December 2018 – Claims & Risk Newsletter

Infusion Confusion: Risks and Preventative Measures

Janet Merrell, RNC

Senior Claims Consultant

Peripheral intravenous infusions are very common in hospitalized pediatric patients, but this common procedure can also pose a significant risk of injury. Infiltration can happen quickly and some medications may be especially damaging to tissue, leading to scarring. Proper insertion of IV catheters and site monitoring are critical nursing functions that prevent this from happening. Consider the following three claims related to pediatric peripheral IV infiltrates:

A nine-month-old child admitted with gastroenteritis had an IV started in his foot. The child was exceedingly irritable during his hospitalization, a state attributed to his diagnosis. However, when his foot was unwrapped approximately 72 hours after admit, gross edema was present and blisters subsequently formed. The child’s wounds were treated at a burn unit, but scarring did develop. The child was subsequently seen by both orthopedics and plastic surgery. A medical review panel found an issue of fact regarding how frequently the IV was checked and if the IV site was actually visualized. The claim was eventually settled as there was no real evidence of the site being visualized in the medical record.

A two-month-old was admitted for projectile vomiting requiring surgery. A saline lock that was started in his foot in the ED wouldn’t flush later when the pediatric floor nurse attempted to start IV fluids. The nurse found the IV catheter was kinked and repositioned it without restarting the IV just prior to starting IV fluids. After the patient was transferred to surgery, the foot was noted to be edematous and the IV infiltrated. Blisters subsequently formed and the wound was treated by the wound care nurse. Although there was no permanent scarring, there was pigment loss to the skin at the site. The claim was settled prior to a Medical Review Panel due to concerns with the repositioning of the IV and lack of documentation of site monitoring.

A 10-month-old was admitted with a cough and wheezing, and an IV was started in her right hand. Documentation of IV site checks was sporadic. On the third day of hospital admission, the hand was unwrapped to discontinue the IV and the child’s fifth finger was noted to be red and somewhat deformed. The child was eventually diagnosed with gangrene of the finger and lost the distal tip, leaving a shortened, deformed digit. Although a Medical Review Panel concluded there was no breach in the standard of care, two other medical experts raised questions about the wrapping of the IV and the inability of the nurses to visualize the tips of the fingers when checking the IV site. Because of these concerns, the claim was settled.

Caroline Stegeman, RN, BSN, MJ, ONC, CPHRM

Senior Patient Safety Consultant

IV therapy is an important part of the practice of medicine as it is one of the most basic treatments given to almost every patient admitted to the hospital.  It is the administration of a fluid and/or medication directly into the vein as a therapeutic treatment.  Many conditions/illnesses rely on medications administered by IV infusion therapy, ultimately requiring an IV to be inserted into a patient’s extremity.  IVs are commonly inserted in the hand or arm area and, in extreme circumstances, can be inserted into the foot or lower leg.  IV medications may irritate the insertion site and vein depending on the type, strength and administration rate of the medication and the patient’s sensitivity to the prescribed medication.  It is imperative for hospitals to have hardwired processes in place governing the assessment and maintenance of an IV insertion site to ensure that the patient does not suffer any untoward complications connected to IV therapy.

What is considered to be a normal IV insertion site?  A healthy vein is round, firm, elastic and engorged without hardened, bumpy or flattened areas.  The IV insertion site must also be free from redness, swelling, bleeding, warmth, pallor, pain or discharge.  The elderly and pediatric populations both have fragile veins that are prone to infiltration and possible complications. In turn, staff should be especially attentive to the assessment and maintenance of IV insertion sites in these populations.

The following are best practices regarding the assessment and maintenance of an IV insertion site, which should be documented at a minimum of every 2 hours:

  • Review physician’s orders to ensure the accuracy of the administration of IV therapy.
  • Review the patient’s medical records for any hypersensitivity to medications, preventing the risk of an allergic reaction.
  • Review the patient’s medical records for their intake and output to assess if there have been any previously noted IV site problems or fluid/electrolyte imbalances.
  • Wash your hands.
  • Assess the IV fluid to ensure it is the right fluid, right additives, right rate and right volume.
  • Assess the IV tubing connections and IV pump.
  • Check the IV site dressing and insertion site for the following:
    • Dampness
    • Redness
    • Warmth
    • Swelling
    • Pain
    • Drainage
    • It is important to remove any excess dressing to ensure the insertion site is visible to the naked eye.
    • These steps assess for any early signs and symptoms of IV site complications such as an infection, infiltration or phlebitis.
  • Address any assessment findings that may be abnormal, are different than the previous assessment and/or any complaints voiced by the patient/family.
  • Document. Document.

The lack of documentation of frequent IV site assessments can be detrimental not only to the patient but to the healthcare provider and hospital whether there is a medical malpractice claim or not.  We have to remember the old saying:  If it was not documented, it was not done! Hospitals and healthcare workers are encouraged to have best practice policies and processes in place regarding the assessment and maintenance of IV insertion sites, including requirements for documentation.  Hospitals are also encouraged to monitor IV site documentation on a routine basis to ensure the organization’s policies and processes in place are hardwired.

If you have any questions related to this newsletter, please contact:

Stacie Jenkins, MSN, RN
Sr. Director of Quality and Patient Safety
Allison Rachal, RN-BC
Sr. Patient Safety Consultant
Caroline Stegeman, RN, BSN, MJ, ONC, CPHRM
Sr. Patient Safety Consultant
Mike Walsh, AIC, CPCU
Liability Claims Manager

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