The patient brought a claim against the neurosurgeon for failure to inform him of the retained catheter in his spine, and failure to respond to the significance of his postoperative back pain.

The claim was settled in the low range (<$100,000).

Clinical Perspective

1. Since the patient had already been closed, the attending surgeon had left the operating room when the resident encountered trouble with the catheter. When he was notified, the attending asserted that it was more important to end the operation and "go in at a later point and remove it." Unfortunately, this plan was forgotten.

   Even a successful surgery leaves some tasks to be done-some with potentially serious health implications for the patient. Highly reliable care is not built on memory or working in isolation. A minute or two spent on a quick "debriefing" of all surgical team members can help identify, for everyone, what is left to do, when it will be done, and who will do it. Team training would emphasize the need to establish a shared mental model to ensure everyone sees the big picture.

2. The patient made a follow-up visit to the surgeon's office, representing another opportunity to remember the retained catheter. He complained of post-operative back pain.

   Patients can be enlisted in ensuring reliability in their care through added communication. Had this patient been told soon after surgery or upon discharge of the need to remove the retained catheter piece, he certainly would have brought it up during the follow-up visits. Additionally, in light of an unexpected post-op complaint, a quick review of the operative notes would have helped reveal the source.

Patient Perspective

1. I understand that what happened with the catheter was secondary to a complicated procedure that saved my life, but it's not like nobody knew there was something still in me. How could they simply forget to tell me or to schedule time to remove it?

   Patients are entitled to expect a process of checks and double-checks that keeps them from being harmed in the course of medical encounters. They expect the system to be flawless, or at least to have the ability to catch and correct errors. Unfortunately, all the good rapport a clinician has established with a patient can be undone by a relatively small misstep.

2. As a result of the pain (from the retained catheter), my life was on hold. I couldn't drive or go back to work for almost a year. And it's not like I didn't tell them about it. When I heard about the retained catheter, I was shocked that they hadn't put two and two together.

   Following a physical complaint to a definitive diagnosis is an important consideration. Patients who believe their doctors are concerned enough about them to make sure a problem is resolved are more likely to trust the physician in other areas of their care.

3. To his credit, once he figured out what happened, my surgeon admitted his memory failed him, and he apologized mistake of memory.

   Openness, honesty, and apology may help the patient cope with the error and maintain a relationship with the provider.

Risk Management Perspective

1. Many opportunities arise for information to be lost, inaccessible, or forgotten as care is handed off across multiple settings and providers.

   To prevent loss of key information, a "flag" or problem list could be set in the medical record that would serve as a trigger for the attending surgeon before completing a critical function (e.g., signing the operative note). In this case a flag highlighting the fact that this patient was different, based on the retained catheter in the operative report, would have been one more reminder to the attending and those writing the discharge summary.

2. The attending in this case was not liable for the resident breaking the catheter and failing to remove it successfully, but he was deemed responsible for failing to adequately follow-up that complication after having signed the operative note.

   A careful reading of the operative notes before signing off on them provides a critical review of needed follow-up for the attending. Juries are not usually sympathetic if told the attending did not read a note that he or she signed.

Legal Defense Perspective

1. Retained foreign bodies are nearly impossible to defend. The attending took full responsibility for the complication and apologized to the patient. The claim was quickly settled, taking into account the pain and discomfort and disability (lost wages) related to the retained catheter.

   Restraining from finger-pointing is critical in mounting the best defense for any malpractice claim. An open, honest, and timely apology may reduce the likelihood of a lawsuit, or improve the chances of a successful settlement for a reasonable sum.