When complications occur during surgery, an experienced surgeon and surgical team can help ensure a positive outcome for the patient. Inexperience can lead to problems – in this case, brain damage. A special concern in this case is that hospital documentation advertised that the surgeon was accredited when he did not meet the requirements. They were convicted of fraud.
When a patient suffers brain damage, the patient safety goal is impacted. Any time the patient safety goal is impacted, an investigation should be performed. In this case, we can look at the issue in a Cause Map, or visual root cause analysis.
With the Cause Mapping approach, we begin with the impacts to the organization’s goals. In addition to the brain damage, the patient also suffered from loss of eyesight, another impact to the patient safety goal. The doctor was convicted of malpractice, which is an impact to the employee. Additionally, the hospital was convicted of fraud, which can be considered an impact to the compliance goal. The hospital was assigned $178 million in compensatory damage and $10 million in punitive damages. Last but not least, the patient services goal was impacted due to the uncorrected leakage in the patient’s abdomen.
We can begin with the first patient safety goal and ask “why” questions to add more detail to the map. In this case, the patient suffered brain damage as a result of a stroke. The patient suffered a stroke because of uncorrected leakage in the abdomen. The leakage occurred as a result of bariatric surgery, potentially due to the inexperience of the surgeon. In addition, the leakage was not treated for 8 days. Again, it is believed that the inexperience of the surgeon contributed to insufficient patient care.
The fact that the leakage was untreated for 8 days was considered reason for malpractice. While the patient was on a respirator due to his stroke, he was not treated with eye drops, resulting in a retinal burn that left him blind. The hospital was convicted of fraud because it used documentation with the accreditation seal from the American Society Bariatric Surgery’s Center of Excellence referencing the surgeon who performed this surgery. However, the surgeon did not meet the requirements for accreditation. He had performed an insufficient number of surgeries and had not taken an adequate number of bariatric education courses to meet accreditation requirements. The use of the seal in hospital documentation was determined to be fraud.
This case reinforces the necessity for patients to be active in their own care in selecting their physicians. Specifically, patients should perform their own investigation of their surgeon’s qualifications. However, in this case accurately determining those qualifications would have been difficult due to the associated fraud. If the patient had asked how many surgeries the surgeon had performed, he may have decided to go elsewhere.
To view the Outline and Cause Map, please click “Download PDF” above.