Malpractice Case: Taking on Too Much Work Can Cause Patient Tragedy

When attending to a weekend surgery at the hospital, make sure you don't find yourself all alone with too much to do.

A 61-year-old patient was the only scheduled surgery on a Saturday morning, where he was to undergo endoscopic retrograde cholangiopancreatography (ERCP) for suspected inflamed gallbladder/bile duct gallstones. The patient had type 2 diabetes, major depressive disorder, essential hypertension, and a remote history of a cerebrovascular accident. Dr A, the anesthesiologist for the surgery, classified the patient as ASA III [having severe systemic disease] and anticipated a difficult intubation.

On the morning of the scheduled surgery, Dr A, the only anesthesiologist on call at the hospital that weekend, learned that he was also to attend to a cesarean section for a patient with failed labor.

The ERCP started at 8:15 that morning and, after a difficult intubation, proceeded without incident. Surgery concluded at 9:25 but hospital staff notes at 9:35 showed the extubated, bag-masked patient in the post-anesthesia care unit (PACU) as unresponsive.

Dr A ordered new dosages of relaxant reversals, without improvement. Dr A then readministered a muscle relaxant and attempted to reintubate the patient. When the reintubation failed, Dr A was successful in placing a laryngeal mask airway (LMA). At 10 AM, with the LMA in place and connected to a ventilator, Dr A left the patient in the care of the nursing staff and respiratory therapists as he began general anesthesia for the cesarean section in the OR next door.

© 2020 Cooperative of American Physicians, Inc.

This case comes from Medicine on Trial, originally published by Cooperative of American Physicians, Inc., to provide risk management lessons from litigated case histories.