Case Study: How an Extravasation Injury Expert Witness Reviewed Nursing Responsibility in a Critical Care Drug Infusion Case

When calcium infusions go wrong expert scrutiny focuses on line monitoring, not diagnosis

This blog post reviews the findings of an Apex extravasation injury expert witness following a complex clinical negligence case involving a critically unwell patient treated with IV calcium after an overdose. The patient developed a serious injury to the right arm, ultimately requiring surgical debridement, nerve decompression, and skin grafts. The injury was later attributed to suspected extravasation of calcium chloride, a high-risk infusion known to cause tissue necrosis if delivered outside the vein.

The central question in the case was whether the critical care nursing staff failed to detect or escalate red flag symptoms in time and whether the extravasation injury could have been prevented or mitigated with earlier action.

What the extravasation injury expert witness concluded about nursing duties and red flag escalation

In their detailed opinion, the expert nurse concluded that the role of critical care nurses was primarily observational and communicative not diagnostic. The nurse’s duty was to:

• Monitor infusion sites for signs of tissue damage

• Use VIP scores to assess cannula health

• Escalate concerns, like swelling, blistering, or pain, to the medical team

• Ensure cannula sites are documented and charted accurately

Key findings included:

• The patient was admitted with two peripheral cannulas, both of which were scored as healthy on arrival (VIP 0)

• Calcium infusion was lifesaving and appropriate under emergency conditions

• A suspected extravasation site became symptomatic later, with pain, swelling, and blistering noted by nurses

• No documentation was found recording when the cannula was removed, a deviation from expected nursing standards

• Nurses escalated concerns appropriately once red flags appeared, but the expert agreed that earlier documentation of pain or line changes would have improved clinical clarity

“The nurse’s job is not to diagnose extravasation, but to report symptoms and line concerns. Once red flags like swelling and blistering occur, medical escalation is essential.” — Apex Extravasation Injury Expert Witness

What an extravasation injury expert witness expects from nursing staff in high-risk IV infusions

When administering known tissue-damaging infusions such as calcium chloride, expert nursing expectations include:

1. Accurate and timely documentation of cannula insertion, site changes, and VIP scoring

2. Close line monitoring, especially within the first 4–6 hours of infusion

3. Prompt escalation to medical staff if any signs of extravasation emerge (e.g., pain, redness, swelling, blistering)

4. Documentation of nursing communication with medical teams

5. Clear nursing handover, especially if patients transition between wards or shifts during high-risk infusions

While this case involved multiple surgical interventions post-injury, the expert deferred on causation to hand surgeons and medical colleagues affirming that nursing documentation and escalation were broadly consistent with practice but imperfect in key areas.

Documentation gaps don’t always mean poor care but they weaken defence

One of the recurring concerns raised by the expert was the absence of a documented time and date for cannula removal. While the nurses clearly escalated concerns after red flags appeared, failing to document a cannula change meant there was no record of when a possible extravasation site was stopped.

This lack of clarity, even if clinically appropriate care was given, could make legal defence more difficult. The expert also noted the patient's report of arm symptoms may have preceded the first documented signs, something that could only be evaluated through thorough chart review.