A common cause of claims at Medical Protection is injection errors. While generally they are relatively low in value, they frequently cause anxiety to patients and clinicians, and are easily avoided. Dr Dawn McGuire, medical claims adviser at Medical Protection, looks at some typical cases.
Case study 1: wrong injection
Ms F attended an appointment for a three monthly vitamin B12 injection. When the appointment was booked, the receptionist had entered the reason as ‘Depo injection’. Nurse C proceeded to administer Depo-Provera, a contraceptive injection. She did not confirm with Ms F her reason for attendance that day and she did not check the patient’s prescription history either.
Nurse C only realised after the injection was administered that vitamin B12 had been recently prescribed to Ms F, and her fears were confirmed when she clarified with Ms F the reason for her attendance. Ms F complained about Nurse C and the practice apologised. A significant event analysis was conducted by the practice for everyone’s learning.
However, Ms F instructed a solicitor to pursue a claim against Nurse C. Ms F alleged anxiety and mental distress as she was trying to conceive. Her solicitors obtained a condition and prognosis report from a consultant psychiatrist who diagnosed Ms F with adjustment disorder requiring a course of cognitive behavioural therapy.
Nurse C and all three GP partners were Medical Protection members.
As this case was deemed indefensible the claim was settled.
Over the last 12 months Medical Protection was notified of ten similar claims in England and Wales alone.
The commonest mistakes involved vitamin B12, used for vitamin B12 deficiency or pernicious anaemia, and Depo-Provera, which are both usually administered every 3 months. Other injections that were wrongly administered were the flu vaccination, depot-antipsychotic medication and Prostap, which is administered for prostate cancer, endometriosis and uterine fibroids.
Injections can also be administered in the wrong site. The most common error is steroid injections (for example, Kenalog) administered into the deltoid or thigh instead of gluteal muscle. Deep intramuscular steroid injections must be given into the large muscles of the buttock. They should not be administered into the upper arm or the thigh as this can result in unsightly lipid dystrophy.
For these sorts of claims the damages (monies paid to the patient) depend on the side effects experienced. The solicitors’ costs are usually higher than the damages paid to the patient.
• Always check with the patient the reason for their attendance and check their prescription history.
• Remind ancillary staff (nurses and healthcare assistants) who undertake these duties to be vigilant of these common errors.
• It is in the interests of Medical Protection members to ensure that nurses and other employees with high levels of clinical autonomy subscribe to an indemnity or insurance scheme in their own right.
Case study 2: flu vaccination administered with used needle
Dr A, a GP registrar, gave two patients their flu vaccinations opportunistically when they attended for their chronic disease management. Dr A re-sheathed the syringes and left them in the packs with the other unused syringes as an aide-memoire to enter the flu vaccination code into the patients’ medical records later. He wrote the patients’ names on the label of the syringe but forgot to follow up as intended.
At the end of the surgery the health care assistant collected the flu vaccination tray from Dr A’s consultation room and placed it back in the refrigerator ready for the next day.
The next morning Dr O saw Mr P for depression and gave him his flu vaccination. After the needle had been inserted into Mr P’s arm, Dr O noticed that she was unable to depress the plunger of the syringe to administer the vaccine. It was then that she noticed that two of the syringes in the pack were empty but were labelled with patients’ details.
Dr O immediately informed Mr P of the error and apologised. She proceeded to give Mr P the correct flu vaccination. Public health advice was sought and a full serious untoward event investigation was undertaken within the practice. Mr P and the original two patients underwent HIV and hepatitis testing, all of which eventually came back negative. Mr P was advised to receive HIV suppressant medication and hepatitis B vaccination while waiting for the final results.
Eight months after the incident, Dr O received a letter of claim from a solicitors firm, alleging clinical negligence and requesting damages plus legal costs. Medical Protection settled the claim with a contribution from the State, on behalf of Dr A.
In this situation, the pre-filled flu vaccination syringes came in packs of five with needles attached. They are for single use only. Once administered, they must be disposed of in the sharps bin immediately.
During the last flu vaccination season (September – December 2017), Medical Protection was notified of three claims where a used needle was administered. In all three cases the staff who administered the initial flu vaccination had re-sheathed the syringe and left it in the pack with the other unused syringes, leading to the subsequent inadvertent incidents.
Patients typically claimed for severe distress and anxiety as they had to undergo infectious disease screening and vaccinations (HIV and hepatitis B and C) for a period of 6 months. Fortunately, none of the claims so far have resulted in transmission of these blood-borne diseases.
• Always dispose of used flu vaccinations immediately and remind nursing staff and health care assistants to do the same.
• Adverse incidents should be investigated using ‘root cause analysis’ or similar methodology and learning disseminated to all staff within the practice.
These case studies are based on issues arising in Medical Protection cases from around the world. Facts have been altered to preserve confidentiality.