Mutual Matters

Communication Errors in Surgery

Posted by Bill Kanich, MD on Dec 15, 2016 2:58:56 PM

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Case Description

Dr. Hunk is a well-trained orthopedist who limits his practice to joint replacements. He has a great reputation, and performs 450–500 arthroplasties per year.

The patient is a 78-year-old woman with a history of multiple joint replacements for rheumatoid arthritis. Both artificial hips, implanted 23 (right) and 25 (left) years ago, need revision. After discussing his plan with the patient and her husband, Dr. Hunk sends them to his surgery scheduler with a surgical form that includes the following:

  • Operation: bilateral revision, staged. R/L
  • Time: 5 hours
  • Equipment: cement remover, revision set.
  • Rep to be present. Call and Template.

On the day of surgery, Dr. Hunk confirms with the patient that he will be revising the older, left hip. She and her husband agree. As is his custom, Dr. Hunk uses an indelible marker to outline the posterior incision and sign his initials. As is his routine, he adds a smiley face at the end of the surgical site.

Following induction of anesthesia and lateral positioning of the patient, the operation proceeds smoothly. The prosthetic stem and cup are removed. Dr. Hunk begins preparing the femoral canal and asks for the revision broach. The operating room nurse hands him a broach for a right stem, and reports that all stems and trial components are for a right femur. Dr. Hunk calls the manufacturing representative, but per hospital policy, the representative is not allowed in the operating room. The following conversation transpired:

Dr. Hunk: “Do you have a left revision set?”

Rep: “I was told it was a right revision.”

Dr. Hunk: “Back to my question. Do you have a left revision set?”

Rep: “Yes. Unfortunately, it will take at least three hours to get it here.”

Patient Outcome

Dr. Hunk washed out the wound and closed the hip without prosthesis. Later that day he apologized to the patient, explained the error, and informed her of his plan to return her to the operating room to complete the operation within two to three days. Unfortunately, she developed postoperative atelectasis which delayed the second surgery. She then experienced a deep venous thrombosis that required six weeks of anti-coagulation therapy. Because of her inability to walk with a walker, she required a three-month nursing home stay. She and her husband sought the services of another orthopedist who told them that Dr. Hunk committed malpractice. The patient filed a lawsuit, and Dr. Hunk subsequently settled out of court based on pain, suffering, and the need for ongoing medical and nursing home care.

Read the full analysis of this case along with our strategies for improving patient safety and avoiding communication errors in surgery. 

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