A 58-year-old man came to Neurosurgeon A for treatment of neck pain with radiation to his arms. At the first appointment, the patient and neurosurgeon agreed to pursue a conservative treatment plan to relieve pain. The patient had a history of hypertension and diabetes.
After trying conservative treatment for six months without results, Neurosurgeon A took the patient to surgery. She performed an anterior cervical discectomy and fusion at C5-6; no complications were encountered. The patient was discharged the next day with instructions to return in two weeks.
A few hours after being discharged, the patient called Neurosurgeon A’s office reporting difficulty swallowing. The nurse instructed the patient to eat soft foods and use throat lozenges. She documented that the patient denied trouble breathing or swallowing liquids. Neurosurgeon A called in prescriptions to the patient’s pharmacy for nabumetone and diazepam.
That night at 9 p.m., the patient went to a hospital emergency department (ED) with respiratory distress. Neurosurgeon B, who was on call, notified Neurosurgeon A of the patient’s condition and planned to take the patient back to surgery.
Hospital staff attempted to contact the on-call anesthesiologist, Anesthesiologist A, to provide services for the surgery. Surgery was scheduled for 11 a.m., the following morning.
The next morning, Anesthesiologist B saw the patient at 10:45 a.m. while the OR was being prepared. He was told that Anesthesiologist A had been called to provide anesthesia services. Anesthesiologist B documented that the anesthesiology team was present and waiting for Anesthesiologist A to arrive. Therefore, Anesthesiologist B proceeded to see other patients.
Neurosurgeon B consulted with the hospital’s on-call general surgeon, who noted the development of a large hematoma in the patient’s anterior neck. Anesthesiologist A responded to the hospital’s call and reported that he had been delayed at another hospital. He reported that he would not arrive at the hospital until 11:30 a.m.-12 p.m. Anesthesiologist B was emergently called back to the OR to intubate and prepare the patient for surgery.
When Anesthesiologist B arrived, the patient was in asystole and CPR was in progress. When Anesthesiologist B tried to intubate the patient, he “was able to visualize the cords; however, they were closed shut.” Bagged valve mask ventilation was attempted. Anesthesiologist B was able to place an 8 Shiley tracheostomy tube and a left femoral central venous catheter, while CPR and advanced cardiovascular life support protocol was underway.
After an hour of CPR and medication, the patient died. Cause of death was asphyxia due to complications of cervical spine surgery. The pathology report noted laryngeal edema, hemorrhages within the neck musculature, and hypoinflation of the lungs.
The patient’s family filed lawsuits against Neurosurgeon A, Neurosurgeon B, Anesthesiologist A, Anesthesiologist B, and the hospital. Allegations included:
- premature discharge after surgery (Neurosurgeon A);
- failure to respond to requests for emergency on-call anesthesiology services (Anesthesiologist A);
- failure to timely intubate the patient resulting in asphyxia and death due to the laryngeal edema (Neurosurgeon B, Anesthesiologist B); and
- inadequate policies and procedures for on-call anesthesiology services (hospital).
Consultants who evaluated this case for TMLT mostly agreed that Neurosurgeon A was not negligent, as she was not present during the patient’s rapid decline. Additionally, all immediate postoperative issues (dysphagia, hematoma) were known complications and not initially believed to be serious.
Consultants were also mostly supportive of Anesthesiologist B. However, he was criticized for not intubating the patient when he first saw him at 10:45 a.m. Surgery was scheduled for 11 a.m., and the patient's condition had deteriorated since arrival in the ED.
It was argued that, with a patient having swallowing and breathing difficulties after neck surgery, it was likely the patient’s airway could close at any time. Therefore, Anesthesiologist B should have intubated the patient. However, Anesthesiologist B believed Anesthesiologist A’s arrival and action was imminent, so he did not act.
Consultants were more critical of Neurosurgeon B, stating that his request for emergent anesthesia services should have been more aggressive. They reasoned that Neurosurgeon B could have alerted the hospital’s surgical desk of the need to perform emergency surgery and borrowed an anesthesiologist from another, non-emergency procedure. The nurses were also criticized for not taking action to find an anesthesiologist when Anesthesiologist A did not respond.
Due to the challenges described, this case was settled on behalf of Anesthesiologist A, Anesthesiologist B, Neurosurgeon A, and the hospital.
Risk management considerations
Communication failures frequently factor in to adverse clinical events and outcomes. According to a recent review of in-hospital deaths, communication errors were found to be the leading cause, twice as frequent as clinical errors.1 In this case, communication errors and misunderstandings led to a delay in treatment and the patient’s death.
Hospitals rely on policies, procedures, and communication processes for quality patient care. In this case, there may have been poor scheduling systems, under-staffing, or a lack of accountability at play. The on-call anesthesiologist was asked to be in two places at once. Nevertheless, it is important that staff remain within reach while on duty.
With a lack of communication from Anesthesiologist A, there should have been a policy in place to prompt the OR nurses to locate and confirm a back-up anesthesiologist. One solution to ensure prompt communication and avoid treatment delays is to improve the systemic health information technology (HIT), such as electronic health records (EHR), scheduling systems, call back systems, and care transition tracking.
All hospital staff members should clearly communicate and document any concerns or lapses they observe. If these staff members were following hospital policies and procedures, then this case illustrates a need for the hospital to revisit guidelines to assure that health care professionals are clearly communicating and empowered to act in a timely manner for the benefit of patients.
1. Coiera, E. Communication systems in healthcare. Clinical Biochemist Reviews. May 2006 Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1579411/. Accessed April 19, 2018.