William C. Wilson

Communication Breakdown Leads to Cascade of Errors

Case History: Mr. R was a 54-yearold man who underwent elective left total knee replacement that devolved into a transfemoral amputation due to miscommunication from the orthopedic surgeon to the hospitalist, and then from the nursing staff to the physician, when a change of condition occurred. By the time the surgical team became involved the day following the surgery, Mr. R’s pulses were no longer palpable. After three unsuccessful surgeries to revascularize and salvage the limb, they had to amputate it. Mr. R blamed the surgeon and the hospitalist for failure to diagnose a large left popliteal pseudoaneurysm that had completely occluded the left popliteal, tibial, and peroneal arteries below the knee. If this had occurred in a skilled nursing facility, the facility likely would have been a target defendant as well, due to the evening nurse’s failure to report the change of condition. The hospitalist defended himself by saying he was only consulted for one thing — the postoperative tachycardia. If the documents supported that focused content of the medical consult, then it was even more incumbent upon the surgeon to examine the patient when he was informed of the uncontrolled pain, and for the evening nurse to report to the surgeon when she discovered that Mr. R was having trouble moving his toes and his pulses were barely palpable.