Over
85% of hospitalized patients will receive some type of IV
therapy. Of the 180 million vascular access devices inserted,
118
million are peripheral IV catheters and 34 million are winged
stainless-steel needles. That translates into about 150 million
opportunities for nurses who are inserting them to become
involved
in litigation.
Most lawsuits related to IV therapy involve infiltration or
phlebitis,
two complications juries tend to feel could have been prevented.
Let's look closely at these two areas of liability.
Liability issues
Infiltration--leakage of IV solutions or medication into the
surrounding tissue is common, although statistics aren't
available to
tell us exactly how common. When it occurs, liability falls
squarely
in the nurse's lap. After all, you're responsible for selecting
the
appropriate device, needle gauge, and venipuncture site, for
inserting the device correctly, and for monitoring and assessing
the
device and site once it's asserted.
By itself, infiltration doesn't necessarily mean you've acted
negligently, however. There are other important issues: What
solution infiltrated? Was it a vesicant that could cause tissue
sloughing? How much solution infiltrated--10 ml or 1,000 ml? How
soon did you find the infiltration--after 1 hour or after
4?
The bottom line is this: Was the patient injured by the
infiltrating
solution? The answer is generally no. But it would be yes if the
IV
site becomes grossly infiltrated, with edema covering large
areas of
soft tissue and causing a nerve compression injury that leaves
the
patient with little or no use of his or her hands and arms.
Also, if a
vesicant infiltrates, it can leave the patient with significant
tissue
loss, resulting in permanent disfigurement and loss of function
despite reconstructive surgery.
Phlebitis--inflammation of the vein wall is in many cases a
precursor to sepsis. At the first signs of trouble (tenderness
followed by changes in skin color over the site, such as a
reddened
area or pink or red stripe along the vein). you should remove
the
venous access device.
Why does phlebitis occur? The cannula may be too large or may
have been left in place for too long (over 48 hours). The vein
may
be in poor condition or may be too small. The solution may be
too
acidic or have an osmolality higher than that of human blood.
There
may be too much particulate matter in the solution, or the
infusion
rate may be too fast. Again, these are things you're expected to
know so you can prevent phlebitis.
Your best defense
Accurate, concise documentation is always your best defense. Be
sure to chart:
the date and time you inserted the venous access device
the specific vein chosen
the gauge and length of the inserted device
the brand and style of the device
the solution that's infusing
whether the solution is infusing by gravity or pump
(include the name and model number of the pump)
any comments the patient has made about how the site
feels.
This sounds like a lot, but it shouldn't take more than two
sentences. Or you could use an IV Flow sheet.
In litigation, you'd also have to justify your actions. So you
need a
working knowledge of the peripheral venous anatomy to help guide
you in selecting the venipuncture site, cannulating the vein,
and
assessing the site for impending complications.
This is the area in which nurses falter. I've found, for
example, that
most can't give sound clinical reasons for how they determined
which vein to use. "Its the only vein I could find" or
"It's the only
vein the patient had" aren't reasons. Instead, you should
be able to
assert that you'd chosen the most appropriate site for the
patient
that day and that the vein was soft, spongy and resilient.
Nor can many nurses give the criteria they used to assess the IV
Site and determine that the venous access device was still in
the
vein. For example, you'd want to say that you'd checked for
tenderness, redness, or pain when injecting an IV. Push
medication.
Dramatic changes
Intravenous therapy has changed dramatically over the past 5
years. If you're involved in delivering it, be sure you
recognize your
responsibilities, accountability and liability. And know the
practice
standards established by your state's nurse practice act, the
Centers for Disease Control and Prevention, the Occupational
Safety and Health Administration, and the Intravenous Nurses
Society--they're what you'd be judged against if you were sued
for
malpractice involving IV therapy.
AUTHOR
& REPRINT INFORMATION: by Sue Masoorli, RN, President,
Perivascular
Nurse Consultants, Inc.,Rockledge, Pennsylvania. From NSO
Risk Advisor, February
1995, Quotes of up to 300 words are permitted with credit to NSO
Risk Advisor. For
further information, contact: NSO Risk Advisor, 4870 Street Rd.,
Trevose, PA 19049.
Nursing
Liability Related CEU Courses
($8.00/Credit Hr Unless Otherwise Noted)
NURSING LEGAL ISSUES
