Patient went to hospital for colorectal surgery and was placed in the prone jack knife position without proper anesthesia. Patient made surgeon and anesthetic nurse aware she was still awake and could feel everything. Surgery was stopped and it took 45 minutes for someone to come and reinsert the IV line. While waiting 45 minutes, patient experienced severe shoulder pain and begged to be let off of the operating table. Patient's pleas were ignored and IV was set and surgery commenced. There is no documentation during said 45 minutes. We have OR notes and a sworn statement from the patient regarding the incident.
Patient ended up with an irreparable torn deltoid and cannot move her right arm. She is in constant pain and cannot resume everyday tasks.
Files:
Q: was this a conscious sedation case with sedation administered by a RN or a monitored anesthesia care case (MAC) provided by a credentialed anesthesia provider?
A: —
Do you believe there might have been medical error?
Positional errors do happen under anesthesia however they are often found after the patients is woken up post operatively. In this case, there was a combination of what seems like an infiltrated IV (this the patient being awake) in addition to the position issue. This was an awake patient actively describing pain with position which should always be immediately responded, assessed, and changed if necessary. There was an error performed here.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The patient was awake and was prone for a colorectal surgery. The fact she has an injury to the deltoid says it all. It’s not secondary to anything else but the position during the surgery. We can discuss the patient’s pre conditions however it likely would not contribute given the complete torn deltoid.
What makes you a good expert for this case?
I am a double board certified anesthesiologist and pain management physician. I review these type of cases quite often for our internal PI/QI committees.
How often do you encounter cases similar to this one in your practice?
At least once a month we encounter a position error.
Do you believe there might have been medical error?
It sounds like the IV infiltrated. Very concerning that patient awareness may have been ignored
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Failure yo recognize awareness under anesthesia
What makes you a good expert for this case?
I am board certified in anesiology and critical care medicine. I am an expert in these areas and have taught these specialties for ten years.
How often do you encounter cases similar to this one in your practice?
This is common, IV infiltration can be recognized earlier
Do you believe there might have been medical error?
This patient was awake and complaining of arm pain during the procedure. Her positioning should have been checked and adjusted during that time. It appears it was not, that is unjustifiable. The patient also asked for the surgery to be stopped, the fact it was not constitutes all further medical treatment as assault and should be prosecuted as such unless the patient lacked capacity for medical decision making (developmental delay, ward of the court, child, conserved status, altered mental status etc) which does not appear to be the case.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Positioning injuries can happen during anesthesia because patient are unable to complain. In this case the patient was awake and complaining and it appears nothing was done. Unless her deltoid was torn preoperatively (does not appear to be the case) this injury was caused by a lack of care during positioning and not paying attention to the patients complaints
What makes you a good expert for this case?
Associate professor at academic medical center, in charge of quality for the department of anesthesiology.
How often do you encounter cases similar to this one in your practice?
Positioning injuries happen with about 1 pct of cases, but we have never had an injury as severe as this in a patient who was actively expressing their discomfort
Do you believe there might have been medical error?
While it is difficult to make a definitive opinion given the limited information, the scenario that is posed leads to many other questions about the case. This does not list what type of anesthesia was employed. I am led to assume that it was a MAC case if the patient was able to speak and tell anyone during the case that she was hurting. If the original anesthesia plan was MAC, a functional IV was absolutely necessary for the case. If there was a CRNA involved in this case, who was the supervising physician? Is this a state that allows for independent CRNA practice. If the surgeon was the supervising physician, why was he not involved in the decisions pertaining to the patient's positioning injury and acute pain in the surgical position? It is the obligation of the anesthesia clinician to document the circumstances that led to losing the IV and it sounds like that documentation is missing. There is also no documentation for why there was such difficulty in placing the IV or how many attempts were made. I would find this negligent given the obvious circumstances that were occurring. This can be documented after the immediate incident is addressed. In addition, if it was taking an excessive amount of time to place the IV, it begs the question why the patient would not have been repositioned back to supine, especially if she was saying that her shoulder was in pain? While the patient may have some memory of these events, given administration of medications presumably, her recollection may be flawed. I would be interested in the notes of the circulating RN and surgeon's operative note. However, the past medical history of this patient implies she has some frailty and fragility. I would like to review more clinical notes pertaining to her preoperative status of any pain. It would also be helpful to know what kind of surgery was planned and if this occurred after incision was made. Did losing IV access occur at a point of the surgery when the procedure could have been aborted in order to place the patient back into supine position? This would have given the team the best ability to place a new IV efficiently. It also may have led to the discovery of her deltoid injury at this point rather than continuing to leave her in pain and in the jackknife position.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Again, I would need to review the preoperative notes from physicians, nursing and the anesthesia personnel to determine if there was any reason for the patient to have pre-existing conditions related to her arm pain. Assuming there was none, it appears the positioning into jackknife/prone position led to her torn deltoid somehow. If it is factual that the patient was aware enough to complain of pain and the team did nothing to reposition her, there is causation. Also, given that the patient was complaining of pain in her shoulder and the team continued to anesthetize her more deeply knowing her position was painful and there was a subsequent injury, this is indicative of less than the standard of care by continuing on without repositioning her arm and continuing with the case. It also begs the question of how the patient got turned into the jackknife position. Did she position herself that way and then they began giving her sedation? Or did they sedate her and the team actively repositioned her from supine which would make her more likely to have incurred an injury. More details are needed here.
What makes you a good expert for this case?
I have been practicing anesthesiology as a physician for 20 years. I regularly cover general surgery cases which require repositioning. I also work in a care team model with CRNAs utilizing medical direction.Therefore, I understand the laws guiding the practice of nurse anesthetists and the training of these types of clinicians. I am currently the Department of Anesthesiology Chairperson and participate in the Quality and Safety Team for my facility. This duty involves review of charts and addressing service recovery when patients have complaints or concerns after their anesthesia care. In this role, I have become adept at reviewing the medical records in these scenarios and knowing where to look for specific information to investigate why complications may have occurred. I have participated in several legal cases to assist the attorneys to determine if there is negligence and have represented both plaintiffs and defendants. I practice full-time in the clinical setting and have the experience to guide what is the standards of care in my specialty.
How often do you encounter cases similar to this one in your practice?
My main facility of practice cares for many surgical oncology patients. Patients with cancer have unique circumstances especially when it comes to frailty and fragility. It appears this case involves a patient with known history of cancer. At least 25% of the practice involves general surgery for both elective and emergency cases. The addition of minimally invasive surgical approaches requires patients are repositioned safely for surgical care at least 50% of my practice. Therefore, I am keenly aware of how much vigilance is required to careful position a patient to avoid injury such as this one. I am a Diplomate of the American Board of Anesthesiology and a Fellow of the American Society of Anesthesiologists. I am active in my state anesthesia society currently and have practiced my specialty in several states across the country. In addition to my role as the Department Chairperson, I am the physician lead for our Anesthesia consensus group for the entire health system which covers quality and safety practices for 40 hospitals across 6 states.
Do you believe there might have been medical error?
It is not clear given the provided case information if this was a sedation case with local anesthesia, a MAC case( monitored anesthesia care) or a procedure requiring general anesthesia. Was the procedure performed in the operating room suite or off site. Was there an initial IV placed that infiltrated or was an IV started after the patient was placed in a jackknife position? Who placed the initial IV- the conscious sedation nurse or the anesthesia team.? Regardless, if the IV infiltrated or otherwise was not working and the patient was aware enough to tell the sedation provider the procedure should have been halted if possible. It's not clear as to why, if this was done in the surgical suite, it would take 45 minutes for"someone to come and reinsert the IV line". The scenario would seem to indicate that this procedure was not performed with anesthesia department involvement. If the patient was aware and able to complain about arm pin during the 45 minute delay and her complaints were ignored then this would rise to a level of negligence in my opinion. As standard of care in my institution, positioning is routinely documented and includes monitoring and padding of pressure points. The patients complaints would indicate that there was a problem with her positioning and a prudent course wouls have included repositioning and/or additional padding to alleviate the discomfort prior to re establishing sedation/anesthesia.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Patient's complaints appear to have been ignored regarding arm discomfort. Patient should have been repositioned and patient comfort confirmed verbally with patient while awaiting restart of IV
What makes you a good expert for this case?
I was an anesthesiologist assistant for 4 years prior to attending medical school and was on the scientific staff and medical staff at Emory University School of Medicine. so I am very familiar with roles of both the anesthesiologist and CRNA/ AA . I have been a practicing anesthesiologist for the past 29 years and have practiced in a wide variety of settings from academic to research and private practice. I am currently practicing in an academic setting.
How often do you encounter cases similar to this one in your practice?
Rarely however IV malfunctions do occur. As for positioning injuries I am aware that positioning injuries occur but I have not experienced any in my practice to date
Do you believe there might have been medical error?
No surgery or procedure that inflicts pain on a patient should be started without proper confirmation that the patient is either asleep or that the chosen anesthetic technique is properly working. It sounds as if the chosen anesthetic technique was IV sedation and that the IV was not properly functioning and therefore the patient experienced pain during the procedure. This should have been recognized and corrected much sooner and before the procedure was started.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
By not properly sedating the patient and making sure they were asleep prior to the procedure being started, it seems the patient experienced distress, pain and emotional trauma. The muscle injury could have been caused by improper positioning. When ever a patient is placed in the prone jackknife position, it is prudent to check whether they are comfortable prior to sedating them to prevent any of these types of injuries.
What makes you a good expert for this case?
I have been practicing as a general anesthesiologist for 5 years and I believe I use good judgment and common sense and always try to treat my patients as if they are my own family. I provide solo anesthesia as well as supervise CRNA’s on a daily basis. My cases range from orthopedics, OBGYN, OB, colorectal, general surgery, trauma and neuro.
How often do you encounter cases similar to this one in your practice?
Quite frequently. This sounds like it was a hemorrhoidectomy or similar type of procedure being performed under IV sedation.
Do you believe there might have been medical error?
I contend that several factors contributed to this unfortunate event, which I believe constitutes a failure of the standard of care expected in such procedures. Specifically: Inadequate Anesthesia: The patient was placed in the prone jackknife position, which requires adequate sedation and monitoring due to the potential for patient discomfort and injury. Despite being informed by the patient that she could feel everything and was still awake, the surgical and anesthesia team did not take immediate corrective action to anesthetize her properly. The failure to administer sufficient anesthesia or analgesia constitutes a breach of the standard of care for patients undergoing surgical procedures, particularly those in vulnerable and uncomfortable positions. Delayed Response to Patient's Distress: The patient reported experiencing severe shoulder pain and requested to be removed from the operating table, which was ignored for 45 minutes. During this period, the patient experienced significant discomfort and distress. There is no documentation in the medical records to indicate any actions the surgical team took to assess or address the patient’s pain or provide any interim relief. This period of neglect exacerbated the patient's suffering and contributed to the eventual permanent injury. Failure to Monitor and Respond promptly: The failure to promptly reinsert the IV line and adequately address the patient’s anesthesia needs led to a 45-minute delay in appropriate care. This delay not only prolonged the patient's distress but also left her vulnerable to further harm, ultimately resulting in a torn deltoid and permanent loss of function in her right arm. Delays of this nature in a surgical setting are not only unacceptable but dangerous, as they can lead to lasting physical and emotional harm. Injury Resulting from Negligence: The patient's torn deltoid, resulting in permanent loss of function and constant pain, was a direct consequence of the events that transpired. Had appropriate anesthesia been administered promptly or corrective measures taken in response to the patient’s complaints, it is likely that this injury could have been avoided. Furthermore, the failure to document the events during the 45 minutes of distress or to take corrective action during that time demonstrates a lack of attention to the patient's wellbeing, a clear violation of medical standards. In light of these facts, it is clear that the medical team involved in this case failed to provide care that met the expected standards, resulting in significant and permanent harm to the patient. The evidence, including the sworn statement from the patient and the OR notes, supports the claim that the failures of the surgical and anesthesia team caused the patient’s pain and suffering.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Yes, there appears to be a direct causation between the medical error and the injury. Several key factors suggest that the medical error led to the patient’s injury: Failure to Administer Proper Anesthesia: The patient explicitly reported that she was still awake and could feel everything during the surgery, which means she was not adequately anesthetized. Being awake and aware while in the prone jackknife position could have led to physical strain and positioning-related injuries. The failure to respond to the patient's distress and administer adequate anesthesia directly contributed to the patient’s suffering and potential muscle or nerve damage. Extended Delay in Addressing the Patient’s Pain: The 45-minute delay in re-establishing the IV line and adequately addressing the patient’s anesthesia needs likely prolonged the discomfort and strain, further contributing to injury. The patient experienced severe shoulder pain during this time, and being in the operating position without adequate sedation or support may have led to mechanical injury, such as a torn deltoid. Irreparable Torn Deltoid and Permanent Disability: The outcome of the incident—the torn deltoid—was directly caused by the prolonged period of distress and improper handling. When the patient was left on the operating table without the proper anesthesia or attention to her distress, she was at risk of musculoskeletal injuries, which culminated in a torn deltoid. The fact that the patient now suffers from loss of function and constant pain in her right arm is consistent with the mechanical and neurological consequences of such a failure in care. The failure to appropriately monitor, assess, and respond to the patient's condition during the surgery likely led to the permanent injury and disability she now faces. Therefore, it can be argued that the medical error directly caused the patient's injury, including the torn deltoid and the resulting functional impairment.
What makes you a good expert for this case?
As an expert, I possess a background in clinical practice and medical leadership, which enables me to offer insight into the technical and systemic aspects of this case. Here are the key factors that make me well-suited to provide expert analysis: Medical Expertise: With my training and experience as an anesthesiologist and pain physician, I have a deep understanding of the principles of anesthesia, pain management, and the risks associated with various surgical positions. I can assess whether the standard of care was met in administering anesthesia and handling the patient’s pain and positioning and how deviations from this standard may have contributed to injury. Understanding of Surgical Protocols: Having worked in both clinical and teaching settings, I am familiar with the typical practices in operating rooms, including patient monitoring, anesthetic management, and the appropriate response to patient complaints during procedures. This knowledge is critical in determining whether the delay in addressing the patient’s anesthesia needs was a failure in clinical judgment and if this contributed directly to the injury. Experience in Medical Leadership and Policy: In my various leadership roles within medical societies and healthcare organizations, I have been involved in developing policies aimed at improving patient safety and quality of care. This perspective allows me to understand the broader implications of medical errors and the importance of adherence to safety protocols. Ability to Assess Causation: My expertise allows me to evaluate the relationship between the medical error and the patient’s injury. I can provide insight into how the failure to administer proper anesthesia and respond to the patient’s distress could lead to significant physical harm and how the injury might be linked to the sequence of events described. Communication and Analysis: As a leader in the healthcare community, I am skilled at synthesizing complex medical information and communicating it clearly and compellingly. I can effectively translate the technical aspects of this case into a format that is accessible and understandable for legal and non-medical professionals. These qualifications, combined with my extensive experience in patient care and medical leadership, position me as an expert in assessing the medical error, causation, and consequences in this case.
How often do you encounter cases similar to this one in your practice?
As an anesthesiologist and pain physician, I regularly encounter situations where patient safety, anesthesia management, and positioning during surgery are critical. While I do not encounter cases identical to this one frequently, I do deal with various scenarios where improper anesthesia or positioning can lead to patient distress or injury. Here are some key examples of similar cases I might encounter: Inadequate Anesthesia and Awareness: Although inadequately anesthetized or aware during surgery, also known as intraoperative awareness, is relatively rare, it does occur. These cases are typically characterized by patients reporting that they could feel pain, hear conversations, or be aware of their surroundings during surgery despite being under general anesthesia. The failure to adequately monitor anesthesia depth or respond to patient concerns can lead to distress, as seen in this case. Positioning-Related Injuries: In surgeries where patients are placed in positions like the prone jackknife, improper positioning or failure to monitor the patient for extended periods can lead to musculoskeletal injuries, such as nerve damage or muscle strains. While these injuries are uncommon, they can result from patient factors (e.g., positioning or pre-existing conditions) and procedural errors, such as failure to adjust positioning or provide adequate padding and support. Delayed Response to Patient Distress: In my practice, I have encountered situations where patient concerns or requests for help are not addressed promptly. This can occur in a busy surgical setting where staff may not be immediately available to respond. While this is not a regular occurrence, it does highlight the importance of effective communication and vigilance in the operating room to prevent patient harm. In terms of frequency, while the exact combination of errors in this case—failure to properly anesthetize, failure to address patient distress, and delayed action leading to physical injury—is relatively rare, elements of these incidents do arise in clinical practice from time to time. My experience with managing anesthesia-related issues, positioning concerns, and patient advocacy gives me a strong foundation for evaluating cases like this one, where a medical error has led to a serious injury.
Want to open a case or submit response?
Comments are accepted only from Anesthesiology - includes all Subspecialties experts.