TO: attorney name

DATE:

RE:

Dear Mr.__________,

I have reviewed the available medical records for Ms. Client from 03/26/2026- 04/05/2026 which included pre-admission testing, outpatient surgery, subsequent emergency department visit and hospital discharge summary. I have included my comments regarding the care Ms. Client received for your consideration as requested in this brief report.

In my opinion this case is meritorious because there was failure to accurately and timely diagnose and treat phlebitis, thrombophlebitis and extravasation (leakage of fluid, such as blood, medication, or other substances, from a blood vessel or IV line into the surrounding tissue) in the left hand or forearm leading to the compartment syndrome requiring Ms. Client to undergo fasciotomy surgery for release of the muscles and three subsequent surgeries for debridement (process of removing dead, damaged, or infected tissue to promote wound healing and prevent infection).

These deviations from standards of care have resulted in permanent injury to the nerves and muscles in the left forearm and left hand resulting in pain, numbness and inability to grasp objects.

According to the available records, Ms. Client had elective surgery for a right shoulder arthroscopy on 03/28/2026. After surgery, during the recovery phase in the PACU, she obtained an IV complication in the upper left extremity.

She received a medication named Anzemet through an intravenous catheter (IV) in her left hand or forearm for nausea control during and after surgery. After administration of Anzemet by the nurse in the PACU area, Ms. Client complained of excruciating pain and burning at the IV site. Approximately 20 minutes later, hives on the left hand and left arm were noted by the ASU nurse and Ms. Client was given a dose of Benadryl through her IV. She was later discharged home without instructions for care of the left hand or left arm.

She arrived at the Emergency department the following morning complaining of left-hand swelling, discoloration and coolness. Ms. Client was then taken for emergent fasciotomy surgery (when tough connective tissue surrounding muscles, is cut to relieve dangerous pressure within a muscle compartment). In addition, she required three subsequent surgeries for debridement (process of removing dead, damaged, or infected tissue to promote wound healing and prevent infection). Ms. Client now has permanent injury to the nerves and muscles in the left forearm and left hand resulting in pain, numbness and inability to grasp objects.

I noted numerous discrepancies and deviations to include the following:

1. Discrepancies in the documentation of the IV site: Left hand vs. left forearm vs. both
2. Preop nurse documents IV started in the left hand; PACU nurse documents that the IV is in the left forearm (no documentation of IV site location change); ASU nurse documents that the IV is in the left hand

It would be important to establish the exact location of the IV site or if there were multiple IV sites.

• Missing documentation of IV site assessment by nurses.
• No IV site assessment by PACU nurse before or after the medication administration
• Standards and guidelines for the care of the IV site were not followed

It would be important to obtain the hospital’s policy for IV maintenance and care.

• No evidence that Anzemet was ordered and administered per the manufacturer’s instructions.
• No documentation to indicate that the medication was diluted prior to administration in the OR or PACU per the manufacturer’s instructions
• Pharmacy dispensed the medication without the dilutant

• No evidence of discharge instructions of care of the left hand or forearm

Causation defenses can include Ms. Client’s delay in returning to the hospital. She inappropriately applied ice packs to her left arm throughout the night. Ms. Client was under the influence of anesthesia, therefore not a reliable witness.

The following documents will be needed to more accurately analyze the deviations from standards of care:

• Policy and procedure manual Table of Contents for OR, PACU and ASU
• Medication administration policy
• Medication Management policy
• IV therapy policies
• Documentation policy and procedures
• Staff education training materials regarding IV therapy
• Assessment and Reassessment policies for OR, PACU and ASU
• Adverse Drug Reaction policy
• Anzemet manufacturer’s instructions for use
• Incident reports, incident events or incident occurrences
• Rule and Regulations for the Medical Staff

I recommend a moderate report to include a detailed chronological timeline with associated standards of care along with expert review by a PACU RN, an anesthesiologist and a vascular surgeon. I can help to locate and source experts. Below are some examples of interrogatories that I would include to help further discovery.

Interrogatories:

• PACU Nurse- Please state your start date at the hospital in the PACU department
• Ms. Client- Who accompanied you home from the hospital and was that person present when the discharge instructions were given?

Thank you for the opportunity to review this case.  Please feel free to contact me if you have any questions or concerns. I will follow up with you in one week and look forward to assisting you in the future with this case and future cases.

Sincerely,

Tiffany Trim RN, MSN, CLNC

Trim Legal Nurse Consultants and Associates, LLC