Toddler's injury from IV line a severe example of a common problem, expert says
Emmy Gunther, 3, sustained a serious injury to her hand after an intravenous line slipped out of her vein
As an Edmonton toddler recovers from severe injury caused by a misplaced intravenous line, one expert says this particular complication is not uncommon, and that patients — and their parents — need to be vigilant in advocating for their own care in busy hospitals.
Emmy Gunther, 3, underwent open-heart surgery at the Stollery Children's Hospital last week. Shortly after an IV line was placed in her hand on Friday night, the toddler began screaming in pain — and continued screaming throughout the night.
Her mother Jalena Gunther said that, despite her family's requests, no nurses or doctors checked on the toddler's IV line until morning when a nurse noticed the wet bandages on Emmy's arm.
Underneath, Emmy's hand was severely swollen and red, and some tissue had started to decay. The IV line had gone interstitial, Gunther said, slipping out of the vein and spilling the fluid mixture of sugar, potassium and sodium underneath Emmy's skin.
According to Chris Power, chief executive officer of the Canadian Patient Safety Institute, this is not an uncommon problem with IV lines.
"It can be because the patient moved, or it just dislodged itself. That would not be an uncommon situation for an intravenous to go interstitial and have to be removed and restarted," Power said.
"There are routine checks that are done in hospitals, or supposed to be done. I started my career as a nurse and we would always, at least once an hour, be checking the IV and making sure that it still was fine and was still running perfectly fine."
The Canadian Patient Safety Institute is a non-profit organization established by Health Canada in 2003 to improve public health care in Canada.
Alberta Health Services reviewing Emmy's care
Emmy has undergone two surgeries to remove the decaying tissue and close the wound. She is expected to remain in hospital for the next two weeks as she undergoes skin grafting.
Emmy is non-verbal and communicates with sign language. Gunther believes her daughter's severe complication was the result of negligence, and is concerned there may be lasting damage to her hand that could impact her ability to communicate.
Alberta Health Services says it is conducting a review into Emmy's care.
In a statement to CBC News, AHS spokesman Kerry Williamson said IVs should be checked "at least once every hour" at the Stollery. Part of the review will include looking into whether this happened, and what can be done to improve care for future patients.
"If changes are recommended following this review, those changes will be made," Williamson said in the statement.
Sandra Azocar, the executive director of Friends of Medicare, said the review will likely look into every aspect of care where it came to Emmy's case, including whether there were enough staff working at the time.
"Specific procedures that were done or not done, staffing that was available, the level of training that the staff had — it's an overall analysis of what exactly happened in that case and in that unit," Azocar said.
"These are situations that make us learn, and we should expect improvement to come out of a very unfortunate situation, and I hope that's the direction Alberta Health Services will be taking."
These are situations that make us learn, and we should expect improvement to come out of a very unfortunate situation, and I hope that's the direction Alberta Health Services will be taking.- Sandra Azocar, Friends of Medicare
Power says what happened to Emmy was likely unintentional. But patients and parents should be vigilant with their own care and persist — as Emmy's mother did — when they believe something is amiss, Power said
"I think everyone who comes to work in a hospital wants to do the best that they can and comes to work wanting to do that. But they're busy places, there's lots that happens," she said.
"I think all of us need to be hugely active participants, we need to ask good questions, we need to be ever-vigilant while we're in the hospital and be sure that we are participating in our care and not just leaving it up to everybody else and assuming that things are going to be perfect."