Certified Registered Nurse Anesthetist - Improper Technique When Performing a Peribulbar and/or Retrobulbar Block

Medical malpractice claims may be asserted against any healthcare practitioner involved in the care of a patient, including certified registered nurse anesthetist (CRNA). This case study involves a CRNA working in an ambulatory surgery center.

Indemnity/ Settlement Payment:  $0.00                                          
Legal Expenses: Approximately $270,000

(Monetary amounts represent only the payments made on behalf of the insured CRNA and does not reflect payments made on behalf of any other parties involved in the claim.)

A 79 year-old male was scheduled to have cataract surgery on the right eye. The insured CRNA was called in to perform a peribulbar eye block on the patient prior to his cataract surgery as the scheduled CRNA was busy with another patient.

The insured CRNA removed the Honan Balloon and utilized a 27 gauge 1.25 inch sharp ended needle to perform the eye block. The insured performed two needle sticks in different locations around the eye to administer the numbing medication. Shortly after the injections, the insured reapplied the Honan Balloon.

When the patient reached the operating room, the Honan balloon pressure was at 20-mm mercury. However, the eye surgeon noted that there was the presence of either a potential vitreous hemorrhage, a retinal detachment, or a choroidal effusion or hemorrhage.  The decision was made to abort the cataract surgery and immediately referred the patient to a retina specialist for evaluation.

The retina specialist diagnosed the patient as having choroidal hemorrhages. Over time, the patient underwent multiple procedures in an attempt to repair the hemorrhage, but eventually lost complete vision to his eye. Prior to his scheduled cataract surgery the vision in his right eye was 20/40.

During treatment of his choroidal hemorrhages, no healthcare provider ever identified a perforation or tear in the globe of the patient’s eye. However, the patient was fine prior to the block and 20 minutes after the block the patient could not see out of his right eye.

One year following the incident, the patient filed a lawsuit only against our insured CRNA. The allegations were that during one of these two injections the CRNA “went too deep” and got “behind the eye” and perforated/tore the globe of the eye resulting in permanent blindness to his right eye.

Risk Management Comments
The patient’s post incident medical costs exceeded $450,000 and future medicals costs were estimated to be an additional $100,000-$150,000. 

The plaintiff’s experts were very critical regarding our insured’s documentation practices. Plaintiff claimed the informed consent was not properly obtained, a post-procedural assessment was not performed after the peribulbular eye block was performed, and the insured falsified his documentation.

During investigation of the claim, the informed consent form did not have our insured’s name listed as the individual who would be administering the nerve block.  While this was not ideal, failure to have his name on the form was due to him being called in to perform the procedure at the last minute. Further, the CRNA entered both his pre and post-procedural notes with the exact same time, giving the appearance that he did not perform a post-procedural assessment on the patient.  Overall, the defense expert did find the insured’s care perfectly within the standard of care. However, the expert found the insured’s documentation practices less than ideal.
The defense expert (eye surgeon and retina specialist) testified that the injury was more likely a hemorrhage due to either a preexisting problem with his choroidal tissue or that he began bleeding after the application of the Honan balloon. The expert testified that he did not see any evidence that the patient’s globe was perforated and according to the healthcare record, neither did the patient’s eye surgeon. He also stated that if the globe was punctured, the pressure inside the eye after the application of the Honan balloon would have been near zero prior to him going back to the operating room.

The defense expert and the patient’s eye surgeon testified that the CRNA’s needle placement and the depth of the injections were within the standard of care for a peribulbar block. Both also testified that they would have expected the retina specialist to locate a puncture site if one was present. Although the CRNA’s name did not appear on the informed consent form, the block procedure was thoroughly explained and documented prior to the injections. 

Resolution
There was an attempt to settle the claim at mediation, but the plaintiffs (patient and his wife) refused to consent to settle the case for anything less than $500,000. Therefore, the matter proceeded to trial.

The jury trial lasted five days, and in the end, a defense verdict was awarded to our insured. The claim lasted more than three years and at a cost of over $270,000 to defend.

Risk Management Recommendations

  • Maintain competencies (including experience, training, and skills) consistent with the needs of assigned patients and/or patient care units.
  • Obtain and document informed consent for the planned anesthetic intervention from the patient or legal guardian, or verify that informed consent has been obtained and documented by a qualified professional.
  • Document pertinent anesthesia-related information on the patient healthcare record in an accurate, complete, legible, and timely 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.
  • Report any patient incident, injury or adverse outcome and subsequent treatment/response to risk management or the legal department.
 
The above examples are not intended to establish any standards of care, to serve as legal advice appropriate for any particular factual situations, or to provide an acknowledgement that any given factual situation is covered under any CNA insurance policy. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. All CNA products and services may not be available in all states and may be subject to change without notice. "CNA" is a service mark registered by CNA Financial Corporation with the United States Patent and Trademark Office. Certain CNA Financial Corporation subsidiaries use the "CNA" service mark in connection with insurance underwriting and claims activities.  Copyright © 2018 CNA. All rights reserved.

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