Page 37 - Avoiding Surgical Mishaps Part 1

SVMIC Avoiding Surgical Mishaps: Dissecting the Risks

CASE STUDY

Such was the case when a patient who had been on
anticoagulants prior to his cholecystectomy had increased

bleeding on his dressings and suffered a significant drop
in his blood pressure and hematocrit, but the surgeon

was not notified of this until several hours later. The
patient’s resulting deterioration made the subsequent

surgery to address the bleeding vessel futile, and the
patient expired within a few hours. The importance of

clearly-communicating the parameters
for notification of a change in patient’s

condition, and working with the nursing
staff to ensure that they understand those

parameters, cannot be overemphasized.

Communicating with Other Providers

Also observed in the cases reviewed were inadequate
communication handoffs between treating physicians, which

accounted for 18 percent of claims paid. The two primary
scenarios are:

• Hand-off failures between physicians assuming call

• Delays related to surgeon response to emergency
department calls

Another area involving a breakdown in communication between
providers is found in communicating consultations.

Once you have received the request for consultation and the

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