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Extravasation Follows Chemotherapy Administration. Potential Complication or Nursing Negligence
Iacano v. St. Peter’s Medical Center, 334 N. j. Super. 547 – NJ (2000)
Summary: Intravenous therapy has inherent risks and potential complications. When you introduce chemotherapeutic drugs and known vesicants, those risks increase dramatically. In this case, a known risk, extravasation, occurred following administration. The question arises, could the nurses have acted sooner to prevent the extravasation and resulting tissue damage.
The patient was an Oncology patient being treated as an outpatient for non-Hodgkin’s lymphoma, a cancer of the lymphatic system. On a regular basis (every third Friday), she would come in for her treatments. Her Chemotherapeutic regimen consisted of four different drugs, three of them given intravenously. The IV drugs were Cytotoxan, Oncovin, and Adriamycin.
Oncovin and Adriamycin are known vesicants (chemicals which can cause tissue damage and destruction if they leak into surrounding tissues) and typically administered via “IV Push” meaning they are injected directly into the bloodstream through an IV access device. It is critical that the patient be monitored for signs/symptoms of adverse reactions or complications during and after this type of administration.
“Extravasation of chemotherapeutic vesicant agents can result in significant tissue damage, alteration in limb function, and pain. Quality of life for long-term survivors can be severely impacted by negative sequelae from vesicant extravasation. Currently, there is no known preventive therapy. Early detection and intervention are paramount to halt tissue damage and reduce the chance of permanent disability or disfigurement.”2
On this day, the patient was accompanied by a friend who witnessed her treatment. She would attest to the patient’s account of administration of the medications and complaints of discomfort soon afterwards. She would state that the nurses on duty had been informed of this discomfort not once but twice but did nothing. Reports of a red, swollen and puffy hand appearance were allegedly made to the nurse with no action taken.
The patient was initially given Cytotoxan (not a vesicant) through a peripheral IV line in her right hand. Shortly after the infusion began, the patient would begin her complaints of discomfort in that hand.
The patient would state that even after describing her hand discomfort, the nurse injected the vesicant medications into the right hand IV site.
The nurse would later state that she got “good blood return” from the site and did not recall any complaints of pain by the patient. No nurse’s notes were available to collaborate her testimony.
Soon after administration of the vesicants, there were further complaints of pain, and new complaints of “burning.” An extravasation was then reported to the physician. Orders were obtained to discontinue the IV in that hand and treat the extravasation with cold compresses. Apparently, it was not until the patient reported a “burning” sensation that the nurse took notice and took action on the patient’s concerns.
“What is Extravasation? The leakage of intravenous drugs from the vein into the surrounding tissue.(1) Extravasation injury usually refers to the damage caused by leakage of solutions from the vein to the surrounding tissue spaces during intravenous administration. Once an extravasation has occurred, damage can continue for months and involve nerves, tendons and joints. If treatment is delayed, surgical debridement, skin grafting, and even amputation may be the unfortunate consequences.”3
(Please visit http://www.extravasation.org.uk/Definition.htm for a photo example of the type of injury involved in this case (center photo))
It is important to note that despite the patient’s complaints of pain, and witness reports, despite the documented report of an extravasation and resulting physician orders to deal with it, despite the restarting of the IV to continue therapy, no mention of these events was available in the nursing portion of the chart when it was reviewed after the fact.
The patient would need an Orthopedic consult to deal with the extensive damage caused by the extravasation. Debridement and tissue repair would leave permanent scarring and irreversible damage.
The patient sued the Nursing staff on duty that day for negligence. The courts returned an award of 1.5 Million dollars. This would later be ruled excessive and reduced to 0.5 Million dollars.
The defense appealed for a new trial based on the excessive award initially granted.
Questions to be answered.
1. Who was responsible for monitoring the patient for potential complications, and was this monitoring carried out within acceptable standards of care?
2. Special precautions/monitoring must be in place when administering vesicant medications. Were the nurses negligent in their duty to monitor for complications of chemotherapy?
3. Was the patient in fact having pain and discomfort well before the administration of the vesicants? If so, was the nurse in error, to administer the medication despite the patients concerns and complaints?
4. Was there appropriate documentation to support either the nurses or the patient’s account of the situation.
5. Could the extravasation and resulting tissue damage have been prevented?
6. Did the jury in the initial trial award an excessive amount based on flawed information in the initial trial.
The two nurses on duty were clearly responsible for monitoring this patient (and all the other patients in the office as well). It is recognized that the greatest responsibility would fall on the nurse who was administering the vesicant-type medications. Before administering any medication into an IV site, it must be assessed for signs/symptoms of irritation, patency and proper placement.
It would seem incredible, that a patient’s complaints of first discomfort, pain, and then burning would not be investigated by the nurses on duty. These are obvious signs/symptoms of potential vesicant complications. Due to the lack of documentation, this is what we must assume happened.
Of the two nurses on duty, at least one of them would have been made aware and had the responsibility to notify both the other nurse and the physician when appropriate. In light of the fact that an extravasation did occur and resulted in tissue damage, a case for negligence in the monitoring of this patient is established.
It can be argued that the “prudent nurse” when made aware of a patient’s discomfort, would have either slowed or stopped the intravenous infusion and checked the site before proceeding. With the patient’s companion echoing complaints of both pain and a “puffy, red” appearance, that IV site should have been discontinued immediately.
It is unfortunate that no nurses notes were available to give the nurses’ side of the story. It can only be assumed that there was in fact a problem with the site (based on the later reported extravasation and tissue injury).
"Each state has enacted a nurse practice act that authorizes an individual to practice as a registered nurse if the applicant meets specific criteria. Laws or administrative rules in each state further outline documentation issues, such as handling of records, falsification of records and confidentiality.6 Regardless of your work setting or nursing specialty, you must document care based upon the requirements of your state’s nurse practice act. For information on your state’s nurse practice act, contact the National Council of State Boards of Nursing at www.ncsbn.org.”4
There is an inherent duty which a nurse (like a physician) owes to a patient which is to do no harm, and protect them from foreseeable complications. In this case, when the nurse injected the vesicants into an IV site that had already been reported as “causing discomfort,” that duty was clearly not adhered to. Her testimony later that she had “good blood return” from the site was clearly an inadequate assessment.
The presence or absent of “blood return” is not a reliable indicator of an intravenous line’s proper placement or appropriate location.
Again, it would seem incredible that a nurse would inject vesicants, chemicals known to damage tissue and cause significant complications, into an already problematic intravenous site. Due to the lack of documentation in the medical record, we must assume this is what took place based on the end results.
If in fact the patient was complaining of discomfort from the site, then the vesicants should never have been injected. It is dictated by standards of care that, the existing site be discontinued and treatment initiated if warranted by nursing judgment or physician’s orders, another intravenous site be initiated and the medications placed in an alternate location. If no other location was available, or accessible a call would need to be placed to the physician for further orders.
Summary: In the end, the appeals court would find that even though the initial award was excessive, it was not based on an error or misinterpretation of fact. The request for a new trial was denied and the $500,000 award for the negligence on the part of the nurses was upheld.
Related Link Sections:
Clinical Charting and Documentation, Nurses Notes:
http://www.nursefriendly.com/nursing/directpatientcare/clinical.documentation.nurses.notes.htm
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Cancer, Oncology, Malignancy, Tumors (over a thousand sites):
http://www.nursefriendly.com/cancer/
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Direct Patient Care Links :
http://www.nursefriendly.com/nursing/linksections/directpatientcarelinks.htm
Extravasation, Vesicant Infiltrations, Complications of Intraveous (IV) Therapy:
http://www.nursefriendly.com/extravasation
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Informed Consent
http://www.legalnursingconsultant.org/legal.nurse.consultants.lnc/informed.consent.medical.legal.htm
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Intravenous Therapy, Nursing IV Team
http://www.intravenousnursing.com
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Nurse Practice Acts, Legal and Medical Links
http://www.legalnursingconsultant.org/legal.nurse.consultants.lnc/nurse.practice.acts.htm
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Nursing Professional Malpractice & Liability Insurance
http://www.nursefriendly.com/nursing/directory/business/insurance/nursing.professional.liability.insurance.htm
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Starting An IV Line, Intravenous Therapy, Infusion Resources:
http://www.nursefriendly.com/nursing/directpatientcare/intravenous.iv.therapy/starting.an.iv.line.htm
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Torts Law & Personal Injury, Legal Resources
http://www.legalnursingconsultant.org/legal.nurse.consultants.lnc/law/torts.htm
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Related Nursing Malpractice Cases:
August 1, 1999: Nursing Duty To Patient, "Does Not Guarantee" Safety Or
Quality Of Care.
Summary: When a nurse accepts report and responsibility for the care of a patient a duty to the patient is also accepted. This duty is to provide a reasonable standard of care as defined by the Nurse Practice Act of the individual state and the facility Policy & Procedures. In this case, a post-op abdominal aneurysm repair patient was injured after falling from his bed to the floor. When a lawsuit was filed the court initially mistook expert testimony to imply the role of the nurse includes a guarantee of safety.
Downey v. Mobile Infirmary Med. Ctr. - 662 So. 2d 1152 (1995).
http://www.nursefriendly.com/nursing/clinical.cases/080899.htm
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August 8, 1999: Pregnant Prison Inmate Complains of Miscarriage, Corrections Nurse On Duty Ignores Symptoms?
Ferris v. County of Kennebec, 44 5. Supp.2d 62 –ME (1999)
Summary: Nursing assessment skills are one of our most valuable assets. They allow us to effectively evaluate our patients and communicate significant findings to physicians and other members of the healthcare team. In this case, a pregnant woman with a previous history of miscarriage complained of vaginal bleeding and abdominal discomfort. The assessment performed by the nurse fell negligently short of the required standard of care.
http://www.nursefriendly.com/nursing/clinical.cases/080899.htm
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September 12, 1999: Sleep Apnea Monitor Turned off or Ignored By Nursing Staff, Patient's Coding Goes Unnoticed.
Monitors and Monitored patients present special challenges to practicing nurses. Like a call bell, when alarms on a monitor are activated, they can signal benign or life-threatening events. In this case, a patient's monitors did not alarm as expected. The patient was in distress and would be found without respirations and pulseless by the nurse on duty.
Odom v. State Dept. of Health and Hosp., 322 So. 2d 91 -LA (1999)
http://www.nursefriendly.com/nursing/clinical.cases/091299.htm
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October 3, 1999: Grand Mal Seizure Follows Cervical Myelogram, Anticipated Risk or Nursing Negligence?
Cascio v. St. Joseph Hosp., 734 So.2d 1099 - FL (1999)
Summary: With a proper Informed Consent obtained, it is accepted that a patient is aware of potential risks & complications prior to a procedure. In this case, following a cervical myelogram, a patient developed seizures and suffered an injury. The physician would blame the nursing staff for causing an "increased risk" by not following procedures.
http://www.nursefriendly.com/nursing/clinical.cases/100399.htm
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References:
1. 41 NLRR 6 (November 2000)
2. Kassney, Elizabeth. (6/1/2004). Evaluation and Treatment of Chemotherapy Extravasation Injuries. National Extravasation Information Service. http://www.extravasation.org.uk/Eval.htm (21 January, 2004)
3. Stanley, A. (6/1/2004). What is Extravasation. National Extravasation Information Service. http://www.extravasation.org.uk/Definition.htm (21 January, 2004)
4. Habel, Maureen. (1/13/03). Document It Right. Would your charting stand up to scrutiny? Nurseweek.com. http://www.nurseweek.com/ce/ce670a.asp (21 January 2004)
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