The Doctor’s Advocate | Fourth Quarter 2016
An Ounce of Prevention
Plastic Surgery Closed Claims: What Can We Learn?
We have just released the Plastic Surgery Closed Claims Study, the latest in our nationally recognized series analyzing claims data from our 78,000 members. This study, which evaluates 1,438 plastic surgery claims that closed from January 2007 through June 2015, provides insights into the most likely risks encountered by plastic surgeons. Here is a brief overview.
—Robin Diamond, JD, RN, Senior Vice President,
Department of Patient Safety
and Risk Management
An examination of the most common patient allegations in plastic surgery claims revealed that the majority were related to improper performance of surgery (49 percent), improper management of the surgical patient (13 percent), and improper performance of treatment or procedure (12 percent). These three categories accounted for 74 percent of the total allegations in plastic surgery claims.
Improper Performance of Surgery
This allegation was often made when the outcome of surgery differed from the patient’s expectations. However, a number of these claims arose from complications that were known to the patients as risks of the procedures, and the documentation showed that the potential risks were discussed with the patients prior to surgery. Our experts determined that substandard care was found in only 5 percent of all plastic surgery claims.
Case Example: A 25-year-old female consulted a plastic surgeon about a breast lift. She weighed 157 pounds and was size 37D. The surgeon recommended breast lifts with implants. The patient signed a seven-page consent form that outlined specific risks, including tissue necrosis. She was given antibiotics prior to her mastopexy and augmentation.
During the seven-hour surgery, the surgeon removed 327 grams of tissue from the left breast and 414 grams from the right. Photos taken postoperatively showed pink nipples. Antibiotics were given following surgery.
At the office visit one week following surgery, cultures were negative, but Levaquin was again prescribed. During the second office visit two days later, the surgeon applied a crisscrossed bandage because of swelling. Four days later, external ultrasound was used to evaluate the cause of the swelling. It was noted that the areolae were changing color. The surgeon asked the patient to return to the office in two days.
During the next office visit, the surgeon noted clear drainage. An examination of both breasts revealed blisters and erythema around incision sites. The blisters were debrided; cultures grew Alcaligenes, and the patient was referred to an infectious disease specialist. He noted bilateral necrosis in areas around the nipples with vertical incision inflammation consistent with infection. He started the patient on IV antibiotics.
Two weeks later, the infectious disease specialist noted hardened black eschar involving both nipple areas with some wound dehiscence and underlying fat necrosis. Ten days later, wound cultures were positive for Pseudomonas aeruginosa. The patient was started on Levaquin and referred to a wound care specialist who started hyperbaric treatments.
The patient underwent several stages of reconstructive surgery. She now has severe scars and deformity of both breasts. Reviewers were critical that too much breast tissue had been removed and that the implants compromised the circulation.
Improper Management of Surgical Patient
These allegations arose from cases in which surgical complications were not managed effectively. Examples included delayed treatment of infections leading to scarring, tissue necrosis, and sepsis; optic nerve infarcts from incorrect positioning of the patient; scarring from an operating room fire near the patient’s face; and decreased circulation resulting in tissue necrosis from improper use of compression garments and hose.
Case Example: A 55-year-old obese female was admitted to the hospital for abdominoplasty and liposuction of her trunk. Surgery lasted eight hours. Her systolic blood pressure remained in the 90s during surgery. The patient was given 500 cc of Hespan along with 7,800 cc of IV fluid. Urine output decreased toward the end of the procedure, so she was given 100 mg Lasix. The patient’s estimated blood loss was 650 cc. At the end of surgery, her blood pressure was 120/80.
In the post anesthesia care unit (PACU), the patient was awake and alert. About 90 minutes later, her blood pressure dropped to 55/43. She developed respiratory distress and became lethargic. The patient was reintubated and given several doses of ephedrine, but her blood pressure continued to drop. Hespan was started. The patient’s heart rate was in the 60s before her blood pressure dropped further. A code was called.
A hospitalist placed a central line for rapid fluid administration. A chest x-ray showed no pulmonary edema. The patient was given bicarb and calcium chloride for acidosis and hypocalcemia. She was started on dopamine. The patient’s hemoglobin was found to be 4.4 gm/dL. Following placement of an arterial line, she was transferred to the ICU.
Numerous consults were requested, and she remained on pressor support. She had no signs or symptoms of disseminated intravascular coagulation, renal failure, or rhabdomyolysis. Following the transfusion of 2 units of packed red blood cells, her hemoglobin was 6.2 gm/dL, and her platelet count was 156,000/mcL.
The working diagnosis was shock due to severe anemia. Initially her physicians thought the anemia was due to massive fluid shifts since the low serum albumin was consistent with continued aggressive fluid management.
The next morning, the patient had a cardiac arrest, became bradycardic, and expired. No autopsy was performed. Physician reviewers thought the low hemoglobin levels were not due to hemodilution by IV fluids but acute blood loss and felt the patient should have had a CT of the abdomen and pelvis to determine the source of blood loss.
Improper Performance of Treatment or Procedure
Examples of this allegation included sclerotherapy injections that resulted in edema and scarring, fat injections that resulted in disfigurement, and pulsed light treatments that resulted in hypopigmentation of the face. Patients also suffered nerve damage and scarring from liposuction of the face and burns during laser facial hair removal or resurfacing of the face.
Factors Contributing to Patient Injury
We engage practicing physicians to help evaluate malpractice cases and identify factors that contributed to patient injury. The top seven factors were identified as technical performance, patient factors, communications between patient or family and provider, selection and management of therapy, insufficient or lack of documentation, patient assessment issues, and lack of or failure in systems for patient care.
Factors related to technical performance—the top contributing factor—included performing a procedure on an incorrect body site, misidentifying an anatomical structure, and using poor technique. Patient factors, which included behaviors and body characteristics, affected the outcome of care, highlighting the important role that patients play in their own care and recovery. Claims were made by patients who were noncompliant with treatment plans, follow-up appointments, and medication plans and by patients who went to other doctors due to dissatisfaction with the care received. By seeking care from other physicians, patients eliminated the plastic surgeons’ ability to address concerns and provide follow-up care. Patient factors also included body characteristics that delayed healing or caused excessive scarring.
Risk Mitigation Strategies
The following strategies can assist plastic surgeons in preventing some of the issues identified in this study:
- Help patients set reasonable expectations about outcomes by discussing the possibility of less-than-optimal results and complications that could delay recovery and affect appearance. In plastic surgery, more than in any other physician specialty, the patient’s appearance following a procedure determines whether the outcome was a success.
- Use patient selection criteria to evaluate and determine if a patient is a good candidate for surgery.
- Take a complete medical and surgical history. Patient histories are important in determining whether a patient is an appropriate candidate for surgery and for selecting a venue that fits the patient’s needs. Patients are not always reliable historians, so it is essential to elicit information about bleeding disorders, family histories of reactions to anesthesia, sleep apnea, and the other conditions that increase risk during or following surgery.
- Train office staff to recognize complaints from patients or families that warrant immediate follow-up. Allocate office time to seeing patients who may be experiencing complications. Although uncommon, deep venous thrombosis, pulmonary embolism, compartment syndrome, peritonitis, and wound infections are outcomes that represent serious threats to patients’ well-being.
- Confirm that patients understand discharge instructions, follow-up care, and medication plans. Use read-back or repeat-back techniques. Patient compliance is a major problem, especially when patients don’t understand discharge instructions.
- Document patient noncompliance. Smoking, unauthorized activity, and failure to complete prescribed antibiotics or other medications may affect the desired results of care.
Read the full study at www.thedoctors.com/plasticsurgerystudy.
The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.
The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.
The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.
The Doctor’s Advocate is published quarterly by Corporate Communications, The Doctors Company. Letters and articles, to be edited and published at the editor’s discretion, are welcome. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of The Doctors Company. Please sign your letters, and address them to the editor.
Fourth Quarter 2016
From the Chairman
Perspectives on the Future of Medicine
The Doctor’s Dilemma
An Ounce of Prevention
Plastic Surgery Closed Claims: What Can We Learn?
Government Relations Report
California Supreme Court Takes a Step to the Left
Foundation Supports Telluride Camp for Health Science Students
The Back Page
Industry and Company News