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Dead after knee surgery, a story of apparent multiple little failures

Posted Oct 05 2009 10:03pm

A 76 year old male entered a hospital for elective knee surgery.   Roughly twenty four hours after the surgery he was dead.   If the article, which appeared in the News and Observer, Raleigh, N.C. (June 8, 2008) , is at all accurate, the patient died because his doctors and nurses did not communicate with each other and no one was willing to say “stop.”   The article describes a series of “little” failures the cumulative effect of which was a fatality.   Note the following:   1) the apparent failure of those in the pre operative area to investigate what appeared to be a marked change in the patient’s medical condition, 2) an anesthesiologist who initiated treatment for angina but who did not appear to have communicated either orally or in writing about his observations or therapy (no progress note), 3) there appeared to be no one who willing to “stop” the operation for additional clincical investigation, 4) surgeons who appeared to deny any responsibility for knowing the patient’s medical condition just prior to surgery, 5) there were apparently multiple failures at many levels to document clinical findings and therapy, 6) an apparent failure to inform those responsible for the patient’s care post operatively about the suspected CHF and angina, and 7) delays in obtaining laboratory results.   Whatever time was “saved” by staying on schedule was lost many times over in the time required to be present at the multiple investigations and answer many hours of questioning.   Does the problem of communication and documentation sound familiar? (link to article: )


David S. Smith, M.D., Ph.D.

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