This case study involves allegations of negligent
surgery and a delay in recognizing postoperative complications.
The attending neurosurgeon, and three residents were named in a
malpractice suit that was settled in the high dollar range.
The patient was a 37-year-old father of four who was scheduled
for back surgery on a herniated left L4-L5 disk. Prior to surgery,
the staff neurosurgeon discussed the procedure with the patient
and his wife; however, the surgery itself was performed by the
chief neurosurgical resident who had considerable experience with
diskectomies. The attending was present for positioning and then
at the end, to inspect the site and remove a small disk fragment.
No surgical complications were noted.
In the recovery room, the patient’s systolic blood pressure suddenly
dropped into the 90s. The resident who did the surgery ordered
fluid boluses and the systolic blood pressure came up to 100. Soon
after, the resident went off duty and the anesthesia resident took
over. During his three-hour stay in the PACU, the patient complained
of nausea and then abdominal pain and was treated with percocet.
Although systolic blood pressure never rose above 100 during his
lengthy stay in the PACU, the patient was never examined, further
testing was not ordered, and senior staff were not consulted. Two
hours after the patient’s transfer to the floor, he was found unresponsive
in the bathroom. The covering neurosurgery resident examined the
patient and ordered increased IV fluids, bringing the patient’s
blood pressure up from 64 to 100.
The next morning, the patient was found unresponsive again with
a distended abdomen, systolic blood pressure of 50, and a heart
rate of 160. Emergency surgery helped determine that the left iliac
vein was avulsed from the inferior vena cava. This was apparently
triggered when bone fragments adhered to it and were removed at
the end of the disk surgery—a rare and unexpected occurrence that
led to slow but massive internal bleeding and coagulopathy. After
the attending neurosurgeon delivered a negative prognosis for a
meaningful recovery, the patient’s wife made the decision to discontinue
life support.
To discuss the patient safety and risk management aspects of this
case, Resource speaks with Dr. Luke Sato. Dr. Sato is chief medical
officer and vice president for patient safety and loss prevention
at Risk Management Foundation.
Dr. Sato, in this case, the unexpected surgical complication
could have happened in the hands of the most experienced surgeon.
But the lawsuit was settled in the high range so what went wrong
with the care?
It is important to keep in mind that the technical complication
didn’t cause the patient’s death; instead it was the response
to the adverse event that more likely led to the fatal outcome.
Monitoring that followed this patient in the recovery room and
then to the floor was found to be problematic. The situation
was never fully worked up either in the recovery room or on the
floor. No stat hematocrit was ordered; no blood gases ordered.
Multiple signs were missed along the way, and some of the deficiencies
point to the challenges involving transfer of care or handoffs.
More specifically, important information was lost as the neurosurgical
resident signed off after being on duty for more than 24 hours.
So, in hindsight, the simple things matter: harm often flows from
multiple simple errors. In this case, the residents failed to take
some basic steps in taking the time—and I want to emphasize time
here—to evaluate the patient’s condition—conducting a physical
exam, considering his pre-operative blood pressure readings in
face of consistently low BP, the patient’s lack of response to
fluid boluses, and his complaints of abdominal pain which had resulted
in a prolonged stay in the PACU. There needed to be further evaluation
by the PACU anesthesia resident – by calling for assistance from
his supervising anesthesiologist or by informing the neurosurgeons
who were also responsible for this patient’s care.
Does the case point to any significant supervision issues?
The three residents did not consider a vascular injury, and the
patient’s blood pressure remained below 100 for several hours.
Now on the other side of the study, discs are not expected to have
any trouble in the recovery period. Human factors experts would
suggest that cognitive failures of judgment or vigilance played
a role. The work by Dr. Atul Gawande on the causes of surgical
error points out that errors in judgment are strongly associated
with inadequate supervision – indicating that systems failures
underlie a subset of the cognitive errors.
The standard of care would have required an order in the chart
by a caregiver that insures frequent monitoring of vital signs
(at least every 15 minutes). No order was written. Of note, the
staff neurosurgeon was not notified of the difficulties in this
case until after the second episode of unresponsiveness – by that
time, it was too late. We need to explore the cultural barriers
to asking for help: lowering the threshold of attendings and residents
working together; attendings talking about their mistakes may also
help.
Does this case contain any lessons for managing the communication
and relationship with the patient and his family?
One insight we have in this case is the wife’s deposition in which
she stated that the neurosurgeon told her husband and her that
the laminectomy was a simple procedure and that her husband would
be able to return home from the hospital the next day. She did
not recall the neurosurgeon discussing any risks or dangers associated
with the surgery. In addition, prior to the surgery, the staff
neurosurgeon never disclosed to them the extent to which the
neurosurgical resident would be involved in her husband’s surgery.
After her husband’s emergency surgery, the neurosurgeon met with
the wife to explain what had happened and what they found during
the surgery. The wife made a comment about why no one seemed to
listen to her husband’s complaints of abdominal discomfort. There
was no documentation in any of the notes to that effect. More specifically,
she recalled that her husband was complaining of abdominal pain
at approximately 9:30 pm. So she found a nurse on the floor and
told her of the complaint. The nurse came into the room and advised
the patient and his wife that the abdominal pain was probably the
result of the way the patient was positioned on the operating room
table. The nurse gave the patient some pain medication and left
the room.
Those hit just three issues around communication, documentation,
and informed consent that we know about. Caregivers need to routinely
make sure the patient understands the central risks of a procedure,
perhaps by asking them to repeat what they’ve heard. Giving them
written material to take home can also help them make an informed
consent, and being clear about who will be performing the procedure
helps manage expectations. Then documenting the key features of
all of these communications helps ensure all the bases have been
covered in preparation for a procedure and in later defense of
any adverse outcome.
In sum, this case illustrates how small things can combine to
cause tragedy. The first place to look for opportunities to minimize
the impact of human fallibility may well be at the handoff where
critical information is often lost. Research has shown that there
is a wide variation in content, format, accuracy and consistency.
Formalizing a structure and process around handoffs might reduce
the loss of critical information and uncertainty around the game
plan. As this tragic case certainly shows, communicating better
at patient transfer is key.
