Question

CASE 18: Failure to Record Patient’s Care

Mrs. Pellerin went to the emergency department at Lakeland Medical Center complaining of chest pain. An emergency department physician, Dr. Gruner, examined her and ordered a nurse to give her an injection consisting of 50 mg of Demerol and 25 mg of Vistaril. The nurse testified that she did not recall giving the injection, and did not deny giving it and her initials are present in the emergency department record. The nurse admitted that she failed to record the site and mode of injection in the emergency department records. She stated that she may have written this information in the nurse’s notes, but these notes were not admitted into evidence. The plaintiff testified that she felt pain and a burning sensation in her hip during the injection. The burning persisted afterward and progressively worsened over the next several weeks. The pain spread to an area approximately 10 inches in diameter around the injection site and the plaintiff stated that she could not sleep on her right side, work, perform household chores, or participate in sports without having pain. She also testified that she had a lump around the injection site and her skin was numb in that area.

questions

6. What evidence would you present?

7. How would you defend the defendant?

8. What are your defense options?

9. If you were on the jury, what would your finding/s be, based on only the facts as presented and the classroom discussion?

10. If you find the defendant responsible, what damages would you award, and for what reasons? If the award was provided in the case study, how much was the award and for what reasons?

11. What are your options if you, as plaintiff or defendant, are unhappy with the jury’s decision?

Answer 1

6. The evidences can be noted as,

• the burning sensation felt by the patient in the hip region.
• lump in the hip area
• the nurse did not deny giving an injection
• the initials were recorded in emergency department records
• nurse's notes can be accepted if entered with valid signatures as a considerable element to substantiate the above prooofs

7. It is the responsibility of a nurse to maintain complete and authentic records. it is the duty of a nurse to safeguard the health of the patients assigned for them, by avoiding all possible careless mistakes

9. first of all, the combination itself has got interaction issues. the patient is expected to remember the injection site and the nurse is obligated to maintain all the records.

11. As a defendant, I would prefer going for a next level appeal, but my health condition needs to be made beeter initially. so I would like to claim a compensation here only.

Here I could see the absence of a clinical pharmacist who could manage the safety of the medication orders,

The details given by the plaintiff points the fingers to the injection site as gluteal muscle.

10.