Legal Aspects of IV Therapy
By Kelli Rosenthal, MS, RN, BC, CRNI, ANP, APRN, BC
Over 90% of hospitalized patients will receive some form of intravenous therapy during the course of their care, and intravenous medication administration represents one of the highest-risk, most invasive procedures performed by nurses. Furthermore, it has been reported that 61% of the most serious and life-threatening adverse drug events are related to I.V. therapy. No wonder intravenous-therapy related law suits are at an all-time high!
Part of the problem is that I.V.s have become so common in nursing care that it is easy to forget the potential serious complications that can arise from improper technique, or from incorrect fluid or drug delivery. Known complications from infusion therapy include: Deep vein thrombosis
Extravasation injury leading to nerve damage, scarring, or burns
Complex Regional Pain Syndrome
Adverse drug reactions.
With proper monitoring and knowing the standards for safe infusion care, many of the situations that lead to the development of these complications can be avoided, minimizing your risk of becoming a defendant in an I.V.-related lawsuit.
So what standards actually govern I.V. care? The Standards of Practice for Infusion Nursing are published by the Infusion Nursesí Society. These standards set the criteria for what constitutes safe infusion care across the continuum of care, and are often cited in IV-related law suits as the benchmark for whether a nurse has violated the standard of care. It is important that agency policy adhere to these standards. The INS Standards are most likely available in your hospitalís medical library under The Journal of Infusion Nursing. If not, you should ask the medical librarian to obtain a copy for your institution. Other examples of standards are your institutionís policies and procedures for I.V. care, the drug or device manufacturerís instructions for use, and your stateís nurse practice act. In a court of law, the most restrictive standard (institutional, legal, or specialty practice) is usually applied.
Pharmacies maintain a list of references detailing the correct compounding, dilution, admixing and administration of medications and solutions approved for use in the facilities they service. If you are ever unsure of the correct means of delivering an I.V. medication, check with your pharmacist. At the minimum, they should be able to provide you with a manufacturerís package insert with directions for use. You should also be aware of the location of policies and procedures relating to infusion care in your facility. Always review your facility policy when administering a new drug, or one you may not have given recently. Nursing drug handbooks and the Physicianís Desk Reference are also useful references regarding particular medications.
Sometimes patient injuries may still occur. Nursing care is performed by human beings, and we are all capable of making mistakes. Patients may experience unexpected outcomes, whether or not the care they received was diligently provided. What, then, constitutes the difference between malpractice and misadventure? In order for professional malpractice to have occurred, it must be determined that:
The nurse was negligent (did not act in the way a reasonable and prudent nurse would have acted in the same circumstances)
(S)he had a duty to the patient
(S)he breached that duty
That breach was the proximate cause of the injury/damages
The plaintiff (patient) must have incurred an injury as a result of the negligence
Damages must have accrued as a result of the injury.
An example of negligence would be a nurse who did not have appropriate training to do so attempting an IV start. An injury would be where the patient developed nerve damage when the negligent nurse attempted venipuncture, and damages would have accrued from the negligent I.V. start if it were determined that the injured patient would never regain full function in their hand as a result of the injury that arose from the negligence of the nurse. This case would meet all the criteria of a professional malpractice case.
Often, both sides of a case will bring in nurse-experts to review the medical records and offer an opinion on whether or not the patientís care met the applicable standards, or were indeed the proximate cause of the injury. It is thus critical to assure that your documentation demonstrates to whomever reads it later that the care you provided met the standard. Your documentation should always record verbal and written consents obtained prior to the procedure . The consents should be obtained from the patient, the family, or the patientís power of attorney (In a hospital setting, written consent may have been obtained when the patient was admitted to service). For more important and useful information on IV documentation see Documentation of IV Therapy.
Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. JAMA. 1997;277:307-311.
Intravenous Nurses Society: "Intravenous Nursing Standards of Practice," Journal of Intravenous Nursing. 23(Suppl, 63), November/December 2000.
Brent, N. (1997). Nurses and the law: a guide to principles and application. Phladephia: W.B. Saunders.