A newborn transferred from a community hospital to rule out a GI bleed suffered an IV infiltrate.

Key Lessons

  • A well-managed response to an adverse event can preserve the care relationship and minimize suspicion of deception.

  • Caregivers who blame other providers, or try to separate themselves from the rest of the team after an adverse outcome, undermine the patient’s best interest.

  • Inappropriately altered documentation complicates the aftermath of an adverse event

Clinical Sequence

A one-day-old girl was transferred from a community hospital to a larger city hospital to rule out a GI bleed. An IV line in her right foot was used to infuse calcium gluconate. Over the next two days, an entry into her medical record during each shift indicated that the IV was running well. On the third day, during the overnight shift, the nurse noted an IV slough with a darkened area at the IV site.

Later that day, the patient was transferred to the ICU. A transfer note specified the time the infiltrate was noted and commented that the IV site had been checked prior to transfer; however, those details did not appear in the patient’s chart. In addition, the nursing flow sheets from the shift when the infiltration was discovered, and the one preceding it, contained scratch-outs and re-writing over the original IV infusion numbers.

When they came in that morning, the parents discovered their daughter’s injury and were upset that the staff had not notified them. When questioned by the parents, the staff characterized the injury as a blister. Subsequently, the parents were told by one of the physicians that the IV medication was very caustic—and was “usually given for babies with heart problems.” The parents had not been told their daughter had heart problems (she did not). Another physician intimated that the problem originated in the community hospital. A third physician told the parents that the infiltrate should not have occurred—and that he would not blame them if they took their child out of the hospital immediately. Two days later, when the child was discharged, her parents were surprised by the extent of her injury.

Claim Sequence

The parents brought suit against the nurse who cared for the baby when infiltration occurred. They alleged her failure to monitor the IV resulting in considerable scarring and subsequent loss of motion as their daughter grew older.


The suit was settled in the low range (<$99,999).


Clinical Perspective

The parents’ trust in the institution and its clinicians eroded when physicians and nurses blamed one another for the injury. One physician blamed the staff at the transferring institution.
After an adverse event, discuss with your colleagues the factual details and sequence of what occurred and attempt to reconcile any opposing perceptions of what occurred. Coordinate your response. Determine how the details of the event, the outcome, and the treatment plan, will be explained to the patient and family. Decide which member of the health care team will discuss the event, and with whom (patient and/or family member).

  1. The clinicians did not initiate, nor did they recommend, any treatment (related to the infiltrate) for the patient.
    The first priority should be to attend to the patient’s medical needs. When appropriate, obtain medical consultation and arrange for consultants to forward necessary follow-up information.

  2. The caregivers did not tell the parents about the infiltrate before they came to the hospital to see their daughter. When the parents discovered the injury on their own, they were told that the injury was minor.
    Discuss the adverse event with the patient, and when appropriate, the family as soon as possible. Consider the time and place to meet with the family. Apprise them of the situation and help them understand the implications. Offer emotional support. Answer their questions factually and directly, but do not speculate about what might have gone awry.

  3. A review of the medical record revealed poor documentation of care rendered, e.g., poor documentation of monitoring of the IV site, no documentation of the discussion with the family, and alteration of the record.
    Good documentation supports good care; inadequate or questionable documentation exacerbates an adverse outcome. Corrections to the medical record must follow guidelines to preserve integrity. Writing over numbers gives the appearance of a cover-up. The proper method is to draw one line through the information that needs to be corrected, writing the word “error” above it, re-writing the correct information, and dating the correction. When documenting an adverse event, assign the most involved and knowledgeable member(s) of the health care team to record factual statements of the event in the patient’s record. Also record any follow-up medical care completed, planned, or needed. In this case—as in many case—the injury may not have been prevented, but the extent may have been mitigated. The lack of documentation of the IV checks made this case difficult to defend.

  4. The baby was discharged in good condition with the exception of the IV infiltrate on her foot. Nevertheless, the parents were very angry about an injury that they thought could have been prevented.
    If appropriate, acknowledge and apologize for the patient’s distress. Accept responsibility for follow-up of serious complaints, but do not admit liability, accept blame, or assign blame to others. Do not criticize the care or responses of other providers. Offer to follow up with the patient or family about what steps have been take to prevent harm to future patients.

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