Français

Reducing risk in surgery


Patient safety during operative treatment

Phases of surgical care


Surgery sceneOperative treatment has potential for serious adverse outcomes and significant medical-legal risks.

Attention to all phases of surgical care are important to reduce risks:

  • pre-operative assessment
  • indications for surgery
  • consent discussion
  • technique of the surgery
  • post-operative care and follow-up

Phases of surgery


Outline drawing of male physician speaking with male patient

Pre-operative assessment

  • Consider the information provided by the referring provider.
  • Obtain an adequate history.
  • Do a physical examination.
  • Undertake any appropriate investigations.
  • Make or confirm the diagnosis.
  • Document your clinical findings and diagnostic impression.

Case example

A patient has been referred by a family physician for removal of a skin lesion on the back. The patient has not previously been seen by the general surgeon at the outpatient surgical clinic. When the name is called in the waiting room, an elderly woman comes forward. The surgeon proceeds to remove a lesion from her back. The nurse soon becomes aware this is the wrong patient; the elderly woman was to have a breast biopsy.

A legal action is later settled. The College is critical of the surgeon for not undertaking a pre-operative assessment and consent discussion.

Outline drawing of male physician speaking with male patient

Indications for surgery

Are there indications for surgery?

Case example

A patient with inflammatory bowel disease receives brief treatment with medical therapy. Surgery is performed and the patient develops several complications that cause significant disability.

A lawsuit follows. It is not possible to find support for the early use of surgery, as peer surgical experts feel the patient did not receive an adequate trial of medical therapy before proceeding to definitive surgery.

Outline drawing of male physician speaking with male patient

Informed consent

The most important part of the consent process is the discussion between the patient and doctor, followed by documentation of the discussion in the medical record.

Case example

The patient should be informed of the various treatment options and their risks and benefits. The consent discussion should be noted in the medical record; the consent form is not the consent.

If a complication is rare, but would be of significance (life-, limb- or health- threatening), the patient should be informed.

Outline drawing of two surgeons

Surgical technique

  • Confirm the correct patient, operation, and side to be operated on.
  • It may be useful to review the medical record.
  • Exercise care to protect vital structures such as nerves and vasculature.
Each surgery has unique risks. For example:
  • When doing spinal surgery, double-check the level.
  • In certain abdominal surgeries, beware of ureteric injuries and document, when appropriate, any efforts to visualize or preserve the ureter.
Outline drawing of male patient in recovery with nurse at bedside

Post-operative care and follow-up

Complications can occur even when the surgery has gone well.
  • It has proven difficult to defend the post-operative care when there is a lack of attendance on the patient.

Follow-up

  • Problems can arise during off-hours and weekends.
  • If the most responsible surgeon is not available while the patient is still in hospital, nursing staff should know who is covering and how to get in touch with them.
  • Patients should have information about who to contact after they are discharged.
  • When going off duty, the surgeon should communicate the clinical status of his or her patients to the physician who is covering.
Outline drawing of hands on keyboard

Documentation

The operative note should include details of:
  • the technique
  • anatomical findings and variants
  • difficulties encountered in the procedure
  • confirmation that sponge and instrument counts were correct

The note should be dictated as soon as reasonably possible. It can be more difficult to defend care if operative reports are dictated only after a post-operative complication has been recognized. It is also more difficult to defend the post-operative care if the physician does not note the progress of the patient in the medical record.

It is important to document:

  • the progress of the patient
  • when problems start
  • what is being done

Previous
Next

Case: Post-delivery care of a young woman
Graphic of infant in utero

Background

A young woman in her first pregnancy has initially progressed well in labour, but she is failing to progress in the second stage.

The patient has been pushing for nearly three hours when the obstetrician on call arrives. He has never met this young woman before. As the patient is tired, he recommends delivering the baby by forceps.

Forceps delivery of the head is followed by shoulder dystocia, which the surgeon is able to successfully manage.

Background continued

Inspection of the perineum and vagina reveals a fourth degree tear. The delivering obstetrician repairs this using a standard procedure, and then transfers the patient back to her attending obstetrician for postnatal management.

Neither physician discusses the tear with the patient.

The tear does not heal well and the patient needs further surgery.

Outcome

The new mother complained to the medical regulatory authority (College) about the on-call physician, citing the following concerns:
  • She would have insisted on a caesarean section if she had known the forceps could cause a recto-vaginal tear.
  • Postpartum care was unsatisfactory.
  • No one told her about the serious nature of the tear, or its possible long-term consequences.

Outcome continued

The College had no criticism concerning the first two complaints relating to the physician's care. However, it did have concerns about the lack of communication with the patient.

The College stated that "best practice" would have been for the doctor to make sure, before the patient was discharged, that she was made aware of the circumstances of the tear and repair, as well as the potential complications that might arise.

The College pointed out that "patients are entitled to be informed of all aspects of their healthcare," including a right to know about complications that have occurred.

Lessons learned

When a complication occurs, it is important to decide who should discuss it with the patient, and when.

Usually this is the most responsible physician, but when more than one physician is involved, good communication between the physicians helps ensure the patient receives both good care and adequate information.

Previous
Next

Case: Check the nurse's notes
Ultrasound image

Background

A young pregnant woman develops acute gallbladder symptoms. When the symptoms do not respond to conservative measures a surgeon is consulted.

Together the surgeon and obstetrician decide to induce labour as early as possible and to follow with definitive gallbladder surgery. However, a spontaneous delivery occurs and is managed by a nurse before the physician can arrive. The obstetrician delivers the placenta and notes a mucosal tear, which he believes does not need to be treated.

Background continued

A study the next day confirms cholelithiasis, and two days post-partum a laparoscopic cholecystectomy is carried out. The patient tolerates that procedure well, but several weeks later complains of passing stool through the vagina.

The patient ultimately requires repair of a recto-vaginal fistula by a colorectal surgeon. She sues both physicians, alleging failure to recognize and treat the fistula in a timely fashion.

Outcome

The nurses' notes for the day following delivery showed the patient had complained to the nurses of passing gas through the vagina.

The obstetrician stated it was not his habit to read nurses' notes and he did not do so on this occasion. The surgeon who performed the cholecystectomy also stated he did not read nurses' notes.

The patient said she clearly recalled speaking to the obstetrician about her symptoms.

Outcome continued

Experts stated that late repair is typically more complicated than an early repair, often requires revision, and causes more pain and difficulty. Had either of the doctors read the nurses' notes, it is likely the diagnosis would have been made and the repair would have taken place earlier. Instead the patient suffered prolonged discomfort and embarrassment before undergoing a difficult repair.

The experts could not support the standard of care provided, and a settlement was paid on behalf of the obstetrician.

Lessons learned

  • Nurses' notes often contain valuable information that can help physicians in the management of patients.
  • The physician who performs an assessment or procedure may be found responsible for an adverse outcome, even if care is transferred to another physician.
  • Communication among members of the care team facilitates safe and effective patient care.
Previous
Next

Case: Post-op discharge instructions
Female healthcare worker on phone

Background

A 62-year-old man undergoes an uneventful arthroscopy and meniscectomy of his left knee.

On discharge from the day surgery the patient receives written instructions to attend the hospital emergency department if he has any trouble with his leg. The orthopaedic surgeon also verbally instructs the patient to call his clinic office if he has any problems.

Background continued

Three days later, the patient calls the clinic and notifies the receptionist of swelling of the knee and shortness of breath. The receptionist reassures the patient and suggests applying ice and elevating the leg.

The next day the patient dies from a massive pulmonary embolus.

Outcome

In the subsequent legal action, the patient's wife alleged the receptionist provided inadequate recommendations, and the reassurances had discouraged the patient from seeking additional medical care.

The trial judge dismissed the action against the orthopaedic surgeon, but the decision was reversed on appeal.

Outcome continued

The Appeal Court believed the surgeon had a duty to inform the patient about the risk of pulmonary embolism. The judgment noted that an uninformed patient would not be able to establish a link between a minor procedure on the knee and breathing difficulties.

The plaintiff was awarded compensation.

Lessons learned

In this case, the Appeal Court stated that post-operative information given to patients is part of the physician's duty to follow up.
Previous
Next

Post-operative information should include not only instructions regarding appropriate care, necessary medication, and frequency and nature of follow-up visits, but also instructions on the predictable complications and any symptoms or signs announcing danger.

The information should be provided to the patient and to the office or clinic staff responsible for triaging or responding to calls from concerned patients.

The courts have an increasing expectation that physicians educate patients to recognize the symptoms and signs that should alert them to seek further medical attention. The information should be tailored to each patient and each clinical situation. It is a fine balance between frightening patients and giving a false sense of security.

At the same time, Canadian courts have traditionally recognized that patients have certain responsibilities for their own health. This includes a duty to give their health information to the healthcare professionals assisting in their care, to follow instructions, and generally to act with their own best interests in mind.

Patients' duty would also include seeking medical attention when required or when sensible to do so. The courts may consider patients to contribute to the negligence (fault in Québec) if they fail to act as might generally be expected of a reasonable patient, and if this failure contributes to the harm or injury the courts may reduce any compensation or damages awarded.

An action against a physician would be dismissed if the injury is due entirely to a patient's own negligence.