Page 35 - 2022 Risk Basics - Anesthesiology
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SVMIC Risk Basics: Anesthesiology
When there is poor documentation on the pre-anesthesia
evaluation such as we have earlier discussed, there are also
related breakdowns in communication between providers.
CASE STUDY
In one case involving a patient having hernia surgery in an
outpatient setting, it was alleged that the anesthesiologist
and surgeon did not discuss the plan of care for this obese
patient with a large hernia. Had they done so, they would
have considered and likely been prepared for potential
airway needs, thereby preventing an emergency situation.
Other communication issues between physicians include the
on-call handoff between anesthesia providers.
CASE STUDY
A 50-year-old who had a Nissen Fundoplasty had an
epidural placed for postoperative pain management. There
was no consent for the epidural in the chart, and thus, it
was assumed that there was minimal discussion of risk for
the epidural with the patient. There was also no procedure
note for placement of epidural. The catheter was placed
while the patient was asleep in surgery. Postoperatively,
the patient was sent to the PACU and then to the medical-
surgical floor with the epidural. Neuro checks were normal.
The anesthesiologist who placed the epidural went on
vacation, and his on-call partner was to follow up. Nurses
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