Early in the course of her career as a nurse practitioner, Ms. V was given some invaluable advice that has guided her throughout her professional life. Her first supervisor, a clinician with substantial experience, took Ms. V under her wing early on and imparted a pivotal piece of information. “In the course of patient management, always take very detailed nursing notes. Whatever you do, write it down,” Ms. V’s mentor insisted. “Whether it’s recording medications dispensed, tests performed, a patient’s reactions, or your personal observations—these can all be critical.”

Now a veteran at age 52 years, Ms. V supervised a nursing staff at a regional suburban hospital, a post she held for almost 20 years. Ms. V thrived in a hospital setting. She enjoyed the diversity of the work, her supervisory duties, and the fact that she could now mentor some of the younger nurses in the same way she was trained.

One of Ms. V’s patients, a 48-year-old woman named Mrs. W, had been in and out of the 
hos­pital for the past several years with a history of chronic pancreatitis. Ms. V came into work one morning to find that Mrs. W had been admitted again. In past episodes, Mrs. W had always needed IV pain relievers, and this time was no different. The attending physician had ordered IV meperidine (Demerol) and prometh­azine (Phenergan).

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Unable to start an IV in Mrs. W’s upper extremities, Ms. V started the IV in the patient’s left foot instead. She inserted the IV into the vein, flushed the line, and started the medication drip. Ms. V made careful notes in the patient’s chart regarding the IV placement, and over the course of the day she checked back frequently to make sure that Mrs. W’s medication was infusing properly. Whenever she checked on her patient, Ms. V would indicate this on the chart. 

The next morning, Mrs. W complained of pain in the foot where the IV was inserted. Ms. V immediately stopped the IV drip and checked the line for return of blood to make sure that the IV had been properly inserted. She then removed the IV and informed the physician. 
Ms. V noted in the chart that she had checked the IV line and that it had been properly placed.

Over the course of the next few weeks, Mrs. W developed gangrene in her left foot, and the foot eventually had to be amputated.

Mrs. W was released from the hospital and immediately contacted an attorney. She explained how she had been admitted to the hospital for pancreatitis treatment and ended up losing a foot. Furious and distraught, Mrs. W asked whether or not she had a case. 

“There is absolutely no reason an individual should be hospitalized for pancreatitis and end up losing an extremity,” said the defense attorney. He filed a lawsuit against the hospital, suing for $3.5 million in damages for nursing negligence in IV administration. 

The hospital informed Ms. V of the suit, noting that she would undoubtedly be called to testify in court if the case went to trial. Ms. V was advised to consult with the hospital’s malpractice attorney.

Ms. V brought copies of her nursing notes to the meeting with her defense attorney. The counselor studied the notes carefully before asking her a few questions.

“Did you take these notes during the course of the treatment, or did you go back and fill them in later?” 

Ms. V assured the attorney that she always kept records during the course of treatment. 

“Do you always take these sorts of detailed notes,” he asked, “or was there something unusual about this case?”

“No,” replied Ms. V. “I always take notes like these. It’s how I was trained. If you look at the chart notes for any of my patients, you’ll see that they contain the same level of detail.”

The attorney seemed satisfied and told Ms. V that she would hear from him if the case actually went to trial.

After months of discovery, depositions, and futile settlement discussions, the case did, in fact, go to trial. At trial, the plaintiff, Mrs. W, took the stand and testified about how difficult life was without a foot. She testified tearfully about not being able to play sports with her children, run with her dog, or engage in the simplest of daily activities. 

Her attorney introduced several experts who testified that the IV must have been improperly inserted. Hence, the medication
—specifically promethazine—was probably infused into the surrounding tissue, causing damage and ultimately requiring amputation of the foot. 

The defense introduced its own expert witness, a vascular surgeon who testified that the nursing care was appropriate in all respects. The surgeon testified that the tissue damage was more likely an unavoidable complication related to the caustic nature of promethazine when administered directly into a vein. Ms. V was called to testify and she explained the IV insertion process and how she had checked to make sure the line was properly introduced. Ms. V made a point of noting how she repeatedly checked on the patient and noticed no redness or edema at the IV site. The nursing notes, which corroborated 
Ms. V’s testimony, were admitted into evidence as exhibits for the jury to peruse. 

The jury deliberated for several hours, finding no negligence on the part of the hospital or Ms. V and her staff, and ultimately awarded no damages to the patient.

Legal background

Evidence is powerful in a trial—especially such physical evidence as chart notes. A jury will give considerable weight to documents that were updated regularly during the course of treatment. In the absence of notes or supporting documentation, the jury has to make a decision based on the testimony of expert witnesses. The jury might have chosen to believe the theory promulgated by the plaintiff’s expert, but Ms. V’s notes were her strongest defense.

With details about the placement of the IV, a record of periodic and timely visits to check on the patient, and additional notes indicating no redness or edema at the IV site, Ms. V’s chart notes convinced the jury that she had acted with the appropriate standard of care. 

Protecting yourself

Ms. V’s early mentor had given her excellent advice. Document everything carefully and thoroughly, and you will be protected in the long run. 

Unfortunately, promethazine administered intravenously can result in serious complications, ranging from paralysis to tissue necrosis. Ms. V, however, was not the one who called for promethazine; the attending physician gave the medication orders. Ms. V was actually following the physician’s instructions and keeping watch to the best of her ability.

Ann W. Latner, JD, a former criminal defense attorney, is a freelance medical writer in Port Washington, N.Y.