In any action alleging negligence by a nurse, it is for the plaintiff to prove a number of ‘ingredients’.
One ingredient is whether the actions of the nurse fell below the reasonable standard expected of the skill and knowledge of the nurse in question. Hence, reference is made to the skill and knowledge of the nurse in question. This can be a factually difficult test to ‘defend’ if the nurse, over time, has no recollection of the alleged negligent action.
In such a situation, the court must make a factual determination. A recent case involving the giving of a heparin injection is illustrative.
The plaintiff (patient) in 2013 had embarked on a program to improve her fitness and lose weight. She succeeded in losing 35kg. This resulted in excess abdominal skin. On 17 May 2014 she saw Dr M, a plastic surgeon, who discussed with her the possibilities of treatment by abdominoplasty.
Dr M operated on the plaintiff on 11 August 2014. The plaintiff returned to the ward at about 2pm. Dr M also ordered the administration of heparin to be given by subcutaneous injection twice daily.
The plaintiff received the first injection of heparin at 8am on 12 August. That injection was given by a nurse who “pinched” the plaintiff’s left thigh and administered the injection just beneath the skin. The plaintiff had no pain at the time of the injection and no complications afterwards.
The second injection was administered by Nurse N, at about 8pm on the same day.
The plaintiff gave the following evidence: “He came into the room. He was holding a green tray … He prepared the injection and then put it straight into my thigh, and he did not pinch my skin. I had instant pain, it was like a bee sting, and I said ‘Ouch’.”
The plaintiff’s husband, who was at the bedside, supported the plaintiff’s evidence.
Nurse N did not remember at trial giving the injection. He gave evidence that he had significant experience giving various types of injections, including subcutaneous injections. He said that as a result of his training, he adopted a “standard practice, an invariable practice”. He described his technique for giving a heparin injection in detail. This involved “gathering” as much subcutaneous tissue as he could and then gently inserting the needle at a 45-degree angle. He would then slowly inject the medication, taking about 30 seconds to empty the syringe. His nursing notes made no mention of the heparin injection.
The plaintiff asserted that after the injection she had pain in her thigh. The next morning, she noticed a lump in the area of the injection. The plaintiff described the pain to an RMO as extending across her thigh to the top of the knee and the back of her leg, and further, that the area hurt when touched. This remained the situation until the plaintiff was discharged on 15 August.
This situation continued post discharge, despite follow-up consultations and various treatments.
In essence, the plaintiff alleged that the defendant (Nurse N):
- Failed to pinch the skin up, lift or pull the top layer of skin away from the muscle before administering the heparin injection, so as to inject into the superficial subcutaneous fat and avoid injecting into the deeper subcutaneous region of the lateral femoral cutaneous nerve, thereby damaging the nerve.
- Injected the needle into the deeper subcutaneous region of the lateral femoral cutaneous nerve and damaged the nerve. The decision focused on factual findings by the trial judge, who stated: “I accept that for a nurse such as Nurse N, the giving of a heparin injection was a reasonably routine mechanical task ... However, Nurse N’s complete lack of recollection of the specific injection … means he can only assert what he believes he would have done by reference to his usual, or ‘invariable’, practice. I should note that I have some difficulty with the notion of an invariable practice. Ordinary human experience suggests that there can always be momentary lapses or careless errors in the performance of mundane or routine tasks.
“That being said, Nurse N impressed me as an earnest and hardworking nurse. However, I have no doubt he had a busy workload and I infer that he was probably under time pressure to complete his tasks before the end of his shift at 10pm.
“I am satisfied that Nurse N did administer the injection in a manner which fell below the standard of care to be expected of a nurse in his position. Whether due to the pressure of work, or just momentary carelessness, he inserted the needle at an angle which allowed the point to penetrate the deeper tissues overlying the plaintiff’s left thigh muscle.
“I find that he probably did not attempt to ‘pinch’ the skin on the plaintiff’s thigh, or that if he did make that attempt, he did not do so effectively. The injection did cause immediate sharp pain to the plaintiff who made an exclamation to the effect of what both she and her husband testified to.”
Accordingly, judgement was entered in favour of the plaintiff. Damages recoverable by the plaintiff amounted to over $250,000.
A momentary lapse of concentration in not pinching the skin or inserting the needle correctly can have serious monetary consequences for a nurse’s employer – in this case, over a quarter of a million dollars.
No matter how small the issue, nursing notes are a nurse’s best friend. Why? Because memories fade and we cannot be expected to remember every nursing care task we undertake years later, particularly those that are minor and routine. In this case, the time between the injection and the trial was about five years.
Scott Trueman is a lecturer in the School of Nursing, Midwifery and Nutrition at James Cook University.Do you have an idea for a story?
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