Claims Case Study: Failure to Follow Pre-Op Procedures

By: Janet McCrossen, BSN, RN
2 Minute Read

A 59-year-old Hispanic man presented to his gastroenterologist with nausea and abdominal pain for a month. The patient’s past medical history was significant for hypertension, diabetes, myocardial infarction, coronary artery bypass grafting, congestive heart failure, and an ejection fraction of 15%, and he was disabled due to his cardiac status. An upper endoscopy was scheduled in a free-standing surgicenter, and the gastroenterologist ordered no cardiac clearance prior to the procedure. He did order a pre-procedural CT chest/abdomen/pelvis, which showed cardiomyopathy with a trace of pericardial effusion and small pleural effusion.

The surgicenter where the upper endoscopy was scheduled required a recent history and physical exam to be submitted two days prior to the procedure. This did not occur as the gastroenterologist brought the information to the surgicenter on the day of the procedure.

The insured anesthesiologist testified that he discussed the procedure with the patient and realized that the patient had not received the 2 days clearance by any other anesthesia provider. However, he did “clear” the patient that day by asking him questions to confirm he was eligible for the upper endoscopy procedure. The pre-anesthesia form completed by the insured identified the patient as a female, and assigned an ASA II physical status classification: indicating mild systemic disease with no substantial limitations.

Shortly after the procedure, the patient became bradycardic and hypotensive. Pulse oximeter reading could not be obtained. Atropine and Dephedrine were administered, and the patient was intubated minutes after receiving the medication. CPR was then initiated, and the patient was transported to the hospital by EMS twenty minutes later. No vital signs were obtained after CPR began. Upon arrival, he was stabilized and sent to the ICU.

Later that afternoon, the patient was found to be in cardiogenic shock; multiple vasopressors were used to treat patient. He continued to deteriorate. The family made the decision to remove the patient from life support and he expired 8 days later.

The case was settled for $1M outside of court.

  • What Went Wrong
  • Chart documentation of post-procedural care was difficult to decipher, and many of the providers had conflicting testimony as to the sequencing of events. Furthermore, the patient did not receive cardiac clearance, and the consent was not signed by the patient. The anesthesiologist also pre-populated the postop record with the patient “having a satisfactory recovery with no anesthesia complications,” despite the patient becoming braindead immediately post procedure. The anesthesiologist also misled the surgicenter by indicating he was board certified, when in fact he was not and had failed the boards twice. It was determined that the patient was over-sedated given his cardiac condition, and he was classified as ASA II when he should have been classified as ASA IV, and the anesthesiologist ignored clear signs of respiratory arrest, failing to move the patient quickly to the hospital.

Key Takeaways:

  • Anesthesia department leaders should always confirm that all staff have obtained the required credentials.
  • Policies/Procedures of surgicenters and hospitals should be enforced, including:
  • Informed consent forms
    Pre-operative clearance
    Appropriate assignment of patient clinical classifications (following protocol for each)
    Confirmation that criteria has been developed for moving patients to a hospital in emergency situations and all staff is educated on these criteria
    Performance of comprehensive history and physicals prior to procedures
  • Physicians and staff should never document events before they occur


For further guidance on this issue, Curi members are encouraged to reach out to our Claims and Risk Management Departments at 800.662.7917.


Janet McCrossen, BSN, RN
Janet McCrossen is a Curi Risk Consultant, based in Philadelphia, PA.

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