Dr Mark Carswell – GP & MIPS Medico-Legal Advisor
“My whole arm is stained like a terrible bruise, what are you going to do about it, doctor?”
Iron staining is a recognised complication of iron infusions, but even doctors are often unaware of the severity of permanent staining. Even ‘mild’ staining can lead to patient distress, complaints, and requests for compensation. Specialised laser therapy delivered by dermatologists can be costly, requires multiple sessions over an open-ended timeframe, and can have varying degrees of success. The Medical Board and the Medical Council of New South Wales have also noted several complaints lodged regarding doctors due to iron staining.
Risk-minimisation strategies have been helpfully summarised by NPS MedicineWise
In addition to the sensible advice from NPS, MIPS has observed some common recurring themes among notifications involving iron staining which are worth sharing with members.
No indication for iron infusion
Often, the ferritin is low but there is no corresponding anaemia. We encourage members to consider if an iron infusion is truly indicated. If a trial of oral iron has failed (or if it is not appropriate or not tolerated) we advise members to document this clearly in the records.
No evidence of informed consent
Informed consent is vital. MIPS has seen cases where there has been no documented consent, or only a vague description of ‘verbal consent given’ recorded in the records. We recommend that written consent is obtained, with particular emphasis being placed on the risk of iron staining, ensuring that the patient is aware of the potential severity of the staining (possibly even with references to images) and that it is likely to be permanent.
Written consent does not have to be a lengthy process. It is important to give the patient sufficient time to absorb the information.
Complications during the infusion
In our experience, members are vigilant for symptoms and signs of extravasation during an infusion. However, MIPS has encountered cases of staining where there have been no obvious complications during the procedure, but where there had been multiple attempts to cannulate the vein prior to initiation of the infusion. Failed attempts at canulation can have the potential to damage the vein, increasing the risk of extravasation. We suggest that members are cautious about starting an infusion if cannulation was difficult.
It is common to utilise practice nurses in the infusion process. It is vital that MIPS members ensure that nurses are properly trained, that infusion guidelines are adhered to, and that they are appropriately educated on the immediate action that is required if there are adverse reactions during the procedure. It is also important that patients are adequately educated to immediately report symptoms suggestive of extravasation. Nurses should have their own medical indemnity, and therefore if you involve your practice nurse in the infusion process it would be prudent to confirm that they have their own indemnity arrangement in place.
If a patient reports iron staining please contact MIPS for advice as soon as possible on 1800 061 113.
Resources:
NPS - Ferric Carboxymaltose Ferinject for iron deficiency anaemia
NPS - Ferinject solution for injection
MCNSW - 5 things you can do to avoid complaint
Case study: Iron infusions – what do you mean this skin stain is permanent?
This information is of general nature only and not intended to be legal advice and, as such, should not be relied on as a substitute. You may need to consider seeking legal or other professional advice about your individual circumstances as appropriate. Should you wish to obtain further information about products offered by MIPS, you can call us on 1800 061 113 or review our Member Handbook Combined PDS and FSG. You may need to consider seeking legal or other professional advice about your circumstances as appropriate. Information is current as of the date published.
