Reference no: EM131715724

Case Study: Malpractice Action Brought by Yolanda Pinnelas

People involved in case:
Yolanda Pinnelas - patient
Betty DePalma, RN, MS - nursing supervisor
Elizabeth Adelman, RN - recovery room nurse
William Brady, M.D. - plastic surgeon
Mary Jones, RN - IV insertion
Carol Price, LPN
Jeffery Chambers, RN - staff nurse
Patricia Peters, PharmD - pharmacy
Diana Smith, RN
Susan Post, JD - risk manager
Amy Green - quality assurance
Michael Parks, RN, MS, CNS - education coordinator
SAFE-INFUSE - pump
Brand X infusion - pump
Caring Memorial Hospital

Facts:

The patient, Yolanda Pinellas, is a 21-year-old female admitted to Caring Memorial Hospital for chemotherapy. Caring Memorial is a hospital in upstate New York. Yolanda was a student at Ithaca College and studying to be a music conductor.

Yolanda was diagnosed with anal cancer and was to receive Mitomycin for her chemotherapy. Mary Jones, RN, inserted the IV on the day shift around 1300, and the patient, Yolanda, was to have Mitomycin administered through the IV. An infusion machine was used for the delivery. The Mitomycin was hung by Jeffery Chambers, RN, and he was assigned to Yolanda. The unit had several very sick patients and was short staffed. Jeffery had worked a double shift the day before and had to double back to cover the evening shift. He was able to go home between shifts and had about 6 hours of sleep before returning. The pharmacy was late in delivering the drug so it was not hung until the evening shift. Patricia Peters, PharmD, brought the chemotherapy to the unit.

On the evening shift, Carol Price, LPN, heard the infusion pump beep several times. She had ignored it as she thought someone else was caring for the patient. Diana Smith, RN, was also working the shift and had heard the pump beep several times. She mentioned it to Jeffery. She did not go into the room until about 45 minutes later. The patient testified that a nurse came in and pressed some buttons and the pump stopped beeping. She was groggy and not sure who the nurse was or what was done.

Diana Smith responded to the patient's call bell and found the IV had been dislodged from the patient's vein. There was no evidence that the Mitomycin had gone into the patient's tissue. Diana immediately stopped the IV, notified the physician, and provided care to the hand. The documentation in the medical record indicates that there was an infiltration to the IV.

The hospital was testing a new IV infusion pump called SAFE-INFUSE. The supervisory nurse was Betty DePalma, RN. Betty took the pump off the unit. No one made note of the pump's serial number as there were six in the hospital being used. There was also another brand of pumps being used in the hospital. It was called Brand X infusion pump. Betty did not note the name of the pump or serial number. The pump was not isolated or sent to maintenance and eventually the hospital decided not to use SAFE-INFUSE so the loaners were sent back to the company.

Betty and Dr. William Brady are the only ones that carry malpractice insurance. The hospital also has malpractice insurance.
Two weeks after the event, the patient developed necrosis of the hand and required multiple surgical procedures, skin grafting, and reconstruction. She had permanent loss of function and deformity in her third, fourth, and fifth fingers. The claimant is alleging that, because of this, she is no longer able to perform as a conductor, for which she was studying.

During the procedure for the skin grafting, the plastic surgeon, Dr. William Brady, used a dermatome that resulted in uneven harvesting of tissue and further scarring in the patient's thigh area where the skin was harvested.

The risk manager is Susan Post, JD, who works in collaboration with the quality assurance director Amy Green. Amy had noted when doing chart reviews over the last 3 months prior to this incident that there were issues of short staffing and that many nurses were working double shifts, evenings, and nights then coming back and working the evening shift. She was in the process of collecting data from the different units on this observation. She also noted a pattern of using float nurses to several units. Prior to this incident, the clinical nurse specialist, Michael Parks, RN, MS, CNS, was consulting with Susan Post and Amy Green about the status of staff education on this unit and what types of resources and training was needed.