Placing an intravenous catheter is so routine that it can often become robotic for the nurses who perform IV starts day after day. However, let the following case remind you that even the simplest procedure can turn into a nightmare if you get sued — especially if the charting is shoddy.

Blisters near infusion site
A 48-year-old female secretary developed carpal tunnel syndrome that required surgery. She had a history of hypertension, diabetes and hypothyroidism. On the day of surgery, a nurse at the surgery center assessed the patient and inserted a routine IV catheter into the patient's right forearm. The physician had ordered half-normal saline with 5% dextrose with 40mEq of potassium chloride. The nurse started the infusion while the patient was in the holding area.

The patient was scheduled to be the second case that morning. However, because the OR team encountered a complication in the first case, the patient had to wait more than 4 hours in the holding area. About 21/2 hours after the infusion began, the nurse noted that blisters had developed near the area where the catheter had been inserted. In the days after surgery, the blisters led to necrosis and painful, permanent scars.

The patient claimed that the blisters developed as a result of improper insertion of the catheter. Over time, her arms developed eschars — buildups of necrotic tissue. She underwent debridement of the dead tissue, but it left permanent scars on the upper inside regions of her forearms. She complained that she suffered from severe pain whenever the scar tissue was stretched. Because of her injury, she had to switch to a steady nightshift at her job in order to avoid the daily physical tasks required on the dayshift.

The lawsuit
The patient sued the surgery center, alleging that her damages arose from the staff negligently inserting the catheter and failing to properly monitor the infusion site. The patient's lawyer argued that either the medication was infused too fast and resulted in a rupture of the patient's vein, or that the catheter may not have been inserted into a vein. Either scenario, he claimed, would have allowed toxic extravasation of the medication. Regardless, the error should have been discovered before 21/2 hours had passed.

The surgery center defended itself on the grounds that extravasation is a known risk for the insertion of an IV catheter and that there is an even more increased risk with a solution containing potassium. Potassium is known to cause tissue irritation and damage whenever it infiltrates into the tissues.

Sparse documentation
During the discovery phase, the nurse testified that she had positive blood return on insertion and that the IV catheter flushed easily before starting the infusion of half-normal saline with 5% dextrose with the added 40mEq of potassium chloride. She further testified that it was her habit, as a nurse with more than 20 years' experience, to assess a new IV catheter site every time she checked the patient's vital signs in the holding area. The surgery center had a policy that the patient had to be assessed at least every 30 minutes while waiting to go from the holding area to the OR. She testified that she surely would have checked the site and assessed it for signs of redness, drainage and infiltration every 30 minutes. The nurse said that it was on her fourth check that she noticed the blisters. Despite her testimony, the medical record had little documentation of the IV site. The only note in the chart referring to the catheter site was the initial note following insertion and then 21/2 hours later, when the nurse discovered the infiltration and extravasation.

ASC settles for $1.5 million
During the course of the trial, an expert witness for the plaintiff said that despite the fact that infiltration is a known risk — and that potassium chloride increases the risk of extravasation due to its irritating quality — the medical record didn't reflect the proper care and treatment that the patient should have received. This supported the plaintiff's position that the surgery center failed to properly monitor the catheter site. The known risk didn't relieve the facility of the duty to properly monitor the IV site and identify an infiltration or extravasation in a timely manner.

After 2 days of testimony, the plaintiff rested her case and the defense approached her with an offer to settle. The plaintiff agreed to a settlement of $1.5 million in damages for her past and future pain and suffering as well as permanent disfigurement.

The surgery center agreed to settle in order to cut its losses. After hearing the expert testimony, the defense was afraid that the jury would believe that the nurse was lying because there was no documentation in the chart about the condition of the infusion site for 21/2 hours. The defense reasoned that if the jury thought the nurse was lying, there was a good chance that it could award the plaintiff even more than $1.5 million.

This legal nightmare could have been avoided if the nurse had taken a few seconds to document that she verified the catheter site every half hour, proving once again the age-old adage that if it isn't charted, it was never done. Adding detailed documentation to a patient's chart may seem time-consuming or a distraction that compromises patient care, but a well-documented medical record is the best evidence should you land in court.