A fall from the surgical table

January 29, 2008

An unfortunate event in the OR, and the physicians in the room – two residents – are sued. Was it their fault?

Moments after undergoing surgery to replace a broken hip, an 86-year-old Dorchester woman fell from an operating room table at Boston Medical Center, causing a massive head injury that killed her a week later, her family said in a lawsuit filed yesterday.

[The patient] fell, buttocks first, through a gap in an orthopedic surgical table on Oct. 6 after a nurse removed a safety strap around her torso as medical staff prepared to transfer her to a hospital bed, according to an investigative report by the state Department of Public Health.

[The patient], who was still under anesthesia and had a breathing tube in her mouth, struck her head on the floor, fracturing her skull and causing internal bleeding, said the Health Department report. She died Oct. 13 despite a second operation that removed part of her skull to relieve pressure from the bleeding.



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{ 10 comments }

1 Anonymous January 29, 2008 at 10:19 am

If the doctors aren’t responsible for the care of the patient, who is?

2 Anonymous January 29, 2008 at 10:40 am

When will people realize that you can’t prevent everything from happening! Unfortunately, it seems that they are just looking for money. And we all know that’s going to make her death that much easier to deal with :::eyes rolling:::

3 Anonymous January 29, 2008 at 11:39 am

Its interesting that the ortho and anesthesia attendings were not named in the suit.

This should remind us that the courts consider residents real physicians with real responsibilities – even if the academic medical establishment treats them like cheap servants.

4 SarahW January 29, 2008 at 12:27 pm

Anon 2:40. It is a wild leap from “you can’t prevent everything from happening” to “you can’t prevent THAT from happening”.
Neglect of the patient led to her demise.

Money can’t return a relative, or undo suffering. It’s a literal price for the suffering and loss caused however, and an incentive to handle patients with the appropriate degree of care.

From the article –
” the hospital did its own “root cause analysis” and determined that the doctors and nurses in the operating room were preoccupied with their own tasks and that the “removal of the . . . safety belt from the patient was not verbally communicated.”

The hospital has adopted a protocol requiring all nurses and doctors put their hands on the patient before removing the safety belt and making sure that there are people on both sides of the table.”

Since the patient was near the end of her days, the wrongful death suit will have lower value. Damages for her own suffering don’t extinguish with her death, however, and the circumstances of the death were terrible and avoidable.

The physicians were present and still responsible for her proper care – and could have assisted her not falling through the table. Assume they were not and examination of the facts would exculpate them – it is still the attorney’s duty to name them in order to investigate their cuplability.

5 Anonymous January 29, 2008 at 1:21 pm

Picture of orthopedic operating tables.

Is one of the above tables probably what was used in this case? Does anyone have a better picture?

6 Anonymous January 29, 2008 at 4:56 pm

As an anesthetist and RN there is no doubt who was responsible and that is the OR nurses. It is both their responsibility and job description to keep the belt in place and monitor the patient once it is removed until they are safely on the stretcher. This has nothing to do with anyone else.

7 Anonymous January 29, 2008 at 7:40 pm

I’m astonished that that the patient isn’t being blamed here.

I think that that safety issue is most directly the responsibility of the nurses, but legally, as they are under physician supervision, the case for resident repsonsibility can be made–but I don’t know any OR nurses taking orders from residents on how to do their jobs.

At a practical level, I think that the residents bear at least some responsibility–if they were in the room still, what were they doing if not attending to the patient and putting out a hand to stop her from falling shouldn’t be too much to ask.

8 ArmyGas January 29, 2008 at 11:10 pm

I would disagree with one of the previous comments, I believe that each person in that situation will bear some responsibility.

9 ArmyGas January 29, 2008 at 11:13 pm

I have to disagree with one of the previous comments, I am a CRNA and I believe that each person in that situation will bear some responsibility.

10 Anonymous January 30, 2008 at 1:12 pm

Surely there’s a Korean dry cleaner they can name.

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