Protecting patients from potential injuries

Ellen K. Murphy

Correct site identification and elimination of wrong site, wrong procedure, and wrong patient surgeries are a national patient safety goal of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The Joint Commission has recommended creation of a preoperative verification process, involving the patient in marking the surgical site, and implementing a time-out pause to verify the consistency of all site, procedure, and patient indicators one more time before a procedure begins. (1)

Certainly, extra effort to ensure patient safety is warranted given the severity of wrong site, wrong procedure, or wrong patient surgery should it occur. As early as 1947, Judge Learned Hand prescribed that a reasonable person should take every precaution that is less burdensome than the frequency of an injury multiplied by the severity of the injury should it occur (United States v Carroll Towing Co, 159 F2d 169 [2d Cir 1947]). Very severe injuries thus require increased precautions even though they occur infrequently; however, less severe injuries require increased precaution as well. This article discusses those less severe injuries that may occur in the OR with more frequency. Facts from cases reported during the last two years were examined to identify injuries occurring in the OR that have resulted in litigation up to and including state appellate and supreme court decisions.

The LexisNexis database was searched for cases reported in the last two years (ie, February 2002 to February 2004) that contain the words operating room and nurse and negligence or malpractice. Seventy-eight cases were listed. In three instances, two cases dealt with the same situation, effectively yielding information about 75 cases. Of these, 44 concerned alleged intraoperative injury. The other 32 involved injuries occurring elsewhere, preoperatively or postoperatively, with operating room appearing as a part of the explanation of what happened but not as the location of the alleged malpractice (eg, workers compensation cases, delayed or erroneous preoperative diagnosis, postoperative complication unrelated to intraoperative care, and occasional criminal cases). The 44 injuries that allegedly occurred in the OR were further analyzed for the frequency and type of injury involved.

INDIVIDUAL ACTION OR INACTION

Twenty cases alleged errors in judgment or skill by the surgeon, anesthesia care provider, or perfusionist. No direct perioperative nurse role in causing or failing to prevent these injuries could be inferred from the case reports. Surgical injuries included

* air embolus and a transected artery during placement of a central venous catheter,

* failure to assess stenosis before initiating tracheostomy,

* a cut on a baby's finger after a cesarean section (C-section),

* a suture placed through a catheter during a bladder suspension procedure,

* puncture of a cribriform plate during septoplasty and functional endoscopic sinus surgery,

* incomplete decompression and near exsanguination during back surgery,

* cardiac arrest during valve replacement surgery, and

* several instances of perforated bowel during laparoscopic and laparotomy procedures.

Injuries allegedly caused by anesthesia care providers included

* perforated esophagus (ie, two cases);

* late arrival, causing a delay in performing an emergency C-section;

* failure to postpone an elective surgery despite a chart notation that the patient had suffered a transient ischemic attack the evening before surgery;

* failure to assess and treat respiratory distress immediately after extubation;

* placement of an esophageal stethoscope in the patient's left lung; and

* unassessed cardiac arrest. One case involved the conceded negligence of a perfusionist who recorded normal blood gas levels on his perfusion record despite laboratory reports of abnormal blood gas levels that were not assessed or treated by the perfusionist.

Although none of these case reports suggested direct involvement of perioperative nurses, perioperative managers may wish to work with their surgery and anesthesia counterparts to re-examine communication and credentialing systems within a context of "could this type of injury happen here?" Several of these cases involved communication breakdowns or credentialing issues.

TEAM ACTION OR INACTION WITH NURSE INVOLVEMENT

Of direct interest to perioperative nurses are the remaining 24 cases, which were categorized by type of injury and revealed a number of common issues, including

* consent (ie, four cases);

* retained foreign bodies (ie, four cases);

* pressure injuries related to positioning (ie, four cases);

* unavailable equipment or implant sizes (ie, four cases);

* medication errors (ie, three cases);

* infection (ie, three cases); and

* burns (ie, two cases).

A possible wrong procedure occurred in only two cases, and these more likely were cases of inadequate explanation before consent or inadequate consent documentation.

Readers should not infer that these were the only cases involving perioperative nurses that were decided during these two years. These are only the cases reported, which means they were decided at the appellate or state supreme court level. There were undoubtedly many other cases decided at the trial court level, which are not included here. Additionally, more cases occurred but did not go to trial because the parties settled or because the injured party chose not to sue. Injuries occurring from wrong site, wrong patient, and wrong procedure surgeries were most likely settled without trial and, typically, would not be decided at the appellate level unless a very novel question of law was involved.

Consent. The consent related cases in this review might have been prevented by a patient and procedure verification process, because most processes use verification of the documented consent as one of the indicators. One case concerned whether the patient had intended to consent to a bipolar arthroplasty or a total hip arthroplasty, but the need for a hip repair was not at issue (Cain v Howorth, no 1012339 [Ala Supr Ct 2003]). Another concluded that the patient orally consented to an exploratory laparotomy even though she had signed a consent for a laparoscopic exploration, but the need for an abdominal exploration was not at issue (Stone v Wilcox, no D038645 [Cal 4th App Div 1 2002]).

Gouveia v Phillips, no 4D99-3951 (Fla 4th App 2002), involved an artist with a crushed dominant right hand. There was no question that he needed a debridement of the hand; however, the patient claimed he never would have consented to the removal of his fingers, and it was established that the words possible amputation of fingers right hand were added to the consent form after he had signed it. Similarly, in Brown v Song, no B146970 (Cal 2d App Div 1 2002), the patient claimed he had consented only to the removal of bone spurs after a previous Lisfranc amputation, although he had signed a consent form for a Syme amputation, and the surgeon claimed he had discussed the need for a Syme amputation with the patient. There was a dispute about when the patient signed the consent form--before or after he was in the OR--and whether the time on the consent had been altered.

Retained foreign bodies. Each of the four cases involving retained foreign bodies revealed familiar possibilities:

* a Babcock clamp was left in a patient after a gastric bypass (Breaux v Thurston, no 1011655 [Ala Supr Ct 2003]);

* a sponge was left in a patient after a C-section (Gianelli v Midstate Medical Center, no CV000599065S [Conn Supr Ct 2002]);

* an unnamed instrument was left in a patient during a cholecystectomy (Wilkins v Methodist Health Care System, no 14-02-00883-CV [Tex App 14 2003]); and

* an epicardial retractor was left behind a patient's heart during a triple bypass surgery (Warner v Stewart, no F037392 [Cal 5th App 2002]).

These injuries highlight the critical importance of accurately conducting count procedures.

Equipment and supply size and availability. Two cases involved the use of incorrect equipment sizes because needed sizes were not available to the surgeon. In Christiana v Sudderth and East Jefferson General Hospital Foundation (841 S 2d 911 [La App 2003), an intestinal anastomosis failed, allegedly because the wrong size staples were used. In McRae v St Michael's Medical Center, nos A-1684-00T1, A-2299-00T1 (NJ Super Ct App 2002), the preferred size of external fixator was not available and poor leg alignment allegedly resulted.

In the other two equipment-related cases, available and functioning equipment was at issue. In Torns v Samaritan Hospital, no 92986 (NY Super Ct App 2003), the plaintiff claimed his anaphylaxis could have been treated effectively if an external pacemaker had been available, in Battaglia v Alexander, no 14-00-00428-CV (Tex 14th App 2002), the cardiac monitor alarm failed to sound during a 17-minute undiagnosed cardiac arrest. Improving the effectiveness of clinical alarm systems is another of JCAHO's national safety goals that may have prevented this tragic result! Nurses also might consider implementing a system to review equipment and implant size availability immediately before each procedure as part of the preoperative assessment.

Positioning and pressure injuries. Four cases involved positioning or pressure injuries. Symptoms of peroneal nerve entrapment manifested immediately after a laparoscopic cholecystectomy in the case of Powell v Methodist Health Care-Jackson Hospitals, no 2001-CA-01881-COA (Miss App 2003). Failure to properly place and maintain a patient's position on the OR bed allegedly caused injury to a patient's left knee during neck surgery (Strom v Memorial Hermann Hospital System, no 01-01-00756-CV [Tex 1st App 2003]). Extended intraoperative times were a factor in two jaw reconstruction procedures. In one case, (Owens v Silvia, no 2002-218-Appeal [RI Supr Ct 2003]) an 11-hour jaw reconstruction procedure resulted in left arm and sciatic nerve injury as well as heel, buttock, and forehead lesions. Likewise during a seven-hour jaw procedure, the alleged failure to properly pad, position, and monitor the patient's arm caused left arm and hand numbness (Lodgsdon v Miller, no 03-01-00575-CV [Tex 3rd App 2002]). To prevent positioning and pressure injuries, the preoperative time-out could be performed before draping begins and include the team's final visual assessment of pad positioning and monitoring adequacy.

Medication errors. Failure to check medication names and dosages led to injuries in three reported cases. In Springhill Hospitals, Inc v Dixon, no 1011120 (Ala Supr Ct 2003), the patient received an injection of 1:1,000 epinephrine diluted to half strength to control bleeding, and cardiac arrest resulted.

Wrong medication also led to injury in two clinic procedure rooms. In Neff v Wetzel, no A-01-290 (Neb App 2002), a foot ulcer was dressed with potassium hydroxide rather than saline moistened wet-to-dry dressings. In Acord v Dominguez, no B154874 (Cal 2d App Div 1 2003), tri-choloracetic acid rather than acetic acid was used during colposcopy. Obviously, systematic attention to adequate labeling and dosage verification is needed.

Infection. Despite the difficulty in proving the necessary element of causation In any negligence case, three cases involved infection. One concerned a mediastinal abscess after coronary artery bypass surgery (Tennyson v Phillips, no 12-02-00154-CV [Tex 12th App 2004]). Two cases that specifically alleged failure to follow aseptic technique or infection control practices were dismissed for lack of causation (Hill v University of Texas Health Center, no 12-0200084-CV [Tex 12th App 2002]; McClain v University of Texas Health Center, no 12-0100363-CV [Tex 12th App 2002]). Although it is difficult for a plaintiff to prevail in an infection case, these cases still required time and resources to defend.

Burns. Burns can result from medication, equipment, or positioning errors. In Pillers v Finley Hospital, no 3-146/021112 (Iowa App 2003), a chemical burn resulted when povidone iodine leaked under the tourniquet during preparation for an anterior cruciate ligament repair. In Winters v Wright, no 1999-CA-00483-SCT (Miss Supr Ct 2003), a thermal burn to the patient's thighs and buttocks resulted from use of a warming blanket. Systems that assure proper use of solutions, proper positioning, and proper equipment use should reduce the potential for burn injuries.

CONCLUSION

Surgery is and always has been dangerous business. Protecting patients from predictable injury is one of perioperative nurses' major roles. Media attention to the more inflammatory cases of incorrect site, procedure, or patient errors should not divert nurses' attention from protecting patients from less publicized injuries. Adherence to AORN recommended practices and JCAHO's national safety goals are crucial to maximizing patient safety.

NOTE

(1.) "2004 national patient safety goals," Joint Commission on Accreditation of Healthcare Organizations, http://www.jcaho.org/accredited+organizations/ patient+safety/04+npsg/04_npsg.htm (accessed 15 March 2004).

ELLEN K. MURPHY

RN, 3D, FAAN

UNIVERSITY OF WISCONSIN, MILWAUKEE, SCHOOL OF NURSING

MILWAUKEE

COPYRIGHT 2004 Association of Operating Room Nurses, Inc.
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