This is the second of a series of articles from The Doctors’ Company (TDC) on potential liability exposures faced by neurosurgeons. For any risk management questions or comments, call TDC Risk Management at (800) 421-2368, ext. 243.
No one doubts that caring for the hospitalized patient requires a team effort, and each team member must have all the information necessary for effective participation. Communication among team members must be clear and complete.
Communication problems can occur in a variety of settings. For example, a patient may be jeopardized when the referring doctor provides too little information to a neurosurgical consultant or when nurse-to-nurse communication lacks critical data. The sort of communication problem that is most likely to precipitate a malpractice action occurs between nurses and physicians. As the following case illustrates, the fault generally lies with both parties.
Clear Instructions Are Essential
Several years ago, a 39-year-old man was brought to the emergency room of a large hospital, shortly after being struck in the head with a baseball bat. He was adequately evaluated and then discharged. Eleven days later, the patient returned to the ER complaining of increasing lethargy. He was hospitalized, and a CAT scan raised the question of an aisodense subdural hematoma crescent. It was late in the evening by the time the scan was interpreted and the patient was alert, so his neurosurgeon decided to wait until morning to perform an MRI.
When the neurosurgeon left the hospital at 10 p.m., he wrote orders for the nurses to check the patient’s vital signs hourly. The neurosurgeon gave no specific direction, however, to note the status of the patient’s pupils or state of consciousness, or to call the neurosurgeon if any alteration occurred.
The neurosurgeon later said he felt it was unnecessary to leave such directions because the nurses should have understood their duty in this regard. The nurses, however, were not alert to a progressive deterioration during the night. It was not until the patient was profoundly comatose at 4 a.m. that the neurosurgeon was called. A craniotomy performed at 6 a.m. identified a subdural hematoma. The patient died five days later.
At trial, several negligence issues arose, but the plaintiff’s attorney mainly concentrated on failed communications-the failure of the neurosurgeon to give the nurses sufficiently clear instructions and the failure of the nurses to call the physician when the patient was obviously deteriorating. The jury returned a verdict against the hospital and neurosurgeon and awarded the patient’s family $700,000 in damages.
Handling an Emergency Situation
Many lawsuits are brought against neurosurgeons when usual and customary complications occur. This shows that the informed consent process failed, either by omission or inadequacy. Neurosurgeons are the specialists on call for motor vehicle accidents and other emergent events. Frequently, the patient is not coherent or capable of providing informed consent. How should a neurosurgeon handle this type of emergency?
Although precedent allows the neurosurgeon to proceed with a surgical procedure and bypass the informed consent process by documenting the emergent condition of the patient, good loss prevention measures suggest another approach. While the patient is in preparation for surgery, the neurosurgeon can communicate with the patient’s spouse, adult children, other family members or even friends and ask one of these people to participate in the informed consent process.
The neurosurgeon should share information about the risks specific to the patient and his or her injuries. The neurosurgeon should assess the level of understanding of the person who will sign the informed consent and should be straightforward. We often see lawsuits brought against a neurosurgeon when a patient dies during surgery or comes out of surgery with paralysis, even when either of these conditionswould have occurred without medical intervention. It is the neurosurgeon’s responsibility to convey these potential outcomes to whomever is reached for consent. A lawsuit may still be brought against the neurosurgeon, but defending the suit will be easier with this kind of communication and documentation of informed consent.
Evaluating the Situation
Whether it is preoperative or postoperative patient care, the neurosurgeon’s responsibilities extend to giving clear and concise instructions to the allied health care professionals who attend the patient. It is important that the neurosurgeon give caregivers explicit written orders, followed by an oral repetition of the instructions. Neurosurgeons also should develop a rapport with their patients’ bedside caregivers before emergencies occur.
John A. McRae, MD, a retired neurosugeon in Southern California, serves on the TDC Board of Govenors. Joan Bristow, RN, MA is Vice President of TDC risk management. TDC offers malpractice insurance at a reduced rate as a benefit of AANS membership.