Nurse Sued For "Too Many Sticks" How Many Attempts Is Too Many?

Clinical Nursing Malpractice Case Studies, January 29, 2002
Coleman v. East Jefferson General Hosp., 747 So.2d 1044- LA (1999)

Summary: Starting Intravenous Lines and Performing Venipunctures are basic nursing skills in the Acute Care or Hospital settings. In this case, a female patient would accuse a male nurse of negligence and causing a resulting injury when he needed three attempts to successfully start an intravenous catheter.

The female patient came to the hospital with vague complaints of abdominal pain and was evaluated in the Emergency Department. The physician’s orders for treatment included intravenous medications for which a line would need to be started.

“Up to 90% of patients who require health care services need some form of I.V. therapy. Unfortunately, many hospitals have done away with I.V. teams, so you may be responsible for inserting and maintaining I.V. lines even if you're inexperienced or have limited opportunities to keep your skills sharp.”2

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Sidebar:

Venipuncture and the insertion of intravenous catheters are basic nursing skills. If a nurse has not learned these skills in Nursing School, it will be often be learned “on the job” in the early months of orientation at an acute care facility.

As with most nursing skills, it is one that improves with practice. The prudent nurse will attempt once or twice and then ask another nurse to give it a try.

In rare cases, you will come across patient’s that are “a difficult stick.” In this case, if there simply are “no veins” the physician should be notified or an expert nurse should be called in.

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A male nurse was assigned to the patient when the Intravenous Catheter was to be placed. The nurse was having difficulty finding veins in the woman’s arms. He then attempted twice to start a line in her hand and was successful on the third attempt.

It was the policy of the hospital at that time, that a nurse may attempt an intravenous catheter insertion no more than two times before calling for assistance.

For the remainder of the patient’s treatment at the hospital, it would be documented that the patient complained of discomfort at the IV site and tolerated it poorly.

Pain or discomfort at the site of an IV insertion should present a “red flag” to an experienced nurse.

When combined with redness, swelling, puss or exudates at an IV site, pain can signal one of many potential complications of Intravenous Therapy including extravasation of IV fluids/medication, infection of the site or a dislodging of the catheter.

When pain or potential complications are reported, the site should be thoroughly evaluated for signs of a problem. If symptoms persist, the placement of another line at an alternate site should be offered for continued Intravenous Therapy.

There was no indication in the hospital record, that other signs/symptoms of a complication existed other than the pain/discomfort. This may have been positional due to the location of the IV site in the patient’s hand.

There was no indication that placement of another line was either offered to, or refused by the patient.

“When an I.V. lawsuit is argued in court, top-notch I.V. skills don't mean much unless they're backed up by appropriate, accurate, and concise documentation. Unfortunately, documentation is where many nurses fall short.”2

Following her discharge, the patient would file a suit alleging negligence on the part of the nurse and hospital. Specifically, she claimed a poorly performed catheter insertion caused her to develop Reflex Sympathetic Dystrophy in her right hand.

“What is Reflex Sympathetic Dystrophy Syndrome?

Reflex sympathetic dystrophy syndrome (RSDS) is a chronic condition characterized by severe burning pain, pathological changes in bone and skin, excessive sweating, tissue swelling, and extreme sensitivity to touch. The syndrome is a nerve disorder that occurs at the site of an injury (most often to the arms or legs). It occurs especially after injuries from high-velocity impacts such as those from bullets or shrapnel. However, it may occur without apparent injury.”3

Summary judgment was entered for the hospital finding that no negligence was evident.

The patient appealed.

Questions to be answered:

1. Was the nurse negligent in his catheter insertion technique? Were certifications and hospital policies/procedures adhered to?

2. Were standards of care, specific to Intravenous Catheter Insertions adhered to.

3. Was it plausible, that the patient’s “Reflex Sympathetic Dystrophy” may have resulted from the multiple catheter insertion attempts that day?

On review of the chart and following expert testimony, no deficiencies in technique could be found in the placement of the catheter. By his employment record and training, he was fully qualified to place intravenous catheters as a part of his scope of practice as a licensed nurse.

It was noted that the hospital’s standards, allowed for a maximum of two attempts before calling for assistance. The nurse in question, attempted three times.

On further review, the “community” standards, which was the measure used for this case, allowed four insertion attempts. By this standard of care, the nurse was within reasonable limits by trying three times.

Expert Testimony addressed the issue of “causation” of the patient’s “Reflex Sympathetic Dystrophy.”

In statements made, no direct causative link could be established between the starting of an intravenous catheter, and a diagnosis of Reflex Sympathetic Dystrophy.

At best, the plaintiff’s expert stated that it was a slim possibility, that a link could be made. The physician offered no support to the claim that the plaintiff’s alleged injuries were caused by the catheter insertion.

The appeals court affirmed the judgment of the lower court.

It should be noted that Intravenous Therapy, while a basic part of nursing practice, is extremely prone to complications and resulting malpractice & negligence actions.

Related clinincal Nursing (Malpractice) Case Studies:

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

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/080199.htm

July 11, 1999: Nursing Home Rehabilitation Stay Proves Terminal. Was Quality of Care Given An Issue?
Nursing homes are frequently a patient's destination for rehabilitation following surgery.  Common conditions fitting this bill include large bone fractures, hip replacements and stroke. Following these acute episodes, the patients are too unstable to go home and not "sick" enough to have their hospital stays reimbursed by insurance companies.  The purpose of admission to a nursing home is to help the patient regain lost function, strength and health.  In this case, the patient would remain in the Nursing Home till her death of complications.
Lloyd v. County of Du Page, 707 NE.2d 1252 - IL (1999)
http://www.nursefriendly.com/nursing/clinical.cases/071199.htm

June 6, 1999: Emergency Department Nurse Verbally Abused, Physician History Well Documented
Official tolerance for verbal abuse and sexual harassment is approaching zero.  It is clear that both are still prevalent in healthcare settings today.  Enforcing and reporting instances of abuse are critical to an end being put to the situation.  In this case, a physician had a "history" of verbal abuse in the facility involved.  It was the documentation of previous events that made formal action and administration of a suspension feasible.
Gordon v. Lewiston Hospital, 714 A.2d 539 – PA (1998)
http://www.nursefriendly.com/nursing/clinical.cases/060699.htm

Resource Link Sections:

Clinical Charting and Documentation, Nurses Notes:
http://www.nursefriendly.com/nursing/directpatientcare/clinical.documentation.nurses.notes.htm

Courtroom Directory (National):
http://www.legalnursingconsultant.org/legal.nurse.consultants.lnc/courtrooms.online.htm

Direct Patient Care Links :
http://www.nursefriendly.com/nursing/linksections/directpatientcarelinks.htm

Emergency Department Nursing:
http://www.nursefriendly.com/emergency/

Intravenous Therapy: Certified Registered Nurse Infusion (CRNI), Conscious Sedation, Heparin Administration, Commercial Infusion Pumps, Home Infusion, IV Fluids, Intravenous Therapy Humor, Nursing Consultants, Nursing Societies, PICC Lines, Professional Associations, Starting An Intravenous IV Line, Venepuncture, Steroid Therapy
http://www.nursefriendly.com/intravenous/

Medical Legal Consulting Nurse Entrepreneurs:
http://www.nursefriendly.com/nursing/ymedlegal.htm

Reflex Sympathetic Dystrophy Syndrome (RSDS), Neurological Disorders, Chronic Pain:
http://www.nursefriendly.com/rsds/

References:

1. NLRR 8 (January 2000)

2. Satarawala, Rebecca . “Confronting the Legal perils of I.V. Therapy.” Nursing2000 August 2000. Retrieved January 23rd, 2002 from the World Wide Web: http://www.springnet.com/ce/p008b.htm

3. National Institute of Neurological Disorders and Stroke, Public Domain. NINDS Reflex Sympathetic Dystrophy Syndrome Information Page. Retrieved January 23rd from the World Wide Web: http://www.ninds.nih.gov/disorders/reflex_sympathetic_dystrophy/reflex_sympathetic_dystrophy.htm