Time for another edition of learning from the mistakes of others. The California Department of Public Health routinely issues press reports about penalties they hand out to hospitals who cause preventable injuries to patients. Since I'm a firm believer that those who fail to learn from history are bound to repeat it, I think it is important we all study how these penalties came to be and how we can keep these incidents from occurring in our own institutions. That's why the Morbidity and Mortality conferences are important and have been a mainstay of medical education for decades. So here we go.
First lesson, don't fondle a patient's breasts while she is under general anesthesia. Dr. Yashwant Giri was caught touching a patient's breasts during a hemorrhoidectomy when the surgeon and the nurses were on the other side of the ether screen. Unbeknownst to him, he was being observed through a window in the OR door that was located behind him. An OR transporter noticed the incident and reported him. When she talked to the Chief of Anesthesia, she discovered that this was not the first reported incident of sexual assault by Dr. Giri on a patient. The previous incidents were never reported to security or the police. For this transgression, Placentia-Linda Hospital was fined $50,000.
Next, don't use an LMA during cardiopulmonary resuscitation. A patient at Memorial Medical Center in Modesto had just completed a cystolithopaxy under general anesthesia with an endotracheal tube. The case went routinely. At the end of the case he was extubated by the anesthesiologist. The patient's monitors were removed to facilitate moving him onto the transport gurney. At this point the patient became agitated and started thrashing around. The anesthesiologist then pushed six ml of propofol to calm the patient. The patient promptly became apneic. He was then quickly moved back on to the OR table. When monitors were replaced, the patient had an oxygen saturation of zero, confirmed with a second pulse ox. The anesthesiologist inserted an oral airway and tried to bag mask the patient to no avail. He then inserted an LMA to improve oxygenation but that too did not work. By then another anesthesiologist was found and suggested that the patient be intubated. This was done and CPR was started. By then the patient had suffered severe anoxic brain injury and died eleven days later. The hospital paid $50,000 for this transgression.
Third, don't give sixty milligrams of morphine after foot surgery. A patient was undergoing heel surgery at Adventist Medical Center in Hartford. Postoperatively the patient complained of a lot of pain. In the recovery room he received Demerol 75 mg, morphine 4 mg, and fentanyl 25 mcg. A morphine PCA pump was started by the CRNA and the patient sent to his floor bed. The PCA was set with a basal rate of one mg/hr and 3 mg boluses at ten minute intervals. The patient arrived in his room at 8:00 PM. Over the course of the evening the patient administered himself over 60 mg of morphine. By 3:00 AM the patient was found to be cyanotic and unresponsive. CPR was started but was declared deceased 45 minutes later. Adventist was penalized for $50,000.
So take some time and go through this treasure trove of tragedies nicely compiled by the state of California. You'll learn why patients should be monitored in preop holding even after getting only two mg of Versed. Or why wrong site surgeries can still happen even when we all go through the rigamarole of preincision time outs. (Hint, apathy and routine can negate even the most rigorous safety precautions.) You may just save your hospital a ton of money and your own medical license to boot.
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