05 Feb A 68-year-old man saw Orthopedic Surgeon A over several months for pain in his right knee, leg, and lower back. Right knee arthroscopic surgery was recommended and scheduled. On No

Failure to communicate and delay in  diagnosing lung cancer 

Presentation and physician action 

A 68-year-old man saw Orthopedic Surgeon A over several months for pain in his right knee,  leg, and lower back. Right knee arthroscopic surgery was recommended and scheduled.  

On November 12, 2017 a preoperative chest x-ray (CXR) was performed. Radiologist A  interpreted the x-ray and found a 3.3 cm mass and noted “neoplasm is the diagnosis of  exclusion.” Radiologist A called but did not speak with Orthopedic Surgeon A; instead, he left a  call back number to discuss results. Orthopedic Surgeon A did not recall speaking with the  radiologist when later discussing the case. 

The CXR report was faxed to the patient’s primary care physician (Primary Care Physician A)  on November 15. The cover page for the fax read, “Please review abnormal CXR, and  radiologist recommends CT of chest.” 

On November 16, Orthopedic Surgeon A performed arthroscopic surgery on the patient’s right  knee. Over the next eight months, the patient returned to Orthopedic Surgeon A for follow-up  visits and continued right knee pain. 

On February 8, 2018, the patient saw Primary Care Physician A for an annual medical exam.  Primary Care Physician A did not mention the CXR; however, he documented during the visit  that a CXR was performed in September 2010 and had a calcium score of 442. It was later  discovered that the 2017 CXR report describing the lung mass was in the patient’s chart at the  time of this visit. 

In June, Orthopedic Surgeon A referred the patient to Orthopedic Surgeon B, a partner within the  orthopedic group, to rule out right leg pain secondary to right lumbar radiculopathy. Orthopedic  Surgeon B and a neurologist diagnosed the right leg pain as primarily from right hip  osteoarthritis. 

A week later, the patient returned to Primary Care Physician A for a routine exam. There was no  mention of the 2017 CXR. 

The patient saw Orthopedic Surgeon A again in July for hip pain and was given an injection.  Orthopedic Surgeon A and the patient discussed hip replacement and scheduled the surgery for  October. Primary Care Physician A cleared the patient for surgery in September. 

Orthopedic Surgeon A ordered a preoperative CXR, which was completed on October 12, 2018.  Radiologist B noted that when compared to the x-ray performed in November 2017, the mass  had enlarged to 5 x 5.2 cm. The x-ray findings were faxed to Orthopedic Surgeon A.

On October 15, a chest CT confirmed the left upper lobe mass, and an incidental right renal  lesion was also found. The patient was referred to a pulmonologist for biopsies, and the results  revealed squamous cell carcinoma in the left upper lobe. 

On November 14, the patient underwent a left upper lobectomy and later completed  chemotherapy. He was staged as a T3N1; IIIA. 

The patient is in remission and has had no further issues since treatment. The hip replacement  was completed the following year by another orthopedic surgeon in the same group as  Orthopedic Surgeons A and B.

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Improper performance of a hysterectomy

by Sara Bergmanson, Digital and Social Media Specialist, and Jennifer Templin, Risk Management Representative 

Presentation  

A 58-year-old woman came to Ob-gyn A for treatment of postmenopausal vaginal bleeding and  dysmenorrhea. The patient’s history included obesity, gastric bypass surgery, and right-sided  salpingo-oophorectomy. Both surgeries occurred more than 10 years before coming to Ob-gyn  A.  

Physician action 

Ob-gyn A performed an ultrasound that indicated a thickened endometrial lining, which had a  normal biopsy, and a uterine fibroid around 2.5 centimeters in diameter. A repeat sonogram and  uterine cuttings were benign and consistent with polyps. Treatment with hormonal therapy was  unsuccessful.  

The patient and Ob-gyn A discussed the risks and benefits of a robotic-assisted total laparoscopic  hysterectomy, left salpingo-oophorectomy, and cystoscopy for dysmenorrhea and uterine  fibroids. They also discussed non-surgical management and non-treatment as alternatives. The  patient agreed to proceed with surgery, and it was scheduled for December 29. 

Upon performing the surgery, Ob-gyn A found dense adhesions in the abdomen making trocar  placement difficult and converted the procedure to an open laparotomy. Surgery was further  complicated by bleeding at the omentum from the failed trocar placement. Additionally, an  enterotomy of the small bowel was discovered and repaired. 

Before completing the surgery, Ob-gyn A inspected the abdomen, pelvis, and bowel. It was  documented that the bleeding stopped and the bowel repair was intact. No other injuries were  identified. 

At 7:45 p.m. that night, nurses notified Ob-gyn A that the patient was experiencing tachycardia  and an EKG was abnormal. At 5:15 a.m. on December 30, the nurses reported concerns about the  patient’s blood pressure to the on-call physician, Ob-gyn B. Ob-gyn B ordered a 1-liter bolus of  lactated Ringer’s.  

By 7:41 a.m. the patient had not improved, and Ob-gyn B contacted Ob-gyn A. At this time, a  phlebotomist came and drew labs according to sepsis protocols.  

While Ob-gyn A was waiting for lab results, the patient became more hypotensive, tachycardic,  and oliguric. Her white blood cell count increased to 16,000 and her creatinine level increased to 

2.5. Her estimated blood loss was documented as 1,500 cc leading to concerns of hypovolemic  shock. 

Intensivist A was consulted, and the patient was transferred to the ICU. Intensivist A suspected  septic shock and acute renal failure. Vasopressors were started, and radiology studies indicated a  possible bowel injury and free air. 

Records regarding the patient’s previous gastric bypass surgery were obtained, revealing she  suffered postoperative complications and had a prolonged recovery. (It is believed that this is the  cause for the adhesions found in the laparoscopic procedure.) 

Ob-gyn A, accompanied by a general surgeon, took the patient back to the OR on December 31.  Several other injuries to the patient’s small intestines were found including three perforations  within the duodenum, an injury to the Roux limb (jejunum), and three more enterotomies. A  large mesenteric defect causing ischemic injury to the transverse colon was also discovered.  Additionally, the patient’s gastrointestinal anatomy was significantly distorted, and a bariatric  surgeon was consulted. Bowel resections and enterotomy repairs were needed to restore her  intestinal tract.  

Due to severe amount of edema within the intestines, her abdominal wall could not be closed,  necessitating seven more returns to the OR for washouts and re-inspections. The patient became  septic and showed signs of respiratory and renal failure. It was felt her condition was terminal  and a DNR order was given by her spouse. She died after two weeks in the hospital. 

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Improper performance of pain management procedure 

Presentation 

On April 14, a 50-year-old man with a long history of chronic pain, spinal  injuries and procedures, depression, and obesity, came to see Anesthesiologist  A for pain management. The patient sought treatment for radiating neck and  low back pain and migraine headaches. The patient’s medications included  methadone, ibuprofen, paroxetine, tizanidine, and hydrocodone/acetaminophen  (7.5/325).  

An MRI of the patient’s lumbar spine revealed degenerative disc disease at the  L3-4 and L4-5 vertebrae with spinal stenosis at L4-5. A cervical spine MRI  showed a C4-5 fusion but was otherwise normal.  

Physician action 

On April 22, Anesthesiologist A performed a bilateral L4-5 epidural steroid  injection (ESI). The patient did not return for a follow-up appointment one  month later.  

However, the patient did return to the physician’s office on July 1. He reported  mild pain relief for approximately ten days following the ESI. The patient’s  motor strength was normal, 5/5 throughout. 

Three weeks later during the next follow-up appointment, Anesthesiologist A  and the patient discussed an epiduroscopy and Percutaneous Ablation and  Curettage and Inferior Foraminotomy (PACIF) with a plan to refer to  neurosurgery if the patient saw no relief. The patient agreed to the procedures. 

On August 16, the patient was admitted for the epiduroscopy and PACIF at L5  on the right side. During the procedure, Anesthesiologist A encountered  epidural space adhesions and could not obtain access to the neural foramen of 

L4-5 on the right. Due to minor but persistent bleeding, Anesthesiologist A  decided to terminate the procedure and injected 5 ml of a hemostatic matrix in  the area of bleeding and retracted the scope. 

A neurosurgery consultation was obtained. Neurosurgeon A noted no  neurological deficits on examination and indicated no need for neurosurgical  intervention.  

Anesthesiologist A saw the patient the next day and noted weakness of the  right leg. An MRI showed postoperative changes at L4-5 with an epidural  collection resulting in mild stenosis starting at L4-5 and extending to S2,  consistent with evolving traumatic epidural hemorrhage. The patient was  discharged to home. 

On August 21 during a follow-up telephone call, the patient reported inability to  raise his big toe and foot on the right side. Anesthesiologist A referred the  patient to Neurosurgeon B. 

Neurosurgeon B performed electromyography and nerve conduction velocity  tests on August 26. The patient had significant pain and weakness and  expressed concern for injury in the past 10 days.  

The next day, the patient underwent decompression and laminectomy of L4-5  and L5-S1 with removal of the hemostatic matrix and an epidural hematoma.  The patient was discharged the next day with an ankle foot orthotic. 

Following physical therapy, the patient’s foot drop resolved; however, there  may be elements of secondary gain in the future.

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Preparing the Case 

Before you begin writing, follow these guidelines to help you prepare and understand the case study: 

1. Read and Examine the Case  Thoroughly 

o Take notes, highlight relevant facts, underline key problems. 2. Focus Your Analysis 

o Identify two to five key problems. 

o Why do they exist? 

o How do they impact the organization? 

o Who is responsible for them? 

3. Uncover Possible Solutions/Changes Needed 

o Review course readings, discussions, outside research, your experience. 

4. Select the Best Solution

o Consider strong supporting evidence, pros, and cons. Is thissolution realistic? 

Drafting the Case

Once you have gathered the necessary information, a draft of your analysisshould include these general sections, but these may differ dependingonyourassignment directions or your specific case study: 

OUTLINE: 

1. Introduction 

o Identify the key problems and issues in the case study. 

o Formulate and include a thesis statement, summarizingthe

outcome of your analysis in 1–2 sentences. 

2. Background 

o Set the scene: background information, relevant facts, andthemost important issues. 

o Demonstrate that you have researched the problems in thiscasestudy. 

3. Evaluation of the Case 

o Outline the various pieces of the case study that you arefocusingon. 

o Evaluate these pieces by discussing what is working andwhat isnot working. 

o State why these parts of the case study are or are not workingwell. 4. Proposed Solution/Changes

o Provide specific and realistic solution(s) or changes needed.

o Explain why this solution was chosen. 

o Support this solution with solid evidence, such as: ▪ Concepts from class (text readings, discussions, lectures) ▪ Outside research 

▪ Personal experience (anecdotes) 

5. Recommendations 

o Determine and discuss specific strategies for accomplishingthe

proposed solution. 

o If applicable, recommend further action to resolve someof theissues. 

o What should be done and who should do it? Finalizing the Case