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RISK MANAGEMENT
Failure to treat
postoperative infection
By TMLT Risk Management Department
This closed claim study is based on an actual malpractice claim writing, but he could not be sure. It was also unclear if the entry was
from Texas Medical Liability Trust (TMLT). This case illustrates how what the patient had relayed to the nurse, or if those observations
action or inaction on the part of physicians led to allegations of pro- were made by the nurse herself. The patient was fitted with a splint
fessional liability, and how risk management techniques may have ei- to continue immobilization of the foot and was told to only remove
ther prevented the outcome or increased the physicians’ defensibility. the splint to bathe. She was also advised to complete wet-to-dry dress-
The ultimate goal in presenting this case is to help physicians practice ing changes, to monitor the wound for signs of infection, and to re-
safe medicine. An attempt has been made to make the material more turn to the office in four weeks.
difficult to identify. If you recognize your own claim, please be as-
sured it is presented solely to emphasize the issues of the case. Nearly one week after this office visit, the patient called the sur-
geon’s office and received a prescription for ciprofloxacin. The only
PRESENTATION record of this encounter, which occurred five days after the patient’s
A 69-year-old woman was referred to an orthopaedic surgeon for last visit, was the pharmacy record. There is no record of the phone
call, what was discussed, or the reason for the prescription.
a defect in her Achilles tendon. She was diagnosed with a chronic
rupture of the Achilles tendon. The patient was given the options of Two days later, the patient came to the surgeon’s office complain-
either living with the defect or undergoing reconstruction to regain ing that her foot was “feeling hot” and noting a “hole” in the wound.
strength and function. The patient chose to proceed with the recon- She was not wearing her splint. The patient claimed that she was not
struction. The orthopaedic surgeon — the defendant in this case — advised to do wet-to-dry dressing changes, but instead was told by
performed a repair with transfer of the flexor hallucis muscle. the surgeon’s nurse to clean the wound with peroxide, then dress with
dry gauze. The surgeon examined the wound, noted minimal celluli-
The surgery was uneventful, and the patient was administered a tis, but did not feel the area was hot. He advised the patient to con-
one-time dose of vancomycin post-operatively. Vancomycin was se- tinue taking ciprofloxacin, discontinue the improper peroxide
lected because the patient was allergic to penicillin. The patient was cleanings, and proceed with wet-to-dry dressing changes.
discharged the following day with instructions to leave her foot in a
splint. She was to follow up with the orthopaedic surgeon within 10 The patient called three days later, while the surgeon was on vaca-
days. tion, to report that the wound drainage was getting worse and now
had an odor. The patient was advised to come to the office, and was
PHYSICIAN ACTION seen by the surgeon’s partner. This office note was incomplete, only
The patient followed up with the surgeon eight days after surgery. stating: “post-op wound infection, culture taken.” This second sur-
geon, not realizing the patient had a penicillin allergy, gave the pa-
She was noted to have some skin irritation and some minimal tient a prescription for amoxicillin clavulanate. Fortunately, this
drainage. Because the wound was slow to heal, the surgeon made the mistake was caught by the pharmacy, and another antibiotic was sub-
decision to leave the sutures in place for another week. stituted. The patient stated in her deposition that this was what made
her lose confidence in the surgeon’s office. She sought treatment from
The patient returned a week later, and the sutures were removed. a wound care facility four days later. The wound care physician di-
The wound was observed to have some minimal wound granulation agnosed her with full thickness dehiscense, necrotic subcutaneous
and drainage from the incision. These observations of the wound fatty tissue, and necrotic areas of the tendon in the wound base.
were written in a different handwriting from the surgeon’s, but were
not initialed. The surgeon believed that they were in his nurse’s hand- Six days later after the patient’s appointment with her surgeon’s
Continued on page 20
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