Where did this
patient’s
I.V. therapy
go awry?
Read this case study to see how good nurses found themselves on the wrong side of a lawsuit—and
learn what you can do to avoid the same pitfalls. BY KELLI ROSENTHAL, APRN,BC, ANP, CRNI, MS
ALL MEDICATION ADMINISTRATION carries cer-
tain risks, but intravenous (I.V.) therapy adds another
level of complexity. Even when you follow the “five
rights,” you can go wrong if your practices don’t meet
the standard of care for I.V. therapy. This case, a com-
posite of several incidents, illustrates how.
November 14, 2002
17:30.... Beatrice Smoltz, 64, is admitted from the
emergency department (ED) to the cardiac step-down
unit with increased dyspnea on exertion; increased
fatigue; a fast, irregular heart rate; peripheral edema;
and pulmonary crackles. Every few months for the
past 2 years, she’s been admitted with worsening heart
failure and treated with I.V. inotropic medications. On
this admission, her cardiologist, Joanne Briggs, orders
I.V. dobutamine and furosemide.
In the ED, the patient receives furosemide via a
20-gauge intermittent I.V. access device. The device is
inadvertently pulled out during her transfer to her bed
in the unit, and the nurses can’t locate another suitable
peripheral vein in her arms or hands.
The charge nurse, Caroline Scott, RN, calls Briggs
to notify her that the staff couldn’t restart a peripheral
I.V. line. Briggs orders stat placement of a central
venous catheter (CVC).
Both the ED attending physician and the on-call
general surgeon are busy with other patients. Scott
pages Briggs to notify her that the other physicians
aren’t available, but Briggs doesn’t respond to the page.
18:45.... Scott inserts an 18-gauge peripheral I.V.
catheter in the dorsum of Mrs. Smoltz’s right foot and
starts the dobutamine infusion.
21:20.... The general surgeon comes to the unit and
inserts a short-term, single-lumen CVC into the
patient’s right internal jugular vein. After a chest X-ray
56 Nursing2004, Volume 34, Number 5
confirms tip placement in the superior vena cava and
rules out pneumothorax, Scott connects the infusion
tubing to the central line and removes the I.V. device
from the patient’s foot. Her documentation indicates
that the right pedal site appears “bruised” and that
Mrs. Smoltz “verbalized no complaints” upon removal
of the cannula. No further documentation about the
site appears in the medical record.
November 16, 2002
Mrs. Smoltz’s condition improves. As ordered, she’s
weaned from the dobutamine infusion, the CVC is
discontinued, and she’s transferred to the general med-
ical unit, where she has bathroom privileges with
assistance.
November 17, 2002
10:35.... A nursing assistant helps Mrs. Smoltz walk
to the bathroom and tells her to press the call bell
when she’s done.
10:37.... Mrs. Smoltz’s roommate yells for help after
hearing a loud thump in the bathroom. The nurse
who responds finds the patient unresponsive and calls
a code blue. The code team can’t resuscitate Mrs.
Smoltz, who’s pronounced dead at 12:01.
November 18, 2002
08:12.... At autopsy, the pathologist finds that a
massive pulmonary embolism caused Mrs. Smoltz’s
death. He notes discoloration and edema of the right
leg and numerous small, deep vein thromboses in the
right popliteal and femoral veins.
February 5, 2004
Mrs. Smoltz’s husband files suit against the hospi-
tal, Briggs, Scott, and the other nurses who cared for
www.nursingcenter.com
his wife in the step-down unit. The allegation: profes-
sional malpractice. (As in this case, many attorneys
wait to file a malpractice lawsuit. This may give the
plaintiff an advantage because the defendants may not
clearly recall the events after time has passed.)
April 28, 2004
In a deposition, Scott testifies that she inserted the
I.V. line in Mrs. Smoltz’s right foot because the
patient’s respiratory symptoms were worsening and
Briggs wasn’t responding to her telephone page. She
admits that she knew Mrs. Smoltz was at risk for deep
vein thrombosis because of her inactivity due to heart
failure. She also acknowledges that she knew hospital
policy prohibits RNs from starting I.V. lines in the feet
and legs, but that she was only vaguely aware at the
time that the practice increases the risk of phlebitis.
Scott states that she got busy with other patients
after inserting the I.V. line and forgot to alert the
physician of her “emergency” measure. She says she
didn’t get an order to start a pedal I.V. line and doesn’t
recall if she notified the oncoming staff about the con-
dition of the discontinued I.V. site during shift report.
Consuela Cartin, an RN on the day shift, testifies in
her deposition that she’d noticed swelling and discol-
oration of Mrs. Smoltz’s right leg but attributed these
signs to the patient’s heart failure. When the plaintiff’s
attorney asks if heart failure can cause swelling and
Did a breach of standards contribute
to the patient’s death?
The Infusion Nurses Society (INS) standards of practice, the
state’s nurse practice act for the nurse’s level of licensure,
facility policy, and Centers for Disease Control and Preven-
tion guidelines determine standards of care for intravenous
(I.V.) therapy. The Smoltz case involved these breaches:
Breach 1: Failure to follow standards of practice for
the nursing skill. The INS standards of practice state,
“Cannulation of the lower extremities in adults should be
avoided because of the increased risk of phlebitis.” The INS
states that vein diameter and the ordered therapy should
determine cannula size. A smaller-diameter cannula allows
greater blood flow around the catheter so irritation to the
vessel wall is less likely.
Breach 2: Violating hospital policy. Hospital policy
prohibiting nurses from inserting I.V. lines in the feet and
legs dictated this standard of care. Even a written order
from the physician wouldn’t override this nursing standard.
Breach 3: Failure to document properly. Nurse
practice acts clearly define accurate assessment and
documentation. According to INS standards of practice,
“Documentation in the patient’s medical record shall
contain complete information regarding infusion therapy
and vascular access.” One of Mrs. Smoltz’s nurses didn’t
document swelling and discoloration of her leg although
problems related to the I.V. insertion site were evident at
autopsy.
www.nursingcenter.com
discoloration on only one side, Cartin’s attorney won’t
let her answer because the question calls for a medical
opinion.
Erica Dannon, RN, the hospital’s assistant vice-
president for clinical affairs, testifies that hospital poli-
cy requires licensed nurses to perform and document
a head-to-toe assessment for every patient on every
shift. She’s asked what assessments she’d have per-
formed on Mrs. Smoltz if she’d been this patient’s
nurse, but the hospital’s attorney doesn’t let her
answer because she hasn’t performed hands-on
nursing for over 20 years. Nor is she permitted to dis-
close whether any disciplinary action was taken
against the nurses involved in Mrs. Smoltz’s care.
Joanne DelToria, RN, CRNI, a practicing nurse cer-
tified in infusion therapy, testifies as an expert witness
for the plaintiff. She concludes that the nurses caring
for Mrs. Smoltz violated several standards of care dur-
ing her hospitalization that could have led to her
death from a pulmonary embolism. (To review the
lapses, see Did a Breach of Standards Contribute to the
Patient’s Death?)
May 3, 2004
Subsequent to DelToria’s testimony, the attorneys
for the defendant Scott and the hospital settle with the
Smoltz family for an undisclosed amount.
Lessons learned
You can learn several lessons from this case:
• Be familiar with your facility’s policies. If you’re
unsure of a policy, look it up or ask your supervisor.
• Follow the chain of command to notify your super-
visor of a health care provider’s failure to respond in a
timely manner. Document the situation and your
actions.
• Follow facility protocol for assessing I.V. sites and
documenting your findings.
• If a patient’s clinical status is deteriorating, follow
facility policy. In this case, the nurse inserted an I.V.
device in the patient’s foot because she believed the
patient’s condition warranted immediate treatment
and she couldn’t reach the attending physician. A
more prudent course of action would have been to
call the house officer to assess the patient stat and
possibly transfer her to the critical care unit for close
monitoring and support until a qualified health care
provider was available to place a CVC.
SELECTED REFERENCES
Cohen, M. (ed): Medication Errors: Causes, Prevention, and Risk Manage-
ment. Boston, Mass., Jones & Bartlett, 2000.
Hankins, J., et al. (eds): Infusion Therapy in Clinical Practice, 2nd edition.
Philadelphia, Pa., W.B. Saunders Co., 2001.
Intravenous Nurses Society: “Intravenous Nursing Standards of Practice,”
Journal of Intravenous Nursing. 23(Suppl., 63), November/December 2000.
Kelli Rosenthal is president and chief executive officer of ResourceNurse.Com in
Oceanside, N.Y.
Nursing2004, May 57