Legal Review & Commentary

IV inserted to nerve results in radial nerve injury: $155,000 arbitration award

By Mark K. Delegal, Esq., and Jan Gorrie, Esq.
Pennington, Moore, Wilkinson, Bell & Dunbar, PA
Tallahassee, FL

News: A woman was admitted to a hospital for elective, outpatient surgery. Preoperatively, an intravenous line (IV) was placed in her wrist, hitting her radial nerve. The improperly placed IV resulted in reflex sympathetic disorder, which required subsequent surgeries, physical therapy, and nerve blocks. A binding arbitration award for $155,000 was granted to the patient.

Background: The 29-year-old divorced mother of two minor children, who worked as a mail carrier, was admitted to the hospital to have her nose reconstructed, which was elective, outpatient surgery. Preoperatively, an IV line was placed on her left wrist. The patient immediately complained of a burning, "shocky" feeling at the area of insertion with the burning sensation extending into her thumb and index finger. She cried and asked that the IV needle be removed, but the hospital staff nurse continued with the IV setup.

Following surgery, the patient was groggy, but in the postoperative suite she noticed that the IV line had been moved to her right arm. Her medical record gave no indication when or why the IV line had been moved, nor did it mention that she complained about pain at the IV site. After recuperating, she was driven home by her brother, who later testified that she complained of severe pain in her left arm during the ride.

She continued to complain to her parents of severe pain and sensitivity in her left arm. Ten days later, still in pain, she was referred to a hand surgery specialist who diagnosed her as with reflex sympathetic dystrophy, which was the result of the radial nerve having been hit by the initial IV needle used in surgery.

At first, the injury was conservatively treated with medication and light therapy. Failing to achieve any measure of relief, the hand surgeon began to administer nerve blocks. When this, too, proved unsuccessful at alleviating her pain, the hand specialist performed surgery to remove a piece of the superficial radial nerve by burying it the muscle of the patient’s left forearm. When the piece of nerve at the original IV site was examined by the hospital pathologist, he found a focus of traumatic nervoma presumably caused by the needle hitting the nerve. Following the initial nerve-shift-burial surgery, a second nervoma formed at the site where the top portion of the nerve was buried in the arm. This led to secondary pain syndrome in the left forearm, which was also diagnosed as reflex sympathetic dystrophy.

The hand surgeon sought a second opinion from a neurosurgeon, who confirmed the diagnosis. He also prescribed medication and physical therapy. Subsequent treatment involved extensive physical and occupational therapy, eight separate nerve block procedures, and two additional surgeries.

The plaintiff claimed that this was a classic "res ipsa loquitur case," which translates as "the thing speaks for itself." Practically speaking, it means the burden of proof that the defendant was not negligent falls upon the defendant because the injury was caused by the instrumentality of the defendant (the IV needle), the IV needle was under the singular control of the staff nurse, and it was an injury that does not ordinarily occur absent negligence.

In this instance, the IV needle impaled the superficial branch of the radial nerve, resulting in reflex sympathetic dystrophy. A plaintiff’s medical expert testified that her radial nerve was not in an anatomically abnormal position, and so the defendant could not argue that the nerve was hit because it was in an unusual place. As the sole provider for her two children, the plaintiff was reluctant to quit her full-time work as a mail carrier and file for disability. However, she misses eight weeks of work and had to wear a protective splint for an extended period of time in order to protect the area of hypersensitivity.

In its defense, the hospital argued that when an IV line is started, there is an inherent risk of hitting a nerve, and that this is a known risk. Alternatively, the hospital maintained that the incident never occurred because the medical records did not indicate that the patient had complained of any pain in the IV insertion area on the day of surgery. However, there was debate about the medical records being accurate and precise. The defendant argued that the injury was greatly exaggerated, and that subsequent treatment and surgeries were only a means to bolster her claim of negligence.

Ultimately, the claim was settled through arbitration for $155,000.

What this means to you: It appears that the patient was neither listened to nor heard.

"Had the patient’s complaints been more closely evaluated, perhaps the untoward outcome could have been avoided. This incident emphasizes the need for communication, which includes listening and hearing, as well as the need for good, thorough documentation," notes Leilani Kicklighter, assistant administrator, safety and risk management, North Broward Hospital District, Fort Lauderdale, FL.

"Specifically recommended is the institution of a required educational program for newly hired staff who are authorized to insert IVs and documented evidence of successful completion of the program in the individual personnel files. And not simply an IV program, but one that is compliant with acceptable standards. Once such educational programs are provided, there should be a system in place to annually evaluate the continued competency of each staff member authorized to insert IVs, which should include monitoring of IV-related incidents. Placing IVs entails more than practicing on fruit. As indicated by this case, the insertion of IV lines is a learned skill," Kicklighter says.

"As for the documentation on the care provided to this patient, there seems to be very little. The adage of If you did not write it down, it did not happen’ comes to mind. Health care practitioners must be sensitive to the fact that patients’ thresholds for pain are highly variable, and if you believe that the patient is ultrasensitive, document it. Further, it is very difficult to defend a case when you are unable to demonstrate what care was provided through the medical record," notes Kicklighter.

Elvia Cortez-Burgueno v. Kaiser Foundation Hospitals, Los Angeles County (CA) Superior Court, Case No.