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Fluid overload following surgery (00HDC00231)

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(00HDC00231, 18 June 2002)

Nurses ~ Private hospital ~ Standard of care ~ IV fluids ~ Hospital protocols ~ Vicarious liability ~ Rights 4(1), 4(2)

A complaint was received from the parents of a nine-year-old child regarding the services provided at a private hospital by an ear, nose and throat surgeon, an anaesthetist, and several nursing staff.

The child was transferred to the ward after an uneventful removal of her tonsils and adenoids, with intravenous (IV) fluids administered by a continuous flow set. The IV line had neither a burette nor a pump to regulate the fluid administration. The child received at least 2500ml of IV fluid over nine hours and the fluid overload made her hyponatraemic and caused cerebral oedema. She had a Glasgow Coma Score of 4 on transfer to the Intensive Care Unit.

Close monitoring of IV flow rate is a crucial part of patient care and a nursing responsibility. The hospital policy required an IV drip to be regulated by a burette or Floguard for children under ten or when intravenous additives were to be administered, and required appropriate record-keeping. Nursing Council guidelines state that nurses must document appropriate nursing information and communicate this to other team members, and must administer and monitor the effect of prescribed interventions, treatments and medications in accordance with current nursing knowledge, the authorised prescription, and established policy and guidelines.

The Commissioner held that:

1 ward nursing staff breached Rights 4(1) and 4(2) in that they did not act in accordance with Nursing Council standards or hospital policy when they failed to ensure that the IV line was reconfigured to connect a burette or pump or both to regulate the IV rate, did not appropriately monitor and regulate the IV fluids to ensure they were being administered at the prescribed flow rate, administered additives without a burette or pump in place, and commenced further bags of fluid without recording this on the fluid balance chart; and
2 the private hospital, as the employer of the nursing staff, had an adequate written protocol on IV management, which accorded with good clinical practice, and therefore had taken reasonable steps to prevent the nursing staff from breaching the Code, and so was not vicariously liable for the employees' omissions, even though there were concerns about the nurses' level of training in IV care.

The Commissioner referred the matter to the Director of Proceedings, who prosecuted three nurses. The Nursing Council found two nurses guilty of professional misconduct and imposed a penalty of censure and a fine.