How to document inadvertent nurse mistake

[Cadet133]

RN was trying to start an IV and twisted this frail guys arms inadvertent and now he has a fracture of the radial head. No one saw it but son. RN didnt document. I order xray and it shows a fracture. Whats the best way to document cause

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[DrMetal]

RN was trying to start an IV and twisted this frail guys arms inadvertent and now he has a fracture of the radial head. No one saw it but son. RN didnt document. I order xray and it shows a fracture. Whats the best way to document cause

How do you know it wasn't already there? Old/frail people fall on themselves all the time and sometimes don't present. Many old fractures are found this way. Ask the radiologist to comment if it looks chronic (would be more calcified along any linear fracture markings, I think!) vs acute.

Are you really a medical student or trainee? kick it up to your attending. He/she should know about the situation.

 

[Cadet133]

How do you know it wasn't already there? Old/frail people fall on themselves all the time and sometimes don't present. Many old fractures are found this way. Ask the radiologist to comment if it looks chronic (would be more calcified along any linear fracture markings, I think!) vs acute.

Are you really a medical student or trainee? kick it up to your attending. He/she should know about the situation.

Its acute unfortunately.

 

[deleted480308]

Its acute unfortunately.

But do you know it’s acute from the nurse doing it? (You don’t).........ask the attending

 

[IMGASMD]

Would document something as “consistent with recent trauma.” I assume the patient is unable to give an accurate account.

If the son saw the incident, would “encourage him” to report to nursing supervisor. Even “consult an attorney.” And go from there.

It’s a fight that will be difficult to win..... tread carefully. Unless you’re the real pcp in and out of hospital, and bring hospital any volume, don’t see how it will end well, for you, that it.

Edit: not sure what op’s current position is. A post two years ago, op was considering a hospitalist job. So, not sure.

 

[chessknt]

I routinely document what patients/family members tell me in a non-judgmental fashion all the time. Here it would be along the lines of Acute fracture detected on plain film, no known history of trauma. Patient's son attributes this fracture to attempted IV placement. No falls documented.

Or something like that. What you dont want to do is state that the fracture is a definite result of something if you arent sure of because that makes the case an automatic win in court for the plaintiff.

 

[DrMetal]

RN was trying to start an IV and twisted this frail guys arms inadvertent and now he has a fracture of the radial head. No one saw it but son. RN didnt document. I order xray and it shows a fracture. Whats the best way to document cause

Distal radius (even in 'frail' patients) is hard to fracture by twisting the arm (not impossible.....but if the force of the twist was great enough, I'd expect the mid-ulna to crack before the radius). Mechanism of distal radius fracture usually involves more force, like a fall on a outstretched hand (again very common in the elderly).

Interesting if the son is so adamant about this. Fractures anywhere else? APS involvement?

 

[NotAProgDirector]

Call risk management before doing anything.

Either the RN really broke the guy's arm, or the family did and are setting you up for a big lawsuit. In either case, risk management. In the meantime, only document facts. There is a fracture. You have no idea how it happened. You could document "Family reports it was caused by ...." Do not speculate in the chart, do not try to blame the nurse to protect yourself. Go directly to Risk management.

 

[acapnial]

For sure speak to risk management. Also for sure don't document cause, since in this case it would be speculation, based on your story in which the only suspected cause you've been given is what the family suggested.

For example, in my own risk management scenario in residency, I had a patient who died on the floor after the icu and various subspecialties declined to perform therapies related to their respective fields. I was instructed by risk management that I couldn't document WHY the icu didn't accept the patient unless they documented or told me directly, and that I could only report that I had asked them to take the patient because I was concerned about x reason at this time and they declined.

They were very easy to work with and I'm glad we called them! Highly recommend you do the same.

 

[thumbz]

Short of a pathologic fracture from a bony met there is no way "twisting an arm" to place an IV can fracture a radial head - even if you're ridiculously osteoporotic. Something is rotten in Denmark - definitely talk to risk mgmt. As above, you did NOT see this event. I would document "XR arm obtained after patient complaining pain, which showed a fracture of the radial head, and I'm doing XYZ. Although patient denies history of trauma, son is concerned it was related to IV placement".

Common things being common - this fracture was already present and when the nurse moved his arm to place the IV it caused pain.

 

[Miles Gloriosus]

I do not believe one could fracture a radial head by manipulating the arm for an IV. I assume by radial head you mean the part of the bone near the elbow.

I manipulate bones a lot. Would be very difficult to break bone. If true, what probably happened was that the patient suddenly tried to forcefully move their arm and the RN instinctively tried to restrain it down for the IV. Not the nurses fault.

 

[Redpancreas]

Stay out of it, especially since you did not witness anything. Progress notes are legal documents. Most likely case, no one reads your note and no one looks further into this. Best case, the nurse is some combination of evil/incompetent and did this and then during the court case, your documentation serves as a minor piece of evidence. Worst case is you rub the nurse the wrong way when they read your note, talk to their nurse manager, who then talks to your attending who calls you and tells you to addend your note which makes them second guess your documentation.

You should document:
Document time and patient's chief complaint which lead to XR being ordered. "XR demonstrates radial fracture which per radiologist appears relatively acute. Etiology unclear. Son had concerns regarding patient's medical care. Directed son to XYZ to voice his concerns".

You should do the following:
Give son an avenue to voice his concern/complaint (Ombudsman, whoever he wants to talk to), notify the attending that this happened when there's time as risk management needs to be involved, and lastly notify the nurse manager exactly what exactly the son said without any color commentary because that's all you witnessed and are therefore responsible for. They're the ones with best vantage point to interpret what happened and are responsible for it as they keep tabs on the nurses and patients on the unit and know how to best handle situations like this.

Also, not to echo what's above, but I fail to see how the twisting motion involved in inserting an IV could fracture a bone. The soft tissue (ligaments, joints, etc) would give away first so that would present more like a dislocation.