Page 16 - 2022 Risk Basics - Surgical Practice

SVMIC Risk Basics: Surgical Practice

signed the form. No additional documentation was added

to the medical record to reflect that the pertinent risks or
injuries were shared. Nor did the documentation confirm

that the patient had an opportunity to ask questions.

The patient underwent a laparoscopic colon resection on
April 27, which included the removal of a 5cm malignant

sigmoid tumor. Pathology identified a T3N1 lesion with one

of 32 lymph nodes as positive. The post-op course was
uneventful and by May 1, the patient was eating and

voiding without difficulty and vital signs were stable. He
was discharged on May 2.

On May 6, which was post-op day nine, the patient

presented to the ER with chest and LLQ pain. His

bloodwork showed a slightly elevated white blood cell
count, but his creatinine was stable. Clear yellow fluid was

leaking from the trocar site in the right-upper quadrant of
his abdomen. The abdomen was noted to be non-tender

and the patient was hungry and said he felt better, so he
was discharged. On May 8, the patient saw his primary

care physician and was found to have moderate

abdominal tenderness, but his abdomen was not
distended so he was told to see the surgeon. No notes are

available regarding that visit, but the patient did see the
surgeon on May 22, and the notes from that visit indicated

that the patient had no complaints and no drainage from

his wounds.

On June 5, he felt a “pulling” sensation in the right-lower

quadrant of his abdomen and returned to the surgeon for

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