Dear Mr. Clause,
I have reviewed the available medical records for Mrs. C. from 3/26/ to 4/5/
This is a case about the failure to timely diagnose and treat phlebitis, thrombophlebitis and extravasation after administration of Anzemet for post-operative nausea. This failure resulted in Compartment Syndrome, Fasciotomy, an 8-day hospital stay and a residual claw deformity of the left hand.
In my opinion this case has merit due to inconsistent charting, deviation from standard of care and no follow up information given to Mrs. C. regarding her left hand upon discharge. Pt is a pack a day smoker, this may be a contributing factor to poor perfusion and resulting compartment syndrome but not likely the cause.
The following summary of Mrs. C’s inconsistent and inadequate charting in relation to her intravenous site is based on the medical records available to me:
1. Pre-Operative Charting:
Intravenous (IV) started in Left Hand No time, number of attempts or gauge (size of catheter used)
documented which is standard of care.
2. Anesthesia Charting:
IV in Left Forearm gauge # 20 Inconsistent location of IV.
3. Surgical Assessment Charting:
IV in Left Forearm gauge # 20
4. PACU Assessment Charting:
IV in Left Forearm Gauge # 20 16:11 Given IV Anzemet 12.5mg.
No documentation of patient complaining of any pain or burning during
medication administration.
5. ASU Charting:
IV in Left Hand