Page 25 - Avoiding Surgical Mishaps Part 1

SVMIC Avoiding Surgical Mishaps: Dissecting the Risks

CASE STUDY

continued
risks associated with the procedure. In this type of surgery,
there is a known risk of a ureteral injury which should
have been discussed and included as part of the consent

documentation, either on the form or in the office visit

notes.

The fact that there was no documentation describing a

discussion of specific risks, particularly the risk of ureteral
injury, made it difficult to refute the patient’s claim that he

did not give informed consent for the surgery. In addition
to the absence of documentation about specific risks,

there was also a seven-week delay in the dictation of the
operative note.

The surgery was performed on April 27, but the operative
note was not dictated until June 19, which generated an

additional concern about the defensibility of the claim.

This late dictation was entered almost two weeks after the
discovery of the ureteral injury, making the note appear
to be self-serving because of the level of detail about the

status of the ureter at the end of the surgery. A nearly two-

month lag between the date of the procedure and the
dictation of the operative note would create difficulties in
convincing a jury to believe that the information was 100

percent accurate, which would also affect the credibility of

the record as a whole.

As a result, the decision was made to settle

the case and avoid creating concern by
jurors over these issues. The case settled

for a sizable amount.

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