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Attending Unaware of Patient Problems

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Attending Unaware of Patient Problems

By Tom A. Augello, CRICO and William Berry, MD, CRICO

Related to: Communication, Diagnosis, Documentation, Surgery, Teamwork Training

Postoperative decline required communication to bring the attending’s wisdom to the bedside.

Commentators

  • William Berry, MD, MPH; CRICO/RMF; Cambridge, MA

Transcript

The following case abstract is based on closed claims in the Harvard system. Some details have been changed to protect identities.

A 60-year-old female patient was evaluated by her surgeon for cancerous polyps, and surgery was scheduled for removal. The operation was complicated by several adhesions that were taken down, and a low anterior resection was done.

Two days post-op, the patient began to complain of abdominal pain. This was a Friday night, and by the next morning her temperature was 100.9; her abdomen was distended and she was tachycardic.

On Monday morning her respiratory rate was increasing and she was experiencing shortness of breath. The general surgery resident ordered a CT scan to rule out a pulmonary embolism. The scan showed a large amount of free air in the upper abdomen.

On Tuesday, five days after surgery, the attending surgeon made the first note in her record since the operation, indicating she had increasing tachycardia and shortness of breath with increased abdominal distention. The attending noted that an enterotomy or anastomotic leak were likely problems.

The patient was returned to the OR and an enterotomy was found. The patient died several days later with uncontrolled sepsis.

Her estate sued the attending surgeon, alleging negligent delay in diagnosis, delay in surgery, and improper management. The case was settled in the mid-range.

To discuss the patient safety and risk management aspects of this case, we are joined by Dr. William Berry. Dr. Berry is a cardiothoracic surgeon and a surgical consultant for CRICO/RMF, the patient safety and malpractice insurance company owned by the Harvard medical institutions.

Bill, the allegation was failure to address this leak and address the sepsis in a timely way.  Besides sort of the ‘captain of the ship philosophy,’ why did this come down on the attending?  There were plenty of residents and other people giving this patient attention for several days.

This is a very good case to illustrate how important the attending’s presence at the bedside at some frequency is. Because the attending when he was performing this surgery encountered quite a bit of difficulty because of the amount of scarring that was present in the patient’s abdomen and I’m certain left the operating room with some concern that there may have been damage to the bowel away from the area where the bowel is actually reconnected. And how do I know that?  Well, it is reflected in the first note that the surgeon puts in the chart after the surgery.

Five days later.

Right, and that isn’t for five days, and in that note the very first name that the surgeon mentions is the possibility of an enterotomy, which is damage to the bowel, causing an opening in the bowel that would have occurred when all those adhesions and that scarring was being dealt with. So, what you have here is a surgeon that does the case, an experienced attending, who probably walked out of the operating room worried. But resident staff then who may not even have been in the operating room when the case was done who were totally unaware of the significance of the length of the surgery perhaps—certainly not aware of the extent of the adhesions that were found inside the patient’s abdomen. And you really couldn’t expect them to have that same concern to where if the attending had been seeing the patient every single day, which it doesn’t appear. That he was he probably would have picked up the early subtle clues that something wasn’t going right in this patient where the resident staff doesn’t have the benefit of his years of experience, doesn’t have the benefit of what he saw when he actually did the case, and is not going to be as concerned about the subtle signs that there is something going wrong inside the abdomen of this patient.

So we know from the literature that a lot of the communication breakdowns that can lead to errors or bad outcomes for the patients do involve attendings and there is this need to bring the attending to the patient post-operatively to have communication post-operatively.  So, what kinds of interventions does all of this suggest?

Well, one of the things that we know—and the malpractice experience teaches us a lot, and for those of us that have spent time working clinically with residents we know—that the culture sometimes in the academic teaching institutions inhibits communication between the resident staff and the attending staff. There is an intervention that is becoming more popular in some of the academic institutions that we work with that I think gives us an opportunity to change the culture and I call that and other people call that a trigger. And what’s a trigger?  Well, it is like a trigger on a gun.  It is something that happens in the clinical course that triggers the resident to communicate to the attending. And it could be something as simple as the resident is very concerned about something that is going on with a patient and needs help from the attending to something very specific like the patient needs a blood transfusion because of a change in a lab value and the attending should be notified about that. Or the patient has had a heart attack and needs to be put in the coronary care unit.  That’s a time when the resident with a trigger in place must communicate with the attending. 

Now I think another way to enhance this communication is actually something that again is being worked on in a number of places across the country and that is the transfer of information at the end of a procedure, at the end of a shift, which really focuses more on kind of a hand-off. Because even in this case, if the attending had done something as simple as passing on to his resident staff his concern at the end of the surgery, verbalizing that concern in the care of this patient for the next several days the thing that you should be looking for is… Now, it could be I’m not worried about anything or it could be as I suspect when he left the operating room that he is very concerned that there might be a leak. Had the awareness of the resident staff been raised it could have changed potentially the outcome in a case like this and in other cases that we see. 


September 1, 2007
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