The Doctor’s Advocate | First Quarter 2015
An Ounce of Prevention
Analyzing Bowel Perforation Claims
by Darrell Ranum, JD, CPHRM, Vice President, Patient Safety and Risk Management
Bowel perforation is one of the most common complications of abdominal surgery and other invasive procedures. Perforations can happen during endoscopic, laparoscopic, or open surgical procedures. They can also occur during liposuction from unintended penetration of the abdominal wall. Nonmechanical perforations can result from tissue necrosis due to vascular compromise, disease, bowel obstruction, or bowel torsion.
In August 2014, The Doctors Company conducted a study of 351 bowel perforation claims that closed from 2007–2013. It revealed the number of cases that occurred during each type of procedure:
- Endoscopic procedures (n = 81).
- Laparoscopic procedures (n = 65).
- Open surgical procedures (n = 142).
- Other causes (liposuction, disease, obstruction, torsion, etc. [n = 63]).
We also conducted studies for endoscopic, laparoscopic, and open surgical procedures but excluded bowel perforation cases that resulted from liposuction, disease, obstruction, or torsion.
Bowel perforations that occur during abdominal surgery or endoscopic procedures are recognized as a possible complication and are not necessarily considered negligence.
Obesity increased the chance that a patient’s abdominal surgery or endoscopy would result in a perforation. It was a factor in almost one in five laparoscopic procedure claims (18 percent) but was less of a factor in open surgical procedure claims (13 percent) and endoscopy claims (7 percent).
Adhesions contributed to bowel perforations in laparoscopic surgeries. Expert reviewers were critical of surgeons who failed to change to an open procedure when faced with extensive adhesions. Adhesions also complicated open procedures, making it difficult to identify and dissect anatomical structures.
If damage was repaired and there were no other injuries, patients rarely filed claims based solely on the fact that their bowel had been punctured.
In almost every case, the patient’s clinical picture deteriorated in the hours or days following surgery (examples include abdominal pain, free air identified in CT scans, vomiting, tachycardia, elevated white blood counts [WBCs], hypotension, and elevated body temperature). At a time when a patient’s condition was expected to improve, symptoms became worse. Some conditions were presumed to be due to postoperative pain. Others were thought to be bowel obstructions or ileus.
In these situations, physicians failed to monitor patients’ WBCs or to order abdominal x-rays or CT scans. Surgeons failed to assess patients who called the office or who returned to the hospital with serious abdominal complaints. By the time a bowel perforation was suspected, patients were suffering from peritonitis, sepsis, septic shock, pneumonia, acute respiratory distress syndrome (ARDS), brain infarcts, or brain herniation, or they had died. Patient deaths occurred in 16 percent of endoscopy claims, 26 percent of laparoscopy claims, and 25 percent of open surgical procedure claims.
The most common allegation in malpractice claims was improper performance of surgery or the procedure (endoscopy, 83 percent; laparoscopy, 77 percent; and open surgery, 71 percent).
This information corresponded with the most common factor identified by expert reviewers as contributing to patient injury: technical performance (endoscopy, 78 percent; laparoscopy, 74 percent; and open surgery, 71 percent). Bowel perforation is a risk of these procedures. In most cases, our reviewers did not find that the perforation was caused by poor technique. Poor technique was identified in only a minority of claims. (See Table 1.)
Diagnosis-related allegations were commonly made (endoscopy, 15 percent; laparoscopy, 32 percent; and open surgery, 21 percent) when there was a delay in diagnosing bowel punctures, peritonitis, and sepsis. This allegation is closely related to patient assessment issues (endoscopy, 16 percent; laparoscopy, 37 percent; and open surgery, 32 percent). (See Table 2.) This factor refers to failure to establish a differential diagnosis, order diagnostic tests, address abnormal findings, and consider available clinical information.
TOP FINDINGS IN BOWEL PERFORATION CLAIMS
| ||Endopscopy ||Laparoscopy ||Open Surgery |
|Allegation: Improper Performance of Surgery or Procedure ||83% ||77% ||71% |
|Factors Contributing to Patient Injury: Technical Performance ||78% ||74% ||71% |
|1. A known risk of the procedure ||73% ||60% ||56% |
|2. Poor technique ||5% ||14% ||15% |
| ||Endopscopy ||Laparoscopy ||Open Surgery |
|Allegation: Diagnosis-Related (Failure, Delay, or Wrong) ||15% ||32% ||21% |
|Contributing Factor: Patient Assessment Issues ||16% ||37% ||32% |
Preoperative Patient Safety Recommendations
- Assess each patient preoperatively to determine if he or she is an appropriate candidate for a surgical or procedural intervention. Patient factors could affect the outcome.
- Review all of the information. For endoscopic procedures, it is important to consider the history of surgeries, complications of previous endoscopies, and the results of diagnostic studies. Without this information, the surgeon is more likely to be unprepared for adhesions, obstructions, tumors, or fragile tissue.
- Ensure that the operating room or procedure room is ready to convert from laparoscopic to an open surgical procedure if a patient’s medical history shows the likelihood of extensive adhesions.
- Use a shared decision-making process when discussing a patient’s individual risk factors, such as obesity, cardiac or pulmonary disease, and diabetes—in addition to discussing the typical risks, benefits, and alternatives of the proposed procedure.
Postoperative Patient Safety Recommendations
- Ensure that the patient and family understand their responsibilities for monitoring the patient’s condition to determine whether any pain, fever, or nausea is a normal part of recovery or a complication that must be addressed by the surgeon.
- Assess and treat a patient promptly when there is a complaint of severe pain and the patient’s temperature is elevated. When there is a bowel perforation, a patient’s condition can deteriorate rapidly unless there is an intervention.
- Help a patient who suffers an injury understand his or her condition, treatment plan, and prognosis. If the injury resulted from a known risk, remind the patient of the pre-op informed consent discussion, and help him or her understand the connection. The patient may not be happy with the result, but he or she may be less likely to attribute the injury to negligence.
- Confirm that the patient is aware of symptoms that require medical assessment and treatment. Surgeons, nurses, and office staff need to be sensitive to a patient’s questions and concerns. This type of call is often the first opportunity for a surgeon to identify and address a bowel perforation.
Bowel perforation is a recognized risk of abdominal procedures or surgeries. Include bowel perforation in the differential diagnosis when a post-op patient complains of pain and other signs of infection. Listen to the patient’s concerns, and don’t hesitate to make an assessment when the clinical picture is different than anticipated. Give your patients the best chance of surviving by quickly recognizing perforations and infections and acting swiftly to repair and address them.
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