Page 65 - 2022 Risk Basics - Surgical Practice

SVMIC Risk Basics: Surgical Practice

A 65-year-old female underwent a vagotomy and

antrectomy for peptic ulcer disease in which the spleen
was inadvertently lacerated. The patient was given a

therapeutic dose of Lovenox very early in the post-op

period, causing her to bleed out from several sites,
eventually expiring. Experts agreed that ordering Lovenox

within the first 24 hours of an abdominal operation in

which a splenic injury resulted would be contraindicated.
The administration of the Lovenox was believed to be the

major culprit in the patient’s demise.

A 67-year-old male had a surgical resection of a colon

polyp which resulted in his death after he was found to

have an infection, an anastomotic leak, and subsequent
bowel necrosis. A pre-op antibiotic was not given, which

allowed the plaintiff to allege the complications would not

have been as severe, or perhaps not have happened at all,
if the proper antimicrobial therapy had been administered.

There was nothing in the chart to suggest any reason for
omitting such a step. It appeared to be an oversight. The

failure by the surgeon to recognize that this medication
was never administered prior to the operation was seen as

a significant failure.

Errors are common at every stage, from medication
verification, to ordering, administration, and monitoring of the

patient’s response. Accurately managing your patients’

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