HLT-313V Topic 2 DQ 1

Using the GCU Library, locate and summarize an allied health malpractice or negligence case study. If possible, select a case within your chosen field of study. What went wrong? What workplace safety, risk management, and/or quality improvement steps were involved? What could have been done differently? If you were in charge of making sure this type of event never occurred again, what steps would you implement into the risk management plan?
You are required to use and cite a minimum of two references from the GCU Library to support your response.

Solution

In any situation where humans are making decisions, errors will inevitably occur, and healthcare is not exempt from this fact. Despite best laid plans and intentions, Medical errors happen every day, making it the third leading cause of death in the United States. One need only do a simple search to find cases where human error or negligence caused harm to a patient.

One such case involves a patient hat had a gynecological surgery performed and suffered serious complications. During the surgery, her iliac artery was severed, impeding blood flow to her lower extremity. Given that the iliac artery is a major supplier of blood flow to the lower extremities, such an injury could potentially cause loss of life or limb. In this case, the patient complained of paresthesia in the lower extremity on post-operative day 1, which the surgeon attributed to the patient having been in lithotomy position for a prolonged period of time during surgery. It was noted that the surgery required extensive dissection of adhesions on the side in question. in close proximity to the vasculature, but there was no follow up check of the blood flow to the extremity. The patient was discharged home, only o call the physician with complaints of worsening paresthesia and her toes turning blue. At this point, the patient was advised to return to the hospital for evaluation. The patient suffered permanent motor damage as a result of this injury.

There are several factors that could have led to this injury, such as inadequate pre-operative planning, poor visualization during the procedure, incorrect surgical technique, failure to correctly identify anatomy, or even equipment malfunction or misuse. That said, there are ways to reduce the risks of such a situation from occurring in the first place. Examples of preventative measures include ensuring that surgeons are properly trained in procedures they perform, and ensuring proper lighting to allow for optimal visualization, utilizing imaging as needed during procedures, and proper post operative monitoring and management.

In order to prevent similar incidents in the future, steps that I would include are to encourage more thorough pre-operative assessment, including 3-D imaging if appropriate to be more aware of potential complications in advance. Additionally, it would be beneficial to employ advanced intra-operative monitoring that alert the surgical team of potential complication. Developing clear guidelines for identifying and managing vascular complications during surgery would also benefit both patients and providers. By implementing these measures, healthcare organizations can work to reduce serious complications and improve outcomes.

“Plaintiff alleges surgeons caused “severed” iliac artery injuries: Was this…” EBSCO. [Online resource, no direct link available]

Stahel, P. F., Mauffrey, C., & Butler, N. (2014). Current challenges and future perspectives for patient safety in surgery. Patient safety in surgery, 8(1), 9. https://doi.org/10.1186/1754-9493-8-9

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