Page 28 - 2022 Risk Basics - Surgical Practice

SVMIC Risk Basics: Surgical Practice

 Handoff failures between physicians assuming call

 Delays related to surgeon response to emergency
department calls

 Referral/consultation communication failures

Communicating the Handoff

As mentioned earlier in this presentation, although physician-
to-patient communication related to informed consent ranked

as the primary issue in communication failures for surgeons,
the second most common issue is the communication

between providers, such as when one physician is handing off

care to another physician. This case study will outline one such
scenario that created a situation which resulted in a lawsuit.

CASE STUDY

A 34-year-old female patient was found to have a gastric
mass and was referred to a surgeon, who performed a

hand-assisted laparoscopic gastric wedge resection on
January 11. She had post-op abdominal pain, and a

nasogastric tube was inserted. She continued to have
drainage from the NG tube while she was in the hospital,

and by January 14, an Upper GI series identified a gastric

outlet obstruction. The NG tube remained in place to allow
the obstruction to take care of itself until January 16, at

which time her clear liquid diet was advanced to a soft diet.
Reglan was added on January 17, because the patient

complained of nausea and abdominal pain. The surgeon

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