Thursday, October 3, 2013

Blame The Anesthesiologist

Hospital administrators and government officials are always trying to eliminate medical errors. It is a worthy attempt as some estimates put deaths due to errors in the hundreds of thousands per year. Unfortunately, no matter how many rules and backstops are put in place, medical errors will still happen. This is because doctors and nurses are all human and humans make mistakes. You can't sign a law banning human error. But there will always be attempts to point the finger at someone when it happens.

A case in point was published by the California Department of Public Health in its quarterly release of hospitals penalized for gross medical errors. The incident at St. Jude Medical Center in Orange County highlights the limitations of multiple precautionary measures in preventing medical mistakes.

A patient was admitted to the hospital in 2012 for a nephrectomy due to a renal mass suspicious for cancer. The surgeon's H+P documented the mass was in the right kidney. When talking to the patient, he complained of pain in his right flank. The surgeon marked the patient's right side in preop to indicate the correct side for the operation. The operating room nurse even called the surgeon's office before surgery to confirm the proper procedure and side. The anesthesiologist also confirmed a right sided nephrectomy after interviewing the patient. The consent for the operation listed the right side was the correct side. The patient then went into the operating room. A Time Out was called before the operation commenced and everybody agreed that it was the right side that was being removed. The procedure went smoothly.

Shortly afterwards, the pathologist notified the surgeon that the kidney that was sent to the lab was completely normal. Startled, the surgeon reviewed the CT scan, which was left at his office the day of the operation. The CT showed that the cancer was in the LEFT kidney. Since the imaging study was performed at a different hospital, it was not available to be reviewed in the operating hospital's computer system, which one of the nurses attempted to do before the operation. Oops.

During the process of identifying the cause of the wrong sided operation, the state's interviewers asked the anesthesiologist if he should have been more thorough in confirming the correct side of the operation. According to the report, "He looked at labs and general medical health. MD 2 (anesthesiologist) stated he would not meet with the surgeon and review CAT scan results and typically did not review test results (x-rays) as it was not a standard of care."

That sounds about right. I don't know of any anesthesiologist who routinely reviews diagnostic studies before an operation. We just take it as faith that the correct operation is being performed since the surgeon, primary care doctor, nurse, and patient have usually unanimously agreed upon the procedure. Why should the anesthesiologist take the time the review the studies one last time? We would just be blamed for unnecessarily delaying the case.

But that's not how the CA Dept. of Public Health sees it. One of their recommendations after their investigation was completed was this:

Prior to commencing surgery, the person responsible for administering anesthesia, or the surgeon if a general anesthetic is not to be administered, shall verify the patient's identity, the site and side of the body to be operated on, and ascertain that a record of the following appears in the patient's medical record.

What the heck? So now we have to be the mother hen and watch over the surgeons because they might not be doing their jobs properly? We already have enough headaches making sure the proper preop workup has been completed prior to surgery. Anesthesiologists are already considered nags for insisting on a cardiac stress test or requesting a pulmonary function test. Now if we don't review all the diagnostic exams we are possibly liable for the surgeon's mistakes? I better get a pay raise if that is considered one of my duties, and the title Captain of the Ship.

The hospital was fined $100,000 for this infraction.

1 comment:

  1. Agreed. I think we should refuse. It is a recommendation, so we should insist that it is a bad one.