Legal Eagle Eye Newsletter for the Nursing Profession (6)9 Sep 98


Quick Summary: The hospital assigned nurses to assist in the procedure who had no experience with the particular apparatus and had not attended hospital training sessions for its use.

   The supervising nurse who made the assignment was unaware of their experience or lack of experience with this particular equipment.  SUPERIOR COURT OF NEW JERSEY, APPELLATE DIVISION, 1998.


   According to the Superior Court of New Jersey, Appellate Division, a hysteroscopy is a simple diagnostic procedure in which death of the patient is not an anticipated risk.

   Nevertheless, the patient did die. A $2,000,000 civil jury verdict resulted. The court ruled the judgment would have to be paid proportionately 20% by the circulating nurse, 25% by one scrub nurse, 0% by the other scrub nurse, 35% by the hospital and 20% by the physician.

   The patient died almost instantly from nitrogen bubbles introduced into her circulatory system, the court said.

   They were using an apparatus designed to inflate the uterus with saline to permit remote visualization on a television screen. The saline pump within the device was powered pneumatically by nitrogen gas from a valve on the ceiling of the operating room.

   Apparently one of the nurses connected the nitrogen exhaust to a suction container, then placed the end of the other tube from the suction container on the sterile field. The physician then apparently mistook this tube as suction for the saline outflow. He connected it so that nitrogen gas was blown directly into the patient's uterus, killing her.

   The circulating nurse had opened the package and had passed the apparatus to one of the scrub nurses. This scrub nurse, who was the only one exonerated by the court, was not familiar with the apparatus. After opening the sterile packaging, this nurse handed the apparatus to another scrub nurse who was directly assisting the physician.

   The second scrub nurse was the one who apparently connected the lines to the saline bag, the nitrogen regulator, the suction canister, etc., then left the open line exhausting nitrogen gas lying where the physician would assume it was suction for saline outflow and complete the ill-fated process by hooking it up to pass nitrogen gas into the patient.

   The court imposed personal liability on two nurses to pay individual portions of the substantial verdict along with the portion the physician had to pay and the portion the hospital had to pay for the supervisor’s negligence.

   The nurses had no experience or training with this particular apparatus. They had not attended the training sessions their employer had offered specifically for this equipment. Their nursing supervisor assigned them to this procedure without any knowledge of their experience or training with this apparatus. Estate of Chin v. St. Barnabas Medical Center et al., 711 A. 2d 352 (N.J. Super., 1998).