Communication and documentation flaws compromised a case that featured allegations of poor assessment and monitoring both pre-op and post-op.

Guest Commentator

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


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

A 48-year-old morbidly obese woman with diabetes and sleep apnea treated with nightly nasal CPAP, required surgery for a detached retina. Two days before surgery, during her pre-operative evaluation with a locum tenens physician in her PCP's office, she reported a 3-4 day history of phlegm-producing cough and intermittent shortness of breath. Her EKG was within normal limits with no acute changes. The physician diagnosed the patient with acute bronchitis, and prescribed antibiotics and a bronchodilator. Because her procedure was scheduled as day surgery, he did not order CPAP postoperatively. The locum tenens sent the patient's pre-operative report to her surgeon

During the patient's pre-operative anesthesia interview, the anesthesiologist noted the patient's acute bronchitis and sleep apnea. There was no documentation of a respiratory assessment, but the anesthesiologist cleared the patient for surgery, which was performed without complications. Given her history of sleep apnea and the late afternoon surgery, the patient's daughter requested that the patient be admitted overnight for observation. Stable, alert and oriented, the patient was transferred to the floor at 6:30pm.

The receiving floor nurse recalled the patient being transferred without report or any mention of her sleep apnea or recent history of bronchitis. Over the next several hours the patient received pain medications and antiemetics.

At 11:45pm the nurse checked on the patient, who appeared lethargic with cool, moist skin. A glass of orange juice improved her blood sugar labs and her alertness. One hour later, the patient again appeared lethargic but arousable. The nurse had the charge nurse assess the patient, and he felt the pain medications had taken effect and the patient was sleeping comfortably.

At 1:15am, the nurse found the patient without a pulse or respirations. She called a code and the patient was resuscitated. She was transferred to an ICU at a neighboring hospital, declared brain dead, and later removed from life-support.

The patient's daughter sued the patient's three anesthesiologists, the attending surgeon, the ophthalmology fellow, the nurse anesthetist, and the nurse caring for her that evening. The plaintiff alleged that the patient should not have undergone a non-emergent surgical procedure in the presence of an acute respiratory infection, which contributed to ineffective breathing; that the patient's sleep apnea was not noted; and post-op monitoring was inadequate, which lead to her death. Following unfavorable expert reviews, the case was settled for more than $1 million.

To discuss the risk management and patient safety aspects of this case, Resource speaks with Dr. William Berry. Dr. Berry is a surgical consultant for CRICO/RMF in the Harvard system.

Q. Bill, some of the clinical and risk management issues that led to settlement occurred before surgery even began. What do we see here?
A. There were two major issues that came up before the patient actually had her operation and we can take them one at a time. The first occurred when the patient was in the primary care physician's office a couple of days before the operation was scheduled with a complaint of a productive cough. The physician at that time felt that she had bronchitis and treated her by beginning an oral antibiotic and administering a bronchodilator to her and recorded all this and appropriately forwarded a note to the surgeon. The problem comes because that note was not accompanied by some kind of more direct contact because it appears that this information never reached the surgeon before the patient was actually admitted to the hospital. So the surgeon didn't have the benefit prior to admission of being able to decide that admission perhaps should have been postponed until the patient was over their acute bronchitis. In deciding whether a note is enough after you see a patient in the office, particularly one that's going to subsequently have some kind of a procedure and operation, there is obviously going to be a graded response in what she should do next. If you see a serious, really serious, problem in the primary care office you want to contact the surgeon as soon as you can and make sure that this information reaches the surgeon's ears. Other times, sending an e-mail or leaving a message on the telephone is going to be adequate. But you want to be certain, if you feel it is appropriate, that the loop gets closed in time for the surgeon to make appropriate decisions, before the patient actually comes into the hospital for the surgery.
Q. And then the anesthesiologist sees the patient and there's sort of a classic risk management problem there.
A. The anesthesiologist, and again we're reflecting back on what notes we have after the fact from the anesthesiologist, but the anesthesiologist apparently was aware that the patient had acute bronchitis. He was also aware that the patient suffered from chronic sleep apnea and was treated for that at home and decided that it was safe to proceed with a general anesthetic in spite of these two issues. That is a decision that is based on the anesthesiologist's clinical judgment. But the risk management problem here is that there was no assessment recorded and no demonstration of the anesthesiologist's rationale for doing something that most anesthesiologists probably wouldn't have done.
Q. Even to simply document that there was an assessment.
A. Absolutely. You know anesthesiologists have a routine when they see patients before surgery and that routine includes a physical examination. In my mind it is almost certain that the anesthesiologist did a physical examination of the patient, but if it didn't get written down it becomes problematic in cases like this where there is a bad outcome and people are looking backwards. Again, though to me the most important part is how did he move from something that would normally lead to a case cancellation, which would be a patient presenting on antibiotics with acute bronchitis to the decision to go ahead that it was safe to proceed. None of his thought processes is in the record and that would have been extremely helpful.
Q. The decision to keep her overnight given her sleep apnea may have been a factor in the patient's clinical outcome. Can you address that?
A. Yeah. I think this actually raises a very important issue that goes far beyond the care of sleep apnea. Sleep apnea is becoming a bigger issue in the community and the problem of obesity is being bigger in the United States figuratively and literally and in this particular case it is impossible to say if she had her CPAP machine in the hospital that night if she would have died, but chances are that if she had her CPAP machine the problems with sleep apnea would have been less of a problem than they probably were and this may not have happened had she had her machine with her, but it is representative I think of a whole class of problems that we're seeing more frequently in medicine now and that is the patient that brings to the hospital with them some complex issues that don't go away at the hospital threshold and are still there when the patient transitions back into the community. This is a similar class of problems like patients that are on chronic anticoagulation that has to be adjusted in order to come into the hospital, but then needs to be restarted in some form, often times when the patient leaves. I think this really ties into the whole issue and problems that surround medicine reconciliation because patients bring medicines with them to the hospital, often times have those changed around, and then have to make the transition back into a community where they had already been on medications and may have been different than the ones they are discharged on. It's a huge issue and it clearly requires attention. Sleep apnea is just one manifestation of a bigger problem.
Q. It is really the individual clinician's problem too. It is probably tempting just to focus on what you're doing for the patient, but the patient is a whole person who brings these other things in.
A. Absolutely. A lot of times the tendency in medicine broadly has been towards specialization, which tends to narrow our view of the patient's particular body subsystem or anatomic part and you do sometimes lose focus of the fact that the patient that has a bad wrist brings into them with the hospital this other problem like sleep apnea that's a much bigger threat to their life than the wrist problem often is, but the wrist will rise to the front and the other issues will fall to the back sometimes to the patient's detriment. I know it is a hard thing and I don't have any easy solutions for people to offer, but it is something that we constantly need to be considering.
Q. Thank you Dr. William Berry, surgical consultant for CRICO/RMF. For Resource, I'm Tom Augello.

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