Case Details
A 37 YO patient underwent a laparoscopic cholecystectomy at an ambulatory surgical center. The surgery was uneventful; however, while awakening from anesthesia and being transferred to the stretcher, the patient unexpectedly rolled off the operating table and was caught by several staff members. The staff members lifted the patient to the stretcher for transport to the recovery room. While awakening, the patient was examined for injuries. Physical exam did not reveal injuries and no lesions, bruising, or abnormal findings were exhibited. No images were obtained. The patient complained only of surgical pain and was given hydromorphone intravenously.
Three days later the patient presented to the hospital’s emergency department complaining of a headache, shoulder pain, nausea, and vomiting and was admitted to the hospital for observation and work-up for the headache. A CT scan was unremarkable. Post-operative narcotics were discontinued, and the patient was started on tramadol and ondansetron to treat the nausea. The neurologist diagnosed a migraine and ordered an MRI/MRA of the brain. The patient was discharged home on sumatriptan with orders to follow-up with the primary care physician.
During the first post-operative follow-up, the surgeon noted that the patient’s neck and shoulder pain was due to whiplash from her fall from the operating room table. The surgeon’s note was also copied by subsequent treating physicians and used as a diagnosis.
A week later, the patient arrived at the primary care physician’s follow-up visit with complaints of neck pain radiating down the left arm since surgery. The physical exam revealed a normal shoulder with right trapezius muscle tightness and tenderness in the right side of the neck and occiput. The patient exhibited full range of motion and was referred to physical therapy.
The physician ordered c-spine and right shoulder x-rays which revealed no acute osseous abnormality; however, there was large posterior spurring at C3-4 with mild neural foraminal narrowing. The shoulder x-ray showed mild acromioclavicular joint arthritis with a large osteophyte next to the supraspinatus tendon.
At the next primary care visit, the patient returned with complaints of bilateral arm pain. The physician noted the patient using the left arm more since the pain in the right arm developed. The patient also complained of both arms feeling like dead weight. The physician diagnosed left shoulder pain possibly due to impingement and cervical radicular pain. Based on the findings an MRI of the c-spine was ordered. The MRI noted cervical spondylosis.
The patient transferred care to an orthopedist and was treated for right shoulder mild degenerative arthritic changes. A left shoulder MRI showed a partial thickness intrasubstance tear of the distal supraspinatus tendon at its insertion with mild tendinosis. After reviewing the radiology films, the orthopedist recommended an exercise program, ibuprofen, and bilateral subacromial steroid injections.
Bilateral subacromial steroid injections were done and did not offer any relief. Since the patient failed conservative treatment, the orthopedist recommended a right shoulder arthroscopy with rotator cuff and biceps tendon repair. The primary care physician and vascular consultant cleared the patient for surgery.
After surgery, the patient completed one month of physical therapy and saw the orthopedist for a six-weeks post-operative follow-up visit. The patient was to continue with a home exercise program. Three months later the patient followed up with the orthopedist with complaints of continued shoulder pain and was referred to a pain management clinic.
The patient brought a suit claiming that the shoulder pain was related to the controlled fall from the operating room table.
Expert Testimony and Resolution
The defense expert opined that the standard of care was not met by the anesthesia provider and operating room staff as it was undisputed that the patient fell from the operating room table. This is considered a preventable event as the patient was under anesthesia and it is the responsibility of the staff to anticipate these types of occurrences.
Causation was limited since the patient had an existing chronic shoulder condition; however, documented hospital acquired injuries are difficult to defend.
This case was settled due to lack of expert support.
Risk Reduction Strategies
Be prepared to respond to an adverse event that will need to be disclosed to the patient and family. Proper disclosure can help maintain and salvage the physician-patient relationship following an adverse event. Consider the following strategies:
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Anticipate a patient fall when a patient is emerging from anesthesia and ensure there are enough OR staff available to assist in patient transfers.
- Develop a disclosure plan that will assist you or other members of your practice with communicating the appropriate information.Do not document speculative information in the medical record.
- Accurately document the occurrence and the interventions that were done for the patient.
- During disclosure do not make statements of blame.
- Do not inform the patient that an incident report was completed.
If you have questions on this topic, please email RiskAdvisor@ProAssurance.com or call 844-223-9648.
