Unprofessional behavior contributes to poor postoperative outcome
A 54-year-old man with a history of recurrent diverticulitis was referred to a general surgeon. After the initial assessment and consult, the surgeon recommended and performed a robotic-assisted low anterior colon resection that was described in the surgeon’s operative note as “without complication.” The day following surgery, the patient reported a greater degree of pain than expected. His nurse called the general surgeon twice to discuss pain management. On the second call, the surgeon yelled at the nurse for calling again.
On the third day after surgery, the patient developed hypotension, confusion, agitation and decreased urinary output. His nurse called a rapid response team to evaluate the man and he was transferred to the ICU. The ICU intensivist ordered antibiotics and dialysis. The patient’s condition improved, and he was transferred back to the surgical unit.
The general surgeon approached the nursing care team and was angry they had called a rapid response team and accused them of mismanaging the patient’s IV fluids. On the sixth day after surgery, the patient developed a fever and increased white blood cell count. He was transferred back to the ICU and abdominal imaging showed an anastomotic leak. The general surgeon took the patient back to surgery the next morning for a laparotomy, lavage drain placement and loop ileostomy.
The patient and his wife then requested transfer of care to another surgeon. Over the next seven months, the man underwent multiple surgeries and procedures due to the delay in recognition of the anastomotic leak. He had permanent kidney damage and was disabled, unable to work. He filed a malpractice claim against the original general surgeon and the hospital alleging improper performance of surgery, improper management postoperatively, and delay in diagnosis and treatment of surgical complications. The malpractice claim was settled against the general surgeon and the hospital.
The experts who reviewed the care felt the general surgeon should have ordered an imaging study sooner, identified the surgical complication quicker and taken the patient back to surgery for re-exploration to repair the anastomotic leak. The experts stated that as a result of the delay in diagnosis of the leak, the patient rapidly progressed from sepsis to severe sepsis, which then required multiple additional surgeries. This resulted in permanent kidney damage, cognitive impairment and disability.
The experts were also critical of the nursing team for failing to invoke the chain of command process. Instead of using this process when the surgeon was unresponsive to their reports of the patient’s deterioration, the surgical nurses kept private journals of their concerns and contentious interactions with this general surgeon. The defense team felt these private notes would be discoverable and damaging to the defense of the claim.
In our analysis of Constellation surgical malpractice claims, general surgeons are the second most frequently cited clinician responsible for care at the time of alleged harm events, with 21.6% of claims, and number one in costs (28.5%). Issues with surgical skill and performance are the top allegations made against general surgeons (59%), followed by poor surgical management claims (30%). Communication breakdowns, including communication among the care team, were identified as contributing factors in 35% of surgical claims.
How to respond when unprofessional behavior threatens patient safety
“Disruptive and unprofessional behaviors are common in health care and often indicate a toxic culture that undermines patient safety.”Betty VanWoert, Constellation Senior Risk Consultant
A recent study revealed that surgeons with higher numbers of complaints of unprofessional behavior typically have patients who experience more complications following surgery.1
Postoperative complications can arise following any well-performed surgical procedure. Surgical care team vigilance, communication and responsiveness to patient complaints throughout the postoperative phase are crucial to seeing surgical patients all the way through their recovery. Failure to quickly recognize and respond when patient complaints and clinical symptoms point in the direction of a problem, rather than toward improvement, can significantly delay recovery and be life-altering for a patient.
- Initiate the chain of command process when unprofessional behavior threatens patient safety. The hospital’s standardized sepsis screening tool was completed three times prior to the surgeon returning the patient to the operating room. Each indicated a high score for possible sepsis. The screening tool outcomes and documented progressive deterioration should have triggered the chain of command process when the surgeon did not respond to the calls about the patient’s deteriorating condition. Access Constellation’s HEAL Best Practices Guide: Implementing a Chain of Command, located in the HEAL Prepare Toolkit Unit 1: Culture.
- Strengthen safety culture. Hierarchical or unprofessional communication, rather than safety-oriented team communication, contributed to a delay in recognizing and responding to this patient’s deterioration. Teach and model collaborative team communication and encourage team members to speak up in support of safety. Access Constellation’s HEAL Insights: Speaking Up, locatedin the HEAL Prepare Toolkit Unit 1: Culture.
- Support patient and family communication. Patients and families deserve and expect transparent, empathetic communication about their condition and care. Keeping the lines of communication open is especially valuable when outcomes are unexpected, or harm occurs. Watch our on-demand webinars, Communicating After Harm Events and the HEAL Best Practices Guide: Communicating After Harm Events, located in the HEAL Prepare Toolkit Unit 3: Communicating After Harm Events.
The HEAL Prepare Toolkit
Constellation’s HEAL Prepare Toolkit will help assess your team’s readiness to respond to a harm event and then help you get to best practices. The Toolkit includes assessments, best practices, sample tools and coaching. Start your journey by taking the HEAL Assessment and then the Action Plan will guide you through the Toolkit’s four units: (1) culture, (2) event response, (3) communicating after harm events, and (4) moving forward. Sign in to ConstellationMutual.com to access the HEAL Prepare Toolkit found in Risk Resources.
Constellation’s HEAL program provides healing benefits for care teams and their organizations because we truly believe that what’s good for care teams is good for business.
1 Cooper WO, Spain DA, Guillamondegui O, et al. Association of coworker reports about unprofessional behavior by surgeons with surgical complications in their patients. JAMA Surgery. 2019;154(9):828-834.
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