A recent focused review of CAP’s closed-claims data by Risk Management and Patient Safety staff reveals that 62 percent of medication errors involving Medical Assistants (MA) occurred in busy primary care practices. These errors were directly associated with injectable medications, such as vaccines, antibiotics, numbing agents, and corticosteroids. Surprisingly, one particular medication made a frequent appearance – the glucocorticoid corticosteroid, Kenalog.
A notable case involved a 31-year-old female who was being treated for an insect bite and received a Kenalog injection in her right upper arm by an MA. The patient later complained of right arm weakness, as well as a palpable lump, a tingling sensation, and pain at the injection site. It was determined that the drug leaked out into the patient’s surrounding adipose tissue, causing necrosis and dimpling. With proper training, the MA would have known to inject the drug employing a Z-track technique deep into the gluteal muscle using a needle at least 1.5 inches long, as indicated in the manufacturer’s medication insert.
Additionally, the CAP Cares team frequently receives calls on the CAP Hotline from member offices wanting guidance in dealing with adverse patient outcomes due to the improper administration of Kenalog. Their unhappy patients sometimes require additional treatment, such as tissue expanders, or liposculpture and fat grafting performed by a surgeon and want the physician to pay for it. We are certain that many adverse outcomes involving Kenalog go unreported to CAP and not every call to the Hotline turns into a claim, but we do know that these errors are preventable and cost the patient, the physicians, and CAP a lot of time and money. The case mentioned earlier settled for $29,999 with just over $20,679 in expenses paid.
CAP Recommends:
- MAs should be trained in the administration of Kenalog and other injectable medications. Competency should be verified and documented by a qualified, licensed clinician, such as a physician, nurse practitioner, physician assistant, or nurse midwife.
- Before a Kenalog injection is given to a patient, a physician must discuss the medication with the patient, including its risks, benefits, side effects, and complications.
- Provide the patient with written patient education about Kenalog. Include a signature line on the handout for the patient and a witness to sign documenting informed consent. The original signed handout should be placed in the patient’s chart and a copy should be given to the patient.
- All Kenalog injections should be given according to manufacturer’s directions – deep into the gluteal muscle (buttocks). It should never be given in the deltoid (upper arm). A Z-track technique is recommended to prevent the medication from leaking into surrounding adipose tissue.
If your MA will be delegated the skillful task of giving injections, such as Kenalog, it is essential that our member physicians provide them with the training necessary to do so safely. Medication errors are preventable. Safe medication administration improves patient safety and reduces medical liability risk.
Amy McLain is a Senior Risk Management and Patient Safety Specialist for CAP. Questions or comments related to this article should be directed to amclain@CAPphysicians.com. The information in this publication should not be considered legal or medical advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.