Wound photos can help determine a clinician’s legal liability

A clinician documents wound photos on a company phone.

In many instances, wound care involves pressure wounds, such as decubiti and poor vascular conditions, such as diabetic foot wounds.

In the following case, the improper administration of chemotherapy agents through an IV line caused a wound that resulted in severe pain and limited the use of two fingers on the patient’s non-dominant hand.

Key evidence in the trial were wound photos of the open wound that occurred because of the negligent administration of chemotherapy by two nurses who were named defendants in the suit — Iacano v. St. Peter’s Medical Center.

Improper chemotherapy administration

The patient was being treated as an outpatient for non-Hodgkin’s lymphoma with IV therapy of four chemotherapy agents, three of which were given intravenously.

Two of the three were vesicants — an agent that can cause blisters — and were given by a nurse via an “IV push.”

On the day in question, one of the nurses initiated the IV therapy. The patient complained of discomfort during this phase.

A second nurse administered the two vesicants. The patient complained of a burning sensation in her hand, so the IV was removed from her right hand and inserted in her left without incident.

However, an extravasation, which is an escape of substances being injected into a blood vessel into the surrounding tissue where they are absorbed, occurred in her right hand and the physician on call was notified.

This can be caused by a needle breaking through a blood vessel. Cold soaks were ordered. But, this development was not documented in the nurses’ progress notes.

Patient presents at hospital

The patient returned to the hospital shortly after being discharged, complaining of pain. A physician saw her, but no treatment was prescribed. 

Shortly thereafter, the patient presented at the hospital complaining of a temperature. She saw an orthopedic surgeon, who debrided the patient’s hand.

A second debridement took place within a short time and “necrotic tissue and purulence from the wound” were removed.

From this late January visit until “early spring,” the patient did dressing changes on the wound four times a day.

In late fall, the wound had “healed over” on its own so skin grafts were not necessary.

Patient files medical malpractice case

The patient filed a medical malpractice case, and the trial court found the nurse employees of the hospital deviated from applicable standards of care.

The nurse who initiated the IV therapy was found 5% responsible and the second nurse who administered the two vesicants was found 95% responsible.

The jury awarded the patient $1.5 million in damages but this amount was subsequently reduced by the trial court to $500,000 on the defendants’ motion for a new trial or alternatively, a remittitur (a procedure to correct an excessive jury award by a court without the expense and delay of a new trial).

All parties appealed the trial court decision to the appellate court on the points the verdict was against the weight of the evidence and was the result of prejudice, partiality or passion.

The appellate court carefully reviewed the evidence presented at the trial court. Focusing on the defendants’ bases of appeal, and of interest to wound care practitioners, is the court’s focus on the orthopedic surgeon’s deposition testimony of his initial debridement:

“Basically the name of the procedure was excision of the eschar on the dorsum of her right and the debridement of the wound. … We took off that entire dead area of scab and scar on the back of her hand … cleaned all the purulent material away by elevating the tissue and cleaning it out as much as we could. … It left her extensor tendons and some other things on the back of her hand. … couldn’t skin graft at that time. … We put her in a big bulky dressing … and told her we would … several days later … do it again.”

Also important to the appellate court were the wound photos of the open wound taken after each debridement procedure.

The court opined that the photogaphs were “very graphic and could even be described as dramatic.” 

Even so, the court opined, the wound photos in no way improperly influenced the determination of liability of the two nurses.

As a result, the appellate court affirmed the judgment of the trial court for the patient and the reduced the amount of the verdict to $500,000.

Tips you should takeaway from this case

This case focuses on several relevant topics for all wound care practitioners.

First, the detailed testimony of the orthopedic surgeon’s treatments of the right hand were not only clinical in tone but also were described in words the jury could understand. 

This is a critical factor in professional negligence trials. Testimony from a treating clinician educated the jury as to what was done medically.

Most jurors, if any, do not have a medical background that enables them to understand what was done when medical speak is used.

When testifying about a patient treatment, providing the jury with an accurate layperson’s description of that treatment can be a deciding factor in a jury’s verdict.

Likewise, the wound photos taken after each debridement and introduced into evidence were critical to the jury’s determination at the trial level.

As the appellate court opined, “the jury apparently focused on the wound at the two points in time depicted in the photographs and extrapolated that vision into the entire healing process.”   

As we discussed in “Legal issues clinicians should know when taking wound care pictures,” photographs alone are not the best practice when treating patients in need of wound care.

Rather wound photos, coupled with accurate documentation of the care provided, are key to the provision of good care and the preparation of a good defense should a lawsuit arise.

Finally, the fact that nurses who provided the IV therapy did not document the incident in the patient’s record is quite remarkable.

It clearly speaks to a breach of their standard of care that we discuss in our blog “Substandard wound care can lead to legal risks for clinicians.”

Wound care practitioners must always remember to document patient care provided, including:

  • Patient complaints
  • Your response to those complaints
  • Who was notified
  • Any changes in your treatment plan as a result

Learn more about wound care today with one of our courses.

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Nancy J. Brent, MS, JD, RN, received her Juris Doctor from Loyola University Chicago School of Law and concentrates her solo law practice in health law and legal representation, consultation and education for healthcare professionals, school of nursing faculty and healthcare delivery facilities. Brent’s posts are designed for educational purposes only and are not to be taken as specific legal or other advice. Individuals who need advice on a specific incident or work situation should contact a nurse attorney or attorney in their state. Visit The American Association of Nurse Attorneys website to search its attorney referral database by state.

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