Nurse Case Study: Deviation from the standard of care

This case involves a registered nurse working in an ambulatory surgery setting.

Total incurred payments and expenses: Greater than $375,000

(Monetary amounts represent only the payment made on behalf of the insured registered nurse and do not reflect payments made on behalf of the other parties involved in the claim.) 


A patient, with a recent prior history of a carpal tunnel release of the left arm (dominant hand), was undergoing a surgical procedure under anesthesia. On the day of his procedure, the pre-operative insured registered nurse documented that the patient’s carpal tunnel surgery was “four weeks ago”.

The insured registered nurse/defendant informed the patient that due to the type of procedure, an intravenous (IV) line was recommended for the patient’s left hand/arm. The patient requested that the IV be placed in his right hand, rather than his left hand, because his left wrist still hurt from the recent release.  

Documentation in the patient’s healthcare information record was unclear regarding the IV and multiple unsuccessful attempts to insert the IV.  The record seemed to indicate that there were only three unsuccessful attempts to start an IV. However, the patient and his wife later testified that there were seven IV attempts made by three different nurses and produced photographs to support their claim. Ultimately, a 20G IV was successfully placed in the patient’s volar aspects of the patient’s left wrist, but documentation was unclear as to the nurse who successfully placed the IV in the patient’s left wrist.  

Prior to departing from the pre-operative area, the patient complained of tingling type pain and numbness in his left wrist. According to the patient, the insured nurse checked the IV and verified that the site was not red, swollen and flushed easily. He further testified that the nurse stated the IV site was fine and “the IV should stop hurting soon”. A few moments later, the patient was taken to the operating room to undergo his procedure.  Unfortunately, the nurse failed to document the patient’s complaint or the interventions to adjust the placement of the IV.

Following the procedure, the patient was sent to the post-anesthesia care unit (PACU) where his wife joined him. The patient commented to the PACU nurse and to his wife that his left wrist was hurting and requested that the IV be removed. The PACU nurse removed the IV and documented that the IV was removed without any complications, and the integrity of the device was intact. The PACU nurse documented the patient’s complaints of wrist pain and that she had notified the surgeon and anesthesiologist of the patient’s wrist complaints.  The surgeon recommended the application of pressure with a dry sterile gauze over the IV site, elevating the extremity to reduce swelling and applying warm compresses. The patient was discharged from the surgical center and instructed to continue with the interventions to his wrist.       

When the patient was contacted the following day, he noted difficulty in using his left hand and forearm.  Over the next several weeks, the patient continued to experience increased pain and decreased range of motion to his left hand and forearm. He sought treatment from his hand surgeon, who diagnosed him with complex regional pain syndrome. Since the patient was left hand dominant and employed as an electrician, he was unable to work and was placed on disability.

The patient asserted that as a result of the injury, he has lost range of motion and the use of his left hand and arm. The allegations included permanent emotional and physical pain and unnecessary surgery in the form of implantation of a spinal cord pain stimulator.

The patient has an extensive prior medical history, as well as a history of depression. His initial intake form completed at the surgical center included self-reporting of migraines, sleep difficulties and left wrist pain. 

Records from his hand surgeon after the IV incident indicated that nerve testing showed mild changes in the median nerve consistent with postoperative endoscopic carpal tunnel release. Specifically, a left median nerve neurapraxia was appreciated across the left wrist consistent with a mild left chronic carpal tunnel syndrome. Range of motion between the right and left wrist reflected a significant difference. He obtained no relief with cortisone injections and was ultimately diagnosed with flexor tenosynovitis and regional pain syndrome. 
 

Risk Management Comments

The patient filed a medical malpractice lawsuit against the insured registered nurse, as well as the two other nurses involved with starting an IV on the patient. The major allegations asserted against all nurses included: 
  • Deviating from the standard of care related to starting an IV;
  • Failure to respond to the patient’s complaints of pain; and
  • Failure to follow documentation standards.   

During their depositions, the nurses were unable to explain the lack in documentation concerning the multiple IV attempts and patient complaints. The nurses were also unable to determine who placed the IV in the patient’s left wrist and acknowledged that their lack of documentation was a breach of the surgery center’s policy regarding patient documentation.    
 
During the discovery phase, the patient and his wife produced photographs of his hands and arms showing the seven unsuccessful IV attempts. The patient/plaintiff’s expert witnesses used the photographs and inaccurate/missing documentation in the healthcare record to demonstrate the nurses’ breach in the nursing standard of care and thus a deviation in patient care.

Defense experts reviewed the patient’s healthcare information record.  The defense experts testified that there was no contraindication to placing an IV into a volar vein, as long as it is not placed too deeply.  The experts found no evidence that the IV was placed too deeply in the patient’s left wrist. Defense experts were able to discredit the patient’s claim of disability related to regional pain syndrome.

However, there were concerns that the overall lack of proper and concise documentation could paint a picture of the nurses as lacking competency in this area. 
 

Resolution

A settlement was reached prior to trial. The portion of the insured’s settlement and expense cost was greater than $375,000. As mandated by federal law, the nurse was reported to the National Practitioner Data Bank (NPDB). 
Settlement on behalf of the other nurse defendants is unknown. 

Risk Control Recommendations

  • Maintain thorough, accurate and timely patient assessment and monitoring, which are core nursing functions.
  • Develop, maintain and practice professional written and spoken communication skills. Follow documentation standards established by professional organizations and comply with your employer’s standards, as appropriate.  
  • 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.
  • Document your patient care assessments, observations, communications and actions in an objective, timely, accurate, complete, appropriate and legible manner
  • Communicate in a timely and accurate manner both initial and ongoing findings regarding the patient’s status and response to treatment.
  • Provide and document the practitioner notification of a change in condition/symptoms/patient concerns and document the practitioner’s response and/or orders.

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