Poor Teamwork Contributes to Anesthesiology Errors and Harm to Patient

Description

Poor communication and inappropriate use of a paralytic led to permanent facial nerve damage and paralysis during surgery. Poor documentation complicated the case’s resolution. 

Key Lesson(s)

• The surgical team’s difficulty achieving rapport and professionalism hindered their ability to adhere to standards of care and provide the best outcomes possible for the patient.
• Timely, accurate, and appropriate documentation is essential to the successful defense of medical malpractice claims.

Clinical Sequence

A patient in their sixties arrived at the hospital for a parotid tumor removal. The patient’s history was significant for GERD, obesity, a partial thyroidectomy, former tobacco use, and current Cannabis use.

The surgical team included an otolaryngologist, an anesthesiologist, and a nurse. The procedure took place within the anesthesiologist’s first month of practicing at this facility, and this was the first occasion these three professionals worked together as a team.

The anesthesiologist completed a pre-operative evaluation for general anesthesia and classified the patient as ASA III. The anesthesiologist administered a long-acting paralytic for intubation. The documentation did not specify the clinical rationale for use of a short-acting paralytic. Several team members recalled telling the anesthesiologist that paralytics were contraindicated for head and neck surgeries. The anesthesiologist did not recall this conversation, and the discussion was not documented in the record.

The anesthesiologist did not complete the train of four muscle twitch testing before the initial incision was made. The otolaryngologist calibrated a facial nerve monitor. During dissection, the otolaryngologist improperly placed a clamp on the facial nerve, mistaking it for a blood vessel, and the facial nerve monitor did not respond. The otolaryngologist asked the anesthesiologist if the paralytic reversal was given. The anesthesiologist failed to document administration of the reversal agent. The otolaryngologist removed the clamp, and the facial nerve response returned. The surgery proceeded and concluded without further incident.

Following extubation, the patient was noted to have a facial palsy. The patient experienced subsequent adverse outcomes, including difficulty closing the eyelid and a persistent dry eye, and was referred to neurology for facial palsy treatment.

The experts who reviewed the case noted several key aspects: the anesthesiologist should have used a short-acting paralytic, all the involved providers exhibited excessively poor communication, and there were significant documentation gaps and failures. Importantly, the documentation reflected many of the relationship issues and poor rapport with providers directing blame for the event at each other.

Allegation

The plaintiff alleged that the use of inappropriate medication caused permanent harm in the form of facial palsy.

Disposition

The case was settled in the medium range ($100,000–$499,999).

Clinical Analysis

The following factors precipitated and contributed to this malpractice claim being filed:

• Hierarchal issues, poor professional relationships and rapport among the surgical team exacerbated clinical issues and reduced the team’s opportunities to address them quickly as well as resolve them in a satisfactory way.
• The most appropriate medication was not used. A long-term acting paralytic was not indicated for this procedure.
• The documentation did not reflect the clinical rationale for choosing the anesthetic and when the reversal agent was administered.
• The documentation reflected poor professionalism of the providers, for example, “finger pointing” in the record, which also hindered the case resolution.

Discussion Questions

• How did the poor rapport and communication amongst the care team precipitate the event?
• How would utilizing standardized checklists or protocols have prevented the care team from omitting several of the required steps in this procedure?
• Would enhanced and more systematic documentation have better facilitated improved care and defense against a forthcoming claim? What would that documentation have looked like?

References/Other Resources

• Surgical Checklists
  • A Verbal Electronic Surgical Safety Checklist for the Intensive Care Unit
  • CRICO Operating Room Team Training Collaborative: Using the Surgical Safety Checklist
• Communication
  • Surgery Safety Communication
• Documentation
  • For the Record: The Effect of Documentation on Defensibility and Patient Safety