deformity and permanent loss of function of plaintiff’s right hand.


CASE STUDY WITH RISK MANAGEMENT STRATEGIES

Case Study: Improper insertion of intravenous access; Failure to properly administer intravenous Mitomycin; Failure to properly monitor Mitomycin infusion resulting in injury, deformity and permanent loss of function of plaintiff’s right hand

Settlement Payment: $235,000 Legal Expenses: $359,248

Note: There were multiple co-defendants in this claim who are not discussed in this scenario. Monetary amounts represent only the payments made on behalf of the nurse. Any amounts paid on behalf of the co-defendants are not available. While there may have been errors/negligent acts on the part of other defendants, the case, comments, and recommendations are limited to the actions of the defendant; the nurse.

The patient / plaintiff was a 40-year-old female undergoing Mitomycin chemotherapy for anal cancer following surgery and radiation. The patient alleged that the defendant nurse incorrectly placed the intravenous line (IV) resulting in infiltration with extravasation of the Mitomycin into the tissues of her right hand. The patient further alleged an inadequate number of nurses resulted in improper supervision of her chemotherapy treatment by the defendant nurse.

The defendant nurse inserted a peripheral IV into a vein on the dorsum of the patient’s right hand for the administration of Mitomycin. The IV was inserted without difficulty. When she later checked the patient’s IV, she noted that the needle had dislodged from the patient’s vein. There was no evidence that the Mitomycin had extravasated into the patient’s tissues.

The defendant nurse immediately stopped the IV, notified the physician and provided care to the patient’s hand. The documentation indicates no immediate adverse effects.

Three months following the event, the patient developed necrosis of the dorsum of the right hand. She required multiple surgical procedures, skin grafting and reconstruction with permanent loss of function and significant deformity including lack of movement of the fourth and fifth fingers. The patient also alleged pain and suffering and permanent disabilities interfering with recreational activities and daily living.
 

Resolution

Defense experts stated that the defendant nurse did not deviate from the standard of care and that infiltration is a known risk of chemotherapy. It was determined that staffing levels were appropriate at the time the event occurred.

State law provided that even if the defendant nurse settled her own case prior to trial, without specific release and indemnification language from the patient’s attorney at the time of the settlement, the jury would be permitted to allocate a percentage of negligence and a percentage of the award to the defendant nurse (as a “Fabre Defendant”). This requirement could potentially result in double payment on behalf of the defendant nurse. The patient’s attorney refused to decrease the demand of $800,000 and refused to provide the necessary release/indemnification language in any settlement reached. Therefore, it became necessary for the defendant nurse to remain in the case, despite positive expert reviews, unless all defendants settled thereby closing the case. Two arbitrations were unsuccessful.

Additional expert reviews were obtained and consistently determined that the defendant nurse acted within the standard of care.

These reviews ultimately resulted in an adjusted patient demand. All co-defendants agreed to the revised settlement demands, allowing the defendant nurse to settle without the risk of Fabre Defendant status.
 

Risk Management Comments

The defendant nurse’s documentation supported expert findings that she had acted within the standard of care, which was a significant factor in achieving pretrial settlement.
 

Risk Management Recommendations

  • Document all actions taken and objective clinical signs observed when creating IV access, including steps to ensure proper catheter placement. (i.e., ease or resistance when flushing the line, ease of blood return and patient complaints)
  • Carefully monitor the infusion of high-risk intravenous medications including those known to be caustic and known to cause injury should infiltration/extravasation occur.
  • Document, date and time monitoring observations and patient condition so that in the event of extravasation, the duration of the infiltration and/or the amount of extravasated fluid/medication can be estimated as accurately as possible.
  • Document all steps taken to treat the area of known or suspected infiltration/extravasation of IV medication and include the patient’s response to treatment.
  • Notify the physician of the event, the patient’s complaints and the response to supportive treatment and document further orders or recommendations for the patient’s care.
  • When such events occur on an outpatient basis, instruct the patient to notify the physician or to obtain prompt medical treatment if pain, swelling, discoloration and/or change in sensation occur and document the instructions provided.


Guide to Sample Risk Management Plan

Risk Management is an integral part of a healthcare professional’s standard business practice. Risk management activities include identifying and evaluating risks, followed by implementing the most advantageous methods of reducing or eliminating these risks— A good Risk Management Plan will help you perform these steps quickly and easily!
 
Visit www.nso.com/riskplan to access the Risk Management plan created by NSO and CNA. We encourage you to use this as a guide to develop your own risk management plan to meet the specific needs of your healthcare practice.
 
*CNA HealthPro Understanding Nurse Liability, 2006-2010: A Three-part Approach, CNA Insurance Company, November 2011. To read the complete study visit www.nso.com/nurseclaimreport2011

This publication is for educational purposes. It is not legal, professional or medical advice. CNA makes no representations as to its correctness or completeness and accepts no liability for any injury or damage that may arise from its use. Specific legal or medical questions should be referred to a competent attorney or medical professional before applying this material in any particular factual situations. This material may address and discuss matters for which your policy does not provide coverage, and the material does not create or imply the existence of coverage. Please consult your insurance policy for the specific terms, coverages, amounts, conditions and exclusions of coverage. All products and services may not be available in all states and may be subject to change without notice. CNA policies are underwritten by the property/casualty companies of CNA, Chicago, IL. CNA is a registered trademark of CNA Financial Corporation. © 2012 Continental Casualty Company. All rights reserved.

This publication is intended to inform Affinity Insurance Services, Inc., customers of potential liability in their practice. It reflects general principles only. It is not intended to offer legal advice or to establish appropriate or acceptable standards of professional conduct. Readers should consult with a lawyer if they have specific concerns. Neither Affinity Insurance Services, Inc., NSO, nor CNA assumes any liability for how this information is applied in practice or for the accuracy of this information. This publication is published by Affinity Insurance Services, Inc., with headquarters at 1100 Virgina Drive, Suite 250,  Fort Washington, PA 19034. Phone: (215) 773-4600. All world rights reserved. Reproduction without permission is prohibited.

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2012 Affinity Insurance Services, Inc. x-8540-0812 Risk Management is an integral part of a healthcare professional’s standard business practice. Risk management activities include identifying and evaluating risks, followed by implementing the most advantageous methods of reducing or eliminating these risks— A good Risk Management Plan will help you perform these steps quickly and easily!

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