Practice of colorectal surgery opens numerous vulnerabilities
- • Failure to timely diagnose disease: eg, colorectal
cancer is the second most common type of cancer cited in malpractice
- • Sphincter injury with fecal incontinence after
anorectal surgery or midline episiotomy.
- • Failure to offer continence-preserving procedure.
- • Iatrogenic medical complications/death
during diagnosis or treatment.
- • Sponges/instruments left in the patient.
- • Iatrogenic organ injury of nontarget structures
(eg, colon, small bowel, ureter, major vessels, spleen, vagina).
- • Lack of informed consent regarding extent or risks
Specific challenges to physicians cited in malpractice cases
- • Type or sequence of diagnostic procedures,
eg, failure to recommend colonoscopy.
- • Missing or insufficient documentation for medical
rationale to recommended treatment, patient education, follow-up.
- • Lack of follow-up on test results, initiation
of follow-up tests (eg, after incomplete colonoscopy).
- • Lack of communication.
Risk of lawsuit can never be completely eliminated but can be
dramatically reduced, if the outlook of success for the plaintiff
is lower, due to the fact that systematic preventive steps are undertaken:
- 1. To reduce misconceptions,
- 2. To follow recommended medical
- 3. To adhere to excellent documentation
in the chart, informed consenting process, and documentation of
refusal to undergo recommended test/procedure.
Delays to Prompt
Diagnostic Evaluation in Patients with Symptoms
- • Routine screening not recommended.
- • Routine screening recommended but not scheduled.
- • Diagnostic test recommended but not scheduled.
- • Diagnostic test scheduled but not performed.
- • Ordering or follow-up of screening or diagnostic
procedures not documented.
- • Inadequate evaluation of abnormal findings.
- • Failure to convey to patient the importance of
keeping test and follow-up appointments.
- • Multiple providers for the same patient fail
to properly communicate important information.
- • Patient not notified of test results.
- • Informed refusal not documented.
- • Important clinical information missing from clinical
- • Adequate documentation of current history
elements; clarification of patient’s vague terminology
(eg, “occasional,” “frequent”) → reduce
misinterpretation of self-reported symptoms.
- • Key statements must be documented by selected
outside medical records, eg, pathology report (cancer, IBD), colonoscopy
report (clearance of rest of the colon), operative notes (definition
of anatomy, problems/adhesions during previous surgeries),
- • Amendments to existing chart/medical
record: if an addendum is absolutely necessary, it should be made
after the last entry, noting current date and time, with both entries
cross-referenced. Inappropriately amended medical records render
a case indefensible if plaintiff’s attorneys demonstrate
in court that the note was written or typed after the fact. No addendum
in anticipation of claim or legal action.
- • Medical record: “what is not documented
has not happened” → record should
reflect in appropriate detail what was done for patient and demonstrate
quality of care given → provide defense
against allegations of inadequate care.
with Patient or Family
- • Document all phone conversations, including
those in which compliance issues are stressed.
- • To ensure that screening tests are performed:
schedule before patient leaves office, or at least document discussion
with patient of the recommendation for the test.
- • Document all follow-up efforts to reach patient
or to reschedule a test/procedure.
- • Document discussions/conversations with
patient and witnesses about recommended action, risks and benefits
of proposed testing, as well as alternatives.
- • Document patient’s refusal to undergo
recommended test or lifesaving procedure, preferably on a specific
informed refusal form signed by patient.
- • Make it a routine for high-risk patients who fail
to keep appointments or when responding to phone calls to reschedule:
- – To use a form for tracking details.
- – To contact them by registered mail (with return
Obtaining the patient’s accurate and detailed history
is the most important tool to direct the subsequent examination,
to create a list of possible differential diagnoses, and eventually
to establish the final diagnosis without wasting valuable resources.
It is further crucial in tailoring the best choice among various
treatment options to the patient’s individual situation.
Preferably, the history is taken from the patient, often from accompanying
individuals (family, translators, referring physicians): risk of “loss
Particularly in colorectal surgery, it is a high art to take
a patient’s history in an unprejudiced, sensitive, but
nonetheless thorough manner. Efficient questioning consists of a
problem-oriented focus and systematic expansion of areas, depending
on the responses. It is advantageous to start by letting the patient
describe the key symptoms in an open end–type narration,
which is subsequently complemented with specific problem-oriented
questions. Even in “simple” cases, a systematic
checklist of relevant background information should be followed
to ensure a complete context and hence avoid legal glitches.
- • Rectal bleeding: amount, color (bright red
vs dark red), onset, pattern, mixed into the stool, triggering factors,
- • Discharge: quality, associated symptoms, etc.
- • Pain: location, onset, pattern, triggering factors,
- • Itching: hygiene habits, incontinence, discharge,
medications applied, etc.
- • Prolapse: what, how much, where? Spontaneous or
manual reduction, nonreducible?
- • Lump/mass: always there or protruding
with bowel movements, pain?
- • Bowel movements: stool quality, sudden change
in bowel habits, complete/ incomplete evacuation, necessary
- • Incontinence: stool, gas, urine.
- • Nausea/vomiting, weight loss, fevers/chills.
- • ...
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