1. 1
Note: This is a fictitious situation and report developed for the sole purpose of demonstrating examples of report
format and length. Actual reports will vary in format and length appropriate to case type and complexity as
determined by legal nurse consultant and attorney-client.
KM Consulting
Sample Brief Report Medical Malpractice
Krystal McMahan, RN, BSN, CLNC
KM Consulting
Phone: (254) 405-3562
Email: krystal.kmconsulting@gmail.com
Confidential Attorney Work Product
October 13, 2014
John Smith
Attorney at Law
Best Law Firm, P.C.
1234 Main Street
Sometown, Texas 12345
Re: Sarah Jones vs. General Hospital
Dear Mr. Smith:
Pursuant to your request, I have reviewed Sarah Jones’ NICU medical records from
1/1/2014 to 1/2/2014. I have included my comments and recommendations for your
consideration.
Sarah Jones is a newborn white female delivered 4:35 am on 1/1/2014 admitted to the
NICU for Respiratory Distress Syndrome. There were no significant prenatal complications or
history. During her hospitalization she sustained a complication of IV medication administration.
In my opinion, this case is meritorious due to failure to timely diagnose and treat
infiltration, extravasation, and phlebitis following administration of Vancomycin. This resulted
in tissue necrosis and the irreversible loss of the right index and middle fingers.
Chronology of Relevant Documentation:
 1/1/2014 5:30 pm Vancomycin administered IV, D.N., RN [MAR]
 6:45 pm Change of shift hand-off. No mention of IV site assessment. [Transfer of
Care]
 7:30 pm “Redness, edema, and leakage at IV site. IV discontinued.” N.N., RN [IV
assessment]

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Confidential Attorney Work Product
Note: This is a fictitious situation and report developed for the sole purpose of demonstrating examples of report
format and length. Actual reports will vary in format and length appropriate to case type and complexity as
determined by legal nurse consultant and attorney-client.
 1/2/2014 2:30 am “A. Dawson, NNP notified of black area around previous IV site and
extending down right index and middle fingers.” N.N., RN [Provider
Notification]
 3:17 am “NNP at bedside.” N.N., RN [Provider Notification]
 3:19 am Nitroglycerin ointment ordered [Medication Orders]
 5:30 am Nitroglycerin ointment administered to right fingers, N.N., RN [MAR]
 5:30 am “Blackened area on right hand extending down right index and middle
fingers. NTG ointment administered per order.” N.N., RN [Skin
Assessment]
Deviations from Standards of Care:
 The day shift nurse (D.N., RN):
o failed to assess the IV site prior to and following administration of Vancomycin
o failed to assess IV site with oncoming nurse during report at change of shift
 The night shift nurse (N.N., RN):
o failed to recognize complications of IV medication administration
o failed to timely notify practitioner of IV complications
o failed to reassess site between 7:30 pm and 2:30 am
o failed to timely administer nitroglycerin ointment
 The neonatal nurse practitioner (A. Dawson, NNP):
o failed to timely assess and treat the infant
My recommendations are as follows:
 Obtain complete medical records for length of infant’s stay in hospital including Labor &
Delivery and NICU as well as any subsequent treatment.
 Obtain policies and procedures from the hospital including:
o IV assessment
o IV care and maintenance
o IV medication administration
o Response and treatment of IV infiltration/extravasation
o Criteria for notifying MD/NNP
 Determine who was responsible for the delay in administering Nitroglycerin
o When did the nurse review the order?
o When did the medication arrive from pharmacy?
 A more detailed report that would include a comprehensive chronological timeline to assist
in developing this case.
 Locate expert witnesses including:
o IV nurse
o Neonatal ICU nurse
o Wound MD
The defense will probably argue that the extravasation of the IV was an unavoidable
complication of Vancomycin administration. However, the healthcare providers deviated from

3. 3
Confidential Attorney Work Product
Note: This is a fictitious situation and report developed for the sole purpose of demonstrating examples of report
format and length. Actual reports will vary in format and length appropriate to case type and complexity as
determined by legal nurse consultant and attorney-client.
standards of care by failing to appropriately respond to and treat this complication in a timely
fashion. These deviations resulted in permanent injuries.
Thank you for the opportunity to assist in evaluating this case. I will follow up within two
days to answer any questions you may have regarding this case and to determine the next steps
you would like me to take.
Sincerely,
Krystal McMahan, RN, BSN, CLNC