This case involves a registered nurse providing services for a vascular surgeon.
Case Study: Negligent performance of sclerotherapy; negligent wound care management, failure to maintain clinical competencies; failure to document the patient’s symptoms, response to treatment and changes in condition in the patient care record;
Total Incurred: Greater than $145,000
(Monetary amounts represent only the payment made on behalf of the insured registered nurse and does not reflect payments made on behalf of the other parties involved in the claim.)
A 40 year-old was seeking sclerotherapy to her right lower extremity and was seen by our insured registered nurse employed by a vascular surgeon. The patient had previously received sclerotherapy, but this was the first time our insured nurse had treated the patient. The patient’s medical history was negative for alcohol use and cigarette smoking. She did not take any prescribed medications, only vitamins, and reported that her occupation was a hair stylist.
Before beginning the therapy, the nurse reviewed the procedure and explained her technique of injecting into a vein in the patient’s leg. The insured provided a pamphlet on sclerotherapy to the patient on the risks, benefits and post-treatment care. Post-treatment care included:
- Do not massage or rub the injected area
- Avoid standing for long periods of time for the next 5 days
- Wear compression stockings for 7-14 days
- Results can take up to 8 weeks
Consent to the treatment and a copy of the pamphlet were signed and dated by the patient and maintained in the patient’s healthcare record.
The procedure was successfully completed and the insured applied compression stockings to the right lower leg. The nurse provided the patient with compression stockings and made a follow-up appointment with the physician.
At the follow-up appointment, the patient reported the development of superficial wounds (blood blisters) at the injection sites. The physician noted in the patient’s healthcare record that the wounds appeared to be without infection or necrosis. The physician educated the patient about management of the wound including changing dressings daily and applying antibiotic ointment. The physician discussed the risks of not maintaining proper wound care (discussion was documented). A second follow up appointment was scheduled two weeks later, but the patient was instructed to come in sooner if the wounds became infected or developed scarring.
A week later, our nurse followed up with the patient over the telephone. The patient indicated that the wounds were slowly healing. (This was the last time our nurse spoke to the patient.)
The patient missed her follow-up appointment, but called one-month later requesting to see the physician about her wounds. According to the patient’s healthcare records, the patient indicated that she had been under the care of a “wound care nurse and using Silvadene Cream”.
At that time, the physician was of the opinion the patient was suffering from superficial necrosis of two areas of her lower right leg; her lower wound was 2”x1” and her upper wound was 0.5cm in diameter with healthy edges and no signs of infection.
The physician had a long conversation with the patient regarding wounds and wound management. After risks and alternatives were discussed, the patient agreed to proceed with wound debridement which was scheduled for two days later.
The patient underwent leg irrigation and debridement with delayed primary closure and dressing under anesthesia. Cultures were taken for further testing and analysis. The wound was packed with Kerlix soaked with betadine and wrapped with a clean dressing. The patient was prescribed antibiotics prophylactically.
Two days following the procedure, the physician noted redness of the lower wound. The upper leg wound was observed to be completely closed and healed without any inflammation. The lower leg wound was noted to have a couple stray sutures present that were removed. The physician irrigated, debrided, and packed the wound and he instructed the patient to continue her antibiotics.
The next day the physician called to check on the patient. The patient reported that she had worked long hours and requested pain medications. The physician's notes indicated that he advised the patient to elevate the right leg and avoid standing for long hours.
Over the next few weeks the patient’s leg remained swollen and the lower wound remained open.
The healthcare records reflected it was clear the condition of patient’s right leg worsened when she stood for long periods of time. The physician had another long conversation with the patient regarding the effects of standing for long periods of time on both leg wounds.
The patient “promised” the physician to rest her leg over the next two weeks because she was going on vacation and would rest and keep her leg elevated. The physician instructed her to stay out of the sun as much as possible, keep her leg elevated and change the dressings every day. He monitored the patient’s wound daily via telephone for the entire duration of her trip. The patient sent pictures of her wound to the physician for further evaluation.
The patient came to see the physician the day after returning from vacation. She appeared very tan and the dressing on the wound had not been changed in several days. Her leg appeared much worse and she was diagnosed with cellulitis and abscess of the leg wound along with Methicillin susceptible staphylococcus aureus (all other cultures taken prior to this date had been negative).
This was the last time the physician saw the patient. When the staff called to remind the patient of her appointment with the physician she told them she was not coming back.
Six months later, the patient filed lawsuit against our nurse and the physician.
Risk Management Comments
The plaintiff alleged that our insured nurse was:
- Negligent in performing the sclerotherapy procedure
- Negligent with the solution used during the sclerotherapy as it was too corrosive, thereby killing the surrounding tissue
- Negligent in managing wound care
The plaintiff further alleged that the nurse was using off-label, non-FDA approved hypertonic saline solution to perform the sclerotherapy, and that it was the high concentration of the solution that caused damage to the patient vein thus resulting in the patient’s injuries.
The patient claimed that her leg was grossly disfigured and that she could no longer work as a hair stylist due to the pain she endured while standing.
Defense experts determined that our insured nurse had not breached the standard of care and at all times provided care commensurate with the degree of care and skill ordinarily exercised by a registered nurse within the field of vascular therapy. Furthermore, to a reasonable degree of medical probability, no act or omission on the part our insured nurse, caused or otherwise contributed to any of patient’s alleged injuries and damages. The experts were complimentary on our nurse’s documentation of the procedure and patient education provided to the patient.
The experts suspected that the patient failed to wear her compression stockings as previously advised, since pictures revealed her lower right extremity swollen and this swelling would impede proper wound treatment.
Defense experts testified that standing for long periods of time also likely contributed to the swollen condition of the patient’s leg and further prolonged the healing of both wounds.
Experts testified that while the solution used in the sclerotherapy was a hypertonic saline, there are a number of physicians who use this solution since it is relatively inexpensive. With the positive expert opinions, defense council filed for a motion of summary judgement, but the courts denied the request.
The patient’s attorney requested a settlement amount of $750,000, which defense council objected to as we felt strongly that our nurse had not breached any nursing standards. Nevertheless, defense experts felt that our chances to prevail at trial were greater than 75 percent.
The case went to a jury trial that lasted seven days, and resulted in the successful defense of our insured.
The jury was so angered by the patient’s claims against our nurse that they awarded defense costs associated with trial be reimbursed (amount paid by plaintiff was greater than $25,000).
Risk Management Recommendations
- Follow documentation standards established by professional nursing organizations and comply with your facility’s standards. The medical record should accurately reflect the care of the patient.
- Develop, maintain and practice professional written and spoken communication skills. When working in a new setting, it is the responsibility of the nurse to be familiar with other healthcare providers that may provide care to your assigned patient.
- Follow-up on any care provided by another healthcare provider to ascertain that the standard of care and the facility’s policies and procedures have been met. It is the responsibility of the assigned nurse to maintain safe and accurate patient care.