Failure to Chart?

  1. This situation was presented during nursing class. I don't understand the failure to chart - yes, the nurse should have charted but couldn't pt sue anyway? And if both sites are acceptable, but greater risk for one than the other, why ever use the other?

    Since the purpose of the chart is to document the care administered to the patient, how can a nurse convince other that care was provided if it is not documented in the health record?

    A nurse, by habit always administers an intramuscular injection in the ventrogluteal site (although both the ventrogluteal and dorsogluteal sites are within the accepted guidelines of care). The nurse however, fails to chart the site on the medication administration record. The patient files suit for sciatic nerve damage. Knowing that there is an identified greater risk for sciatic nerve injury with the dorsgluteal site, do you think it would be difficult to defend the care given in this case?
    Last edit by KristinWW on May 25, '04
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  2. 16 Comments

  3. by   SCRN1
    Fortunately, I've never been in a lawsuit, but I've always been told, "if it wasn't charted, it wasn't done". In this case, since she did sign off on the MAR that she gave the injection, that part was done. BUT, since she didn't chart WHERE she gave it, I would think it would be her word against the person suing and the burdon of proof is on the patient. Just my guess. By the way, is she the only one who gave an injection to this person?
  4. by   KristinWW
    Quote from SCRN1
    Fortunately, I've never been in a lawsuit, but I've always been told, "if it wasn't charted, it wasn't done". In this case, since she did sign off on the MAR that she gave the injection, that part was done. BUT, since she didn't chart WHERE she gave it, I would think it would be her word against the person suing and the burdon of proof is on the patient. Just my guess. By the way, is she the only one who gave an injection to this person?
    I don't understand; why would proof be on the pt? Does the doctor have to write in the orders WHERE the injection is to be done, or only that it is done IM?
  5. by   SCRN1
    Quote from KristinWW
    I don't understand; why would proof be on the pt? Does the doctor have to write in the orders WHERE the injection is to be done, or only that it is done IM?
    Like I said, it was just my guess. I'm no lawyer and I've always heard the burdon of proof is on the one doing the suing.

    Where I work, the doc does have to order if a med is to be given IM, PO, SC, etc., but they don't order the site if IM or SC. I don't know if this is how it's done other places.

    If this went to court, they would probably (just my guess again) bring in the medical record and it would show how the doc ordered it.
  6. by   psychomachia
    Quote from KristinWW
    I don't understand; why would proof be on the pt? Does the doctor have to write in the orders WHERE the injection is to be done, or only that it is done IM?
    The pt. has to prove that the injury was caused by the injection given by the nurse, just like you can't accuse someone of murder and demand they show proof they didn't do it. The burden of proof is on the one who makes the assertion.

    And no, the MD does not have to write where the injection is to be given, unless he/she has a specific reason for wanting/not wanting the injection to be given in a certain site.
  7. by   SCRN1
    Speaking of burden of proof...the patient would also have to prove that they did indeed suffer sciatic nerve damage and that it was done by this nurse. Otherwise, anybody could say they sustained any kind of injury and blame it on whomever they choose to sue.

    Here's my question for anyone who knows...
    Have you ever heard of anyone suing and winning a case like this? Am I wrong in thinking that this sounds like one of those frivilous lawsuits because this being one of the risks in accepting in IM in that area? Personally, I try to give an IM in the thigh when possible.
  8. by   KristinWW
    Thanks to both of you! Wow, you have given me much to think about here. Still thinking.........
  9. by   elkpark
    Doc's orders have to specify a route, but not a site -- that's nursing judgment. There are four elements that must be satisfied in a malpractice suit (for the plaintiff to win, that is) -- that the defendant (the professional) had a duty to the plaintiff, that that duty was breached (the defendant failed to follow standard practice for the profession), that the plaintiff suffered harm, and that the breach of duty by the defendant was the proximal cause of the harm. The burden of proof is on the plaintiff, and the standard of proof is different in civil cases ("a preponderance of the evidence" instead of "beyond a reasonable doubt").

    I work as a surveyor/inspector for my state and for the feds, and I can tell you in plain English that (as you've heard before, I'm sure), IF IT ISN'T CHARTED, IT DIDN'T HAPPEN. In the case you're describing, it might well come down to which "side" the jury believes about where the injection was actually given (which attorney does a better job of presenting her/his version of the story). The nurse certainly can't prove that s/he did give it in the VG site ...
  10. by   obrnteacher
    Many years ago our hospital had a case like this. One of the nurses in PACU gave an injection and didn't document where she gave it. Patient later sued the hospital and the nurse for sciatic pain damage. THe hospital settled out of court even though it was felt the nurse did not injure the patient. Many inservices were given on the proper documentation of injections.. THis brought home how important it is to document EVERYTHING!!! I use this example with some of my nursing students since it really did happen.
  11. by   KristinWW
    You guys are excellent! I love this board! How many times can I say it
  12. by   psychomachia
    Quote from SCRN1
    Here's my question for anyone who knows...
    Have you ever heard of anyone suing and winning a case like this? Am I wrong in thinking that this sounds like one of those frivilous lawsuits because this being one of the risks in accepting in IM in that area? Personally, I try to give an IM in the thigh when possible.
    Here's one, and I'm sure there are others...



    December 2003 Legal Case Study
    Inferior Gluteal Neuropathy From Post-Operative Injection in Buttock - Severe Pain in Leg - $3.5 Million Pennsylvania Verdict.
    Elnor Whitehead sought care from Richard B. Kanoff, M.D., for pain in her low back and lower leg in October 1998. Whitehead had previously been diagnosed with significant spinal stenosis and had undergone conservative therapy. She continued to have severe pain and, on Kanoff's suggestion, decided to undergo spinal surgery.

    On October 23, Whitehead was admitted to City Avenue Hospital, part of the now-defunct Allegheny University Hospitals group, for surgery to be performed by Kanoff. The surgery went off without complications and Kanoff prescribed her post-operative pain medication. Whitehead received several injections of pain medication in her buttocks on the day of the surgery as well as on the next day. Nancy McGrane and Sosamma Raju were the nurses rendering treatment to Whitehead. Raju was removed from the suit, however, when it was discovered that she had not given the injections. After one of the injections, Whitehead began experiencing severe pain in her left leg. The pain became so severe that on October 25, she was almost incoherent when Kanoff saw her. Because Whitehead was in so much pain, Kanoff ordered large doses of pain medication and Whitehead underwent an MRI of the lumbar spine. The MRI showed a large subdural hematoma, but that condition was inconsistent with Whitehead's complaints.

    Kanoff performed a second surgery on Whitehead for wound exploration but was still left without an answer. While at the hospital, Whitehead was seen by a neurologist, who theorized she might be suffering from a sciatic nerve injury caused by a post-operative injection. Whitehead was discharged and later underwent an EMG test, which showed inferior gluteal neuropathy, a condition consistent with her complaints. Kanoff continued to treat Whitehead, prescribing medication to alleviate the severe pain in her left leg. Whitehead later underwent spinal cord stimulation therapy, which was only successful for a little while, and then implantation of a morphine pump. Whitehead continues to use the pump but is unsuccessful in controlling her severe left leg pain.

    In her suit Whitehead argued that because of an improper post-operative pain medication injection, she suffered an injury to her sciatic nerve, causing severe and permanent damage to her left leg. Coupled with a previous injury to her abdomen, Whitehead's pain now means she can't do much of anything. Defendants argued that the injection was administered properly and that Whitehead's pain was due to her back problems.

    According to a published account, a $3.5 million verdict was returned. Defendant's Experts: Lawrence Kerson, M.D., neurology, Newtown, PA. Elnor Whitehead v. Nancy McGrane, County (PA) Common Pleas Court, Case No. _. Stephen J. Pokiniewski, Jr. and Lisa R. Schwartz, Anapol, Schwartz, Weiss, Cohan, Feldman & Smalley, for the plaintiff. Daniel P. Lynch of Harvey, Pennington, Cabot, Griffith & Renneisen, for the defendant.

    (from http://www.nso.com/case/cases_area_i...c52ddd2e669da0)
  13. by   jemb
    In a legal nursing course that I took several years ago, we were told that a nurse's testimony of 'I know that is how I did it/ where I gave the injection because I always do it that particular way/give it in that particular location' is acceptable as proof.

    I still go by the CYA method of documenting.
  14. by   BHolliRNMS
    sadly enough, most health care facilities do just settle small cases because of the expense involved in defending them. They don't admit guilt, but they don't deny it either and the patient gets money they don't deserve. It makes me so mad!

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