alleged wrong-site surgery

Below is a case study based on alleged violations of HIPAA privacy rules. This study describes how actions by physicians or their employees led to the allegations, and how risk management techniques may have prevented the violations. The ultimate goal in publishing this study is to help physicians comply with privacy ...
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By Wayne Wenske, Communications Coordinator, and Louise Walling, RN, Senior Risk Management Representative

ALLEGED WRONG-SITE SURGERY PRESENTATION A 35-year-old man came to Orthopedic Surgeon A on referral from his primary care physician. The patient reported pain in his right buttock, thigh, and leg for a period of seven to nine months. The patient had been performing physical therapy exercises at home, but without improvement. PHYSICIAN ACTION Orthopedic Surgeon A ordered an MRI that revealed an extruded intervertebral disc at the L5-S1 level. Approximately six weeks later, Orthopedic Surgeon A performed surgery on the patient. Documentation noted, “a decompression of the right nerve root of S1 by the right laminectomy of L5 and discectomy of L5 sacrum via posterior approach.” It was further documented that the operative level was confirmed via intraoperative x-ray. Initially, the patient’s pain improved; however, recurrent pain later developed. A subsequent MRI, taken approximately two months after surgery showed the same extruded disc at L5-S1 and post-surgery changes at L4-5. Orthopedic Surgeon A diagnosed “recurrent laminectomy herniated disc.” Soon after the MRI was conducted, the patient brought a copy of the MRI report to a follow-up appointment with the

surgeon. The patient asked the surgeon about the report findings, specifically that surgery had been performed at L4-5 and not at L5-S1. The patient later testified that the surgeon told him to “not believe the MRI report.” During the appointment, the surgeon and the patient called the radiologist who performed the MRI via speakerphone. The radiologist supported his report that surgery had been performed at L4-5 only, but when the surgeon informed the radiologist that the patient was in the room, the radiologist stated he would review the films again. The radiologist submitted an addendum to the report stating that surgery was performed at both levels L4-5 and L5-S1. One month later, Orthopedic Surgeon A performed a revision laminectomy on the patient and noted, “widening this and taking part of the S1 lamina.” He further noted an “abundant amount of scar that was adhered to the dura on both its ventral and dorsal surface.” No disc herniation was noted. Four months later, Orthopedic Surgeon A sent the patient to a pain management specialist for treatment of hip bursitis and persistent coccyx pain. The specialist noted in her records, with regard to the patient’s first surgery, “Rt L4-L5 laminotomy, discectomy (was supposed to be L5-S1).” The

This closed claim study is based on an actual malpractice claim from Texas Medical Liability Trust. This case illustrates how action or inaction on the part of the physicians led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician’s defensibility. This study has been modified to protect the privacy of the physicians and the patient.

specialist treated the patient with two thoracic epidural steroid injections, one performed soon after the initial consultation and the other performed eight months later. Approximately one year after the revision surgery, the patient consulted with Orthopedic Surgeon B. The patient reported persistent, severe pain in his right buttock down his right leg and pain radiating down his left leg. An MRI was ordered. Upon review of the films, the surgeon noted a “similar L5S1 herniated nucleus pulposus.” He further noted that the MRI revealed a “previous hemilaminectomy at L4-5 on the right, some irregularity of the posterior disk space at L4-5, and Modic changes at L4-5 with irregularity of the disc.” He also noted significant scarring on the right and “some lateral recess stenosis at S-1 worse on the right than the left and significant foraminal stenosis bilaterally at L5-S1. There is bilateral arachnoiditis.” Orthopedic Surgeon B returned the patient to surgery where he performed a hemilaminectomy at L4-5 on the right