Surgical Error

Simon, a 3-month-old, presents to the Emergency Room with an incarcerated right inguinal hernia. Simon was born at term and the mother recently noticed a bulge on and off in his right groin. His hernia is the size of a golf ball and tender. The skin is red. You are able to reduce it after sedation with difficulty. You explain the procedure to the parent and the risks of the surgery.

At the time of surgery, the tissues are still very inflamed and after some dissection, you realize that the vas has been cut. You tag the two ends with prolene and complete the hernia repair.

Questions to consider:

1. What should you tell the parents post-operatively?

2. What are your institutional policies about medical/surgical error?

5-year-old Marcy was admitted with perforated appendicitis. She was worked-up with an ultrasound and labs prior to surgery. The usual pre-operative antibiotics have been ordered. The open appendectomy is uneventful but on POD 2, Marcy starts complaining about increasing pain in her incision.

After examination and work-up, Marcy is found to have necrotizing fasciitis, which needs immediate debridement in the Operating Room. You explain the situation to the parents who are quite upset. Marcy is left with a debridement wound measuring 5.0 x 3.0 cm. It will take a while for the wound to close. Marcy will most likely need more surgery for hernia repair/wound closure.

Reviewing the chart, you notice that Marcy did not receive her pre-op antibiotics.

Questions to consider:

1. What would you divulge to the parents?

2. What would be your approach to minimize conflict in this situation as this is going to be a long admission? Who else would you get involved?

3. If the situation becomes conflictual with the parents, what would be your approach?

4. Discuss one conflictual relation with parents at your institution and how it was resolved.

Workshop 4

Topic: Surgical Error

Curricular objectives

  1. To know the epidemiology of surgical errors and understand the principles of system errors
  2. To understand the principles of truth telling, justice and trust

Ethical messages:

  • A blame-free milieu needs to be in place to promote reporting of errors and implementation of better systems
  • Truth-telling preserves patient autonomy and trust.

Pre-workshop readings:

  1. Wu AW, Cavanaugh TA, McPhee SJ, et al.  To tell the truth: ethical and practical issues in disclosing medical mistakes to parents.  J Gen Inter Med 1997; 12:770-775
  2. Kriezek TJ.  Surgical error: ethical issues of adverse events.  Arch Surg 2000; 135:1359-1366
  3. Reason J. Human error: models and management.  BMJ 2000; 320: 768-770
  4.  Disclosing adverse clinical outcomes.  CMPA Oct 2001 Bulletin

Paradigm case:

A 3-year-old undergoes an orchidopexy; the testicular vessels are inadvertently avulsed during the surgery.

Teaching modality:

Case discussion after interactive presentation.

CanMeds competencies targeted:

Medical expert