This case takes place in Nebraska and involves a male patient who was diagnosed with a rare blood disease, for which he was receiving medical treatment. A port was to be placed to help administer the needed drugs. During the catheter placement surgery, the physician accessed a large vein but could not get the access that he needed – he then used an alternative approach that was apparently successful on the first try. Some weeks later, the patient returned to hospital for the first round of therapy. A nurse placed a syringe needle into the port and pulled the syringe plunger back to draw blood and informed the patient that it was working properly. However, the patient informed the nurse that he did not see any blood return. Nevertheless, the nurse proceeded with the therapy. Despite the fact that the man repeatedly told the nurse that he was in severe pain, the nurse continued to administer the treatment. When the patient left the hospital that afternoon he was in pain which was worsening as time went on. It became increasingly difficult for the patient to breathe, at which point he was taken to the emergency room by his wife. The patient presented to the ER with pain in his chest, where it was discovered that a large amount of the drug administered during his treatment had pooled within the tissues in his chest.
