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Outpatient Surgery E-Weekly

Contact Congress Over Drug Shortage Issues

A Kentucky congressman is urging surgical facilities to contact their members of Congress and request that they sign his letter demanding changes to...

N.J. Posts ASC Inspection Reports Online

State and federal inspection reports of New Jersey's ASCs are now available online, giving patients an opportunity to make more informed choices abo...

Are Opioids Necessary?

While it's not always practical, or even possible, to eliminate opioids from your post-op pain management regiment, reducing their use in favor of n...

Archive > February, 2010 Vol. XI, No. 2

Medical Malpractice

Epidural-to-Spinal Switch Spells Disaster

Sharon Smith, RN, JD; and Tyler Smith, JD

When the one hand doesn't know what the other is doing in the OR, disaster can strike. In this month's case, an 87-year-old woman recovering from successful knee replacement surgery was plunged into a drug-induced vegetative state because her anesthesiologist didn't bother telling the surgeon or the nursing staff that he changed from epidural to spinal anesthesia and that he left the unmarked spinal catheter in place in case additional pain medication would be needed later. He noted these facts in the patient's chart, but didn't communicate them to the people in the room.

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CRNA; Marking; Sympathetic; accepted; actions; active; additional; adequate; administer; administered; administering; admission; admitted; adult; adverse; ages; anesthesia; anesthesiologist; anesthesiology; anesthetic; anoxic; apologized; approximately; argued; arrest; arrhythmia; assumed; attending; awarded; bed; began; believed; birthday; blame; bolus; bother; bothered; brain; call; called; cardiac; care; case; cath-eter; catheter; catheters; caused; change; changed; chart; check; children; choice; claim; code; communicate; complain; complicated; conduct; consented; consistent; contacted; critical; criticized; dancing; dangerous; days; death; decedent's; defendants; defense; diagnose; died; directly; disaster; documented; doses; drug-induced; due; employed; ensure; epidural; evidence; exceeded; exercise; expert; extensive; faced; facilities; facility; fact; failed; failure; family; felt; figure; found; friends; group; hand; held; honored; hospital; hour; hours; including; increased; influence; infusion; interests; intubated; involvement; issues; jurisdiction; jury; knee; large; leading; leaving; led; left; letting; liberal; life; lived; living; longer; made; make; manage; manner; marked; marking; medical; medication; members; million; minutes; mistake; monitored; monitoring; month's; needed; negligent; noted; noticed; noting; nurse; nursing; operation; order; ordered; orthopedic; outcome; overlapping; pain; parties; patient; people; period; perioperative; photos; place; plaintiff; plaintiffs; playing; plunged; policies; poor; post-operative; practice; presents; proceeded; progress; proper; protocols; provider; rate; recognize; recognizing; records; recovering; reflect; reflected; refrain; removed; replacement; require; requiring; respiratory; responsible; returned; review; revised; room; ropivacaine; service; settle; settlement; severe; shared; social; space; spinal; spine; spread; staff; standard; state; strongly; successful; sued; suffered; support; surgeon; surgery; survival; sympathy; talking; team; telling; terms; test; testimony; time; timely; treat; trial; type; ultimately; unanimously; unaware; undisclosed; unmarked; unmonitored; vegetative; vicariously; wait; woman; wrongful

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