Where knowledge and evidence converge: Defending yourself in court
Documenting site-specific knowledge is the sure route to legal protection
When administrators at Mclaren Hospital in Flint, MI, asked Debbie Ward, RN, to help design computer programs for documenting IV placement, she assumed the end product would include detailed site drawings with vein names clearly marked. But an unexpected change was on the way.
"What we had done for 10 or 15 years was use an IV flow sheet with a diagram of the arm with drawings of the major veins," Ward says. "So when I helped design the screens, I used the vessel names and divided the forearm into thirds."
Ward, who sees computer charting as equally important for home infusion therapy documentation as it is in hospitals, was dismayed when the hospital’s final screens deleted vessel names and gave left forearm, right forearm, and upper arm as documentation choices. The hospital administration’s explanation for this was its belief that most nurses wouldn’t know vessel names anyway, so why confuse them?
Such option reduction makes documentation very difficult.
"Obviously, you’re going to have more than one site in a person’s forearm," Ward says. "When a patient has an IV for any length of time, a restart will be required. If a problem should arise with one peripheral line — and a patient has already had two or three sites in that same forearm — how can you differentiate the line that had the problem from the other sites? You don’t know whose line caused or resulted in the complication, and so which nurse is implicated? From what I’ve read, a nurse who is called to defend the choice of vein in court has to back up that choice with very good reasons, not just, That was the only site I could find.’"
Ward acknowledges that there is some disagreement about using vessel names. "But certainly the computer screens need to be more specific. Even if the site is just described in words, a nurse needs more options than just left or right forearm.’"
Keith Allen, RN, CRNI, manager of clinical nursing practice for Olsten Health Services in Plainview, NY, uses the IV documentation form with arm drawings (see chart, p. 123).
According to Darnell Roth, RN, CRNI, LNC, an IV therapy nurse who does legal consulting through her St. Louis-based firm, D/R Intravenous Therapy Consulting Inc., the historical documentation practice did not include denoting vessel names.
"It was left forearm, right upper arm, inner arm, right hand, etc.,’" she says. "Once the peripherally inserted central catheters (PICCs) came on the scene, you started seeing people denoting the vessel into which the tip was inserted. Certainly this raises the question, Should we not be doing this with other peripheral lines?’ Designating vessels in documentation is not being taught in nursing schools, and the majority of nurses — unless they are really attuned to IV therapy — are not accustomed to doing this kind of documentation."
| Infusion Nursing Malpractice Lawsuits Handled by Perivascular Nurse Consultants Inc. from January 1997 through January 1999 (listed by type) | |
| Nerve Injuries | 19 cases |
| Extravasation | 18 cases |
| Infiltration | 15 cases |
| Catheter Fracture | 9 cases |
| Sepsis/Infection | 6 cases |
| Thrombosis | 6 cases |
| Phlebitis | 6 cases |
| Catheter Malposition | 6 cases |
| Air Embolism | 1 case |
| Total | 80 cases |
| Source: Perivascular Nurse Consultants, Philadelphia. | |
Documentation is your friend
With today’s fast-paced health care environment, nurses often do not always have time to document as thoroughly as they would like. However, nurses are clearly not well-served by failing to designate vessels if IV therapy results in injury and a subsequent malpractice case. Sue Masoorli, RN, heads Perivascular Nurse Consultants Inc., an infusion therapy and legal consulting agency. Masoorli, who teaches PICC and IV insertions nationwide, spends about 30% of her time reviewing and testifying in IV therapy malpractice cases, says the most important issue in any lawsuit is documentation.
"The biggest problem when you get to court for liability is that the documentation doesn’t back up what you said you did or didn’t do," she says. "I don’t think that flow sheets work well for IV documentation, so I’ve designed my own set of documentation forms." (See forms, right and p. 124.)
Source: Perivascular Nurse Consultants, Philadelphia.
The most court cases Masoorli sees are for nerve compression, puncture, or contact injuries. "We see a lot of infiltration lawsuits in which the infiltrations are so large that the weight of the fluid in the tissue causes nerve compression injury, so these patients may have permanent carpal tunnel injury," she says.
The second-largest case type is catheter malpositioning. Masoorli stresses that the only way to document catheter tip placement is by X-ray verification.
"You have to obtain the X-ray report, which will tell you where the tip is," she recommends. "The Intravenous Nurses’ Society has that in their standards in four different places; NAVAN has a position paper on tip placement. That’s a very big issue when it comes to central lines."
Masoorli says that though most nurses have the X-ray taken, many still do not read the results. "I can’t tell you how many cases I’ve had where the nurse infused medication and never knew where the tip of the catheter was. It usually results in death. The liability does not go back to the person who inserted the tip, but to the nurse who infused the medication without checking the tip placement — it’s that nurse’s job to know where the tip is. Nurses have to know the placement of all central lines, not just PICC [peripherally inserted central catheter] lines."
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