Since the 1998 introduction of the “Sign Your Site” campaign by the American Academy of Orthopaedic Surgeons, much attention has been directed to preventing wrong site surgical procedures. What resulted was a paradigm shift in pre-operative processes, evolving into the pre-operative procedure that is today generally accepted and implemented in most operative facilities, whether it is a hospital, ambulatory surgery center, or office setting. Today’s pre-operative process involves:
Without a doubt, these procedural changes have succeeded in preventing wrong site surgical errors. However, despite the development of these pre-operative procedures and the industry’s overall attention to this problem, wrong site surgical error persists. Surgery involves humans, and humans make mistakes. This article discusses one such wrong site surgical error, the legal claim that followed, and its ultimate resolution.
Ms. Johnson, a twenty-year-old female, presented to an ambulatory surgery center for ACL repair of her left knee. CRNA Turner administered a nerve block pre-operatively for post-operative pain control. By his own admission, CRNA Turner went too fast in his care of Ms. Johnson, got distracted, and administered the nerve block to the right (wrong) knee.
CRNA Turner quickly recognized his error. He informed his supervising anesthesiologist, the orthopedic surgeon, and Ms. Johnson what had happened. It was determined that the ACL repair of the left (correct) knee would proceed as scheduled, but without the pre-operative nerve block. Another modality would be used to address Ms. Johnson’s post-operative pain. The surgery on the left (correct) knee proceeded uneventfully, and Ms. Johnson was sent home with immobilizers on both knees. She was instructed not to attempt to ambulate on her own. Despite these instructions, Ms. Johnson tried to walk on her own at home and fell, causing pain and swelling in her right knee. Ms. Johnson reported the injury to her orthopedic surgeon, who added the right knee to the physical therapy protocol already planned for the left (operative) knee. Fortunately, the injury to the right knee was mild and resolved with physical therapy and time.
Only a few months after the surgery, Ms. Johnson decided to pursue a legal claim against CRNA Turner. She contacted an attorney, who sent a letter to CRNA Turner. CRNA Turner reported receipt of the letter to SVMIC’s Claims Department, and defense counsel was retained to assist him. After investigating the claim, it was decided that by all involved that it would be prudent to engage Ms. Johnson in settlement discussions. These discussions were productive, and a settlement was reached between the parties. The parties thus avoided a lawsuit and resolved the matter fairly quickly.
There are several lessons to consider from this wrong site surgical error claim:
Significant progress has been made over the past two decades to avoid wrong site surgical errors. However, even the three-step pre-operative process is not a guarantee that this medical error will never occur. Despite all precautions, mistakes still happen. Slow down, take the pre-operative process seriously, and do your best. In the end, even if right is wrong, SVMIC is here to help you through it. Members can find extensive resources to assist with questions and issues such as the one discussed here in the Vantage® portal, by emailing us at ContactSVMIC@svmic.com, or by calling us at 800.342.2239.
 The names of individuals in this closed claim have been changed.
Kathleen W. Smith is a Senior Claims Attorney in the Claims Department of SVMIC. Ms. Smith is a licensed Tennessee attorney admitted to practice law in all Tennessee state courts and before the United States District Court for the Middle District of Tennessee. She is a member of both the Tennessee Bar Association and the Nashville Bar Association. Ms. Smith manages litigated and presuit claims brought against SVMIC policyholders in all jurisdictions where SVMIC insures medical providers. She also advises SVMIC policyholders with the varied legal, regulatory and risk management issues arising during the day-to-day provision of healthcare. Prior to joining SVMIC, Ms. Smith practiced law with a defense litigation firm, defending SVMIC policyholders in medical malpractice lawsuits.
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