Yolanda Pinellas is a 21-year-old female studying to be a music conductor. She was admitted for chemotherapy. The medication mitomycin was administered by intravenous infusion through an infusion pump.

During the evening shift, the infusion pump began to beep. The RN found that the IV was dislodged, discontinued the infusion, notified the physician, and provided care to the infusion site. The patient testified that a nurse came in, pressed some buttons, and the pump stopped beeping. She was groggy and not sure who the nurse was or what was done. The documentation in the medical record indicates that there was an IV infiltration.

Two weeks after the event, the patient developed necrosis of the hand, required multiple surgical procedures, skin grafting, and reconstruction. She had permanent loss of function and deformity in her third, fourth, and fifth fingers. The patient alleges that, because of this, she is no longer able to perform as a musical conductor.

While reviewing charts, the risk manager had noted that during the 3 months prior to this incident, there were short-staffing issues with many nurses working double shifts (evenings plus nights) then coming back to work the evening shift again. The risk manager also noted a pattern of using float nurses among several units.