miscommunication among surgical team results in patient blindness

In the past, our blog has discussed how studies have routinely shown how relatively simple steps such as surgical checklists, pre-surgical huddles and even concerted efforts to maintain communication among surgical team members can drastically reduce the incidence of operative errors.

While these types of steps may seem redundant to the average person, the simple reality is that it is absolutely imperative for surgical team members — from surgeons and anesthesiologists to nurses and technicians — to make sure they are on the same page before, during and after the procedure, as the failure to do so can result in a potentially disastrous outcome for the patient.

By way of illustration, consider a recent medical malpractice case out of North Carolina where a simple communication breakdown among surgical team members resulted in a patient going blind in one eye.

According to the facts of the case, a man was undergoing cataract surgery on his left eye at a North Carolina hospital back in 2008.

Here, the surgeon performing the procedure asked for a member of his surgical team to procure VisionBlue, a dye that is used stain the cataract for safe removal. However, rather than secure the requested ophthalmic dye, the nurse instead secured a bottle of methylene blue, which is a dye used mostly in intestinal surgery and known to be toxic to the eyes.

Unfortunately, the incorrect dye was passed from the nurse to a surgical technician, who in turn passed it to the surgeon who placed it into the patient’s eye.

The resulting damage from the use of the methylene blue was so great that both an initial corrective surgery and full corneal transplant proved ineffective. The patient ultimately went completely blind in his left eye.

During the course of the trial, both the nurse and the surgical technician testified that they announced the methylene blue, while the physician indicated that he heard nothing to that effect.

The jury ultimately sided with the plaintiff, awarding him close to $2 million for all the harm he was forced to endure.

While the outcome of this legal matter was entirely warranted given what transpired, it also underscores just how important it is for surgical teams to be in constant communication and introduce the necessary safety protocols.

Remember if you or a loved one have suffered unnecessary pain and suffering due to a surgical error here in Pennsylvania, consider speaking with a legal professional to learn more about your rights and your options for pursuing legal action.

Source: Outpatient Surgery, “Drug mix-up blinds patient, spurs malpractice verdict,” Jim Burger, Aug. 22, 2014

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