A recent malpractice case named an orthopedic surgeon who had prophylactically placed a patient on antibiotics days before performing arthroscopic surgery to clean up scar tissue on the patient’s ankle.
"The surgeon failed to appreciate that the patient had developed the early stages of Stevens-Johnson syndrome," says Nan Gallagher-Auferio, JD, Esq., an attorney at Kern Augustine Conroy & Schoppmann in Bridgewater, NJ.
The plaintiff alleged that if a proper medical history been obtained and a thorough preoperative examination been performed, the surgery would have been aborted and the patient would have been sent to the hospital for immediate interventions to be performed.
"Here, the surgeon putting the patient under general anesthesia only intensified the adverse reaction of the syndrome, and the patient went into multi-organ failure in the lobby of the surgery center. She subsequently died," says Gallagher-Auferio, adding that the case was settled for $550,000.
In another case involving failure to monitor a patient, an anesthesiologist was sued after a patient developed disseminated intravascular coagulopathy in the post-anesthesia care unit (PACU) following removal of a malignant testicle at an outpatient surgery center.
"The anesthesiologist left the building without properly monitoring the patient’s postoperative vital signs, and failed to respond to multiple pages from the PACU nurses," says Gallagher-Auferio. "The patient later died. The physician’s conduct was indefensible."
Claims from communication lapses
Communication lapses are a frequently cited cause of medical malpractice cases, according to Cindy Wallace, CPHRM, senior risk management analyst at ECRI Institute, a Plymouth Meeting, PA-based organization that researches approaches to improving the safety, quality, and cost-effectiveness of patient care.
To protect themselves against these claims, Wallace recommends these practices:
• The surgical team should conduct a preoperative briefing to share information on the patient.
For example, the physician/surgeon and anesthesia provider should review the pre-anesthesia evaluation of the patient to discuss any known risks and the plan to minimize these risks.
• The physician/surgeon should ensure that the recovery team knows how to reach him or her, as well as a back-up contact, in case any questions or concerns arise.
• There should be an established process for handing off the patient from the surgical team to the recovery team.
"Standardized communication tools, such as the SBAR [Situation-Background-Assessment-Recommendation] briefing tool, should be used to clearly describe the patient’s condition and key concerns and recommendations for the patient’s recovery," says Wallace.
Risk of fragmented care
The responsibility for caring for postoperative patients is now being divided between more providers, reports Hugo Quinny Cheng, MD, director of the medicine consultation service at University of California, San Francisco Medical Center.
"Hospitalists are often asked to manage the medical’ aspects of care in lieu of the surgeon," says Cheng. In some cases, the hospitalist serves as the attending of record for surgical patients, while the surgeon is a consultant.
"This shared responsibility allows each physician to focus their efforts on the areas they have the greatest expertise," says Cheng. "But it can also create risk if care becomes fragmented." For example, there could be uncertainty as to which provider is responsible for monitoring a specific issue, such as anticoagulation. "The surgeon and the hospitalist may each assume the other party is monitoring this, whereas in fact neither physician is doing so," says Cheng.
Another problem that can arise is the surgeon turning over care to hospitalists that lack adequate training or experience to deal with surgical problems. "The availability of hospitalists can untether subspecialists and surgeons from their responsibilities to closely follow their patients after surgery or to take call for emergency room patients," says Cheng.
Cheng says there is potential for the surgeon and hospitalist to be held liable in this scenario. If providers are going to divide up responsibilities, it’s important to have a protocol in place that clarifies their roles, he adds.1
"Who will monitor and order anticoagulants? Who will monitor for bleeding and order transfusions?" says Cheng. "Even with protocols in place, however, there needs to be frequent communication between providers."
- Cheng HQ. Comanagement: Who’s in charge? AHRQ Cases & Commentaries [serial online]. June 2012.