The importance of properly preparing the OR

AORN Journal,  Dec, 2002  by Ellen K. Murphy

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Perioperative nurses are familiar with the importance of carefully cleaning and resupplying the OR after one patient leaves and carefully preparing the room for the next patient. Failure to attend to these seemingly minute details can result in cross contamination and infection; confusion of patient specimens; a confounded sponge, needle, or instrument count; or administration of the wrong medication or wrong dose to a patient. Now what happens between procedures in the OR has taken on a legal dimension as well.

AN EXAMPLE

A June 2002 Colorado Supreme Court case, HealthONE v Rodriguez, ex rel Rodriguez (50 P3d 879 [Colo 2002]), held that a professional practicing in the OR has not only a professional duty to his or her patient but also a common-law duty to subsequent patients. Traditionally, liability has required that a professional-patient relationship be established.

This case deals with anesthesia care providers and medication left on an anesthesia cart. It also provides a vivid example to all perioperative practitioners of the importance of adhering to any applicable facility policies related to provision of care.

The facts of the case. The plaintiff in this case had reflex sympathetic dystrophy in his left arm caused by a work-related accident. He received guanethidine nerve block treatments to alleviate his discomfort from 1991 to 1995, when the events that gave rise to this case occurred.

In August 1995, the plaintiff presented for a nerve block treatment. His anesthesia care provider mistakenly took a vial of phenol from the anesthesia cart instead of the vial of guanethidine he had ordered from the pharmacy. He then injected the phenol into the plaintiff intravenously. The vials of phenol and guanethidine were identical except for the names on the labels. Both were kept in clear glass vials, which were identical in size and shape. Each was sealed with identical green stoppers covered with a foil seal and had labels that were identical in size, shape, color, size of print, and background.

The vial of phenol had been left on the anesthesia cart three weeks earlier by another anesthesia care provider who had used it to inject the nerve of a different patient. He kept the vial despite an alleged single dose policy at this facility. The first anesthesia care provider claimed he did not leave the vial on the cart. He claimed he wrapped the partially used vial in aluminum foil, placed it in a plastic bag labeled with the patient's name and date, and secured it in a locked compartment of the cart. There was no mention in the case about who maintained, restocked, or had access to the cart between uses.

This error set in motion a series of events. The phenol injection caused left arm compartment syndrome, requiring that the plaintiff undergo an immediate fasciotomy. Two days later, the plaintiff was sedated to change the dressing over the fasciotomy incision. He allegedly was over sedated and consequently suffered cardiopulmonary arrest with an ensuing irreversible anoxic brain injury. The plaintiff now is incapacitated severely and requires supervised living and attendant care for the rest of his life. The plaintiff sued the anesthesia care provider who left the phenol on or in the cart; the anesthesia care provider who injected the phenol, administered the sedative, and managed the resuscitation; and the facility where these events occurred.

The rulings. The trial court dismissed the claim against the first anesthesia care provider because a professional-patient relationship did not exist between the provider and the plaintiff. A professional-patient relationship is required for a medical malpractice action to be maintained. The patient also sued for common-law negligence, which does not require a professional-patient relationship. Common-law duty requires everyone to behave reasonably so as not to injure others, regardless of whether they are professionals.

In Colorado, a common-law negligence claim requires the court to decide whether the defendant owed the plaintiff a duty based on

* the risk involved;

* the foreseeability and likelihood of injury weighted against the social utility of the defendant's conduct;

* the burden of guarding against the harm; and

* the consequences of placing that burden on the defendant.

If the court finds that a duty is owed, then the court must decide whether a breach of that duty caused the plaintiff's injury. In this case, the trial court found the risk of harm (ie, from leaving the phenol vial on the cart) was slight and the injury was unforeseeable. In addition, the trial court found that the action of leaving the phenol in or on the cart was not the proximate cause of the plaintiff's injuries.

The plaintiff settled with the treating anesthesia care provider, and because the claims against the first anesthesia care provider had been dismissed, the plaintiff proceeded to trial against the facility as the sole remaining defendant. The jury awarded $4,950,730 for past and future damages, found the facility 30% at fault, and attributed 70% of the fault to the treating anesthesia care provider.