Medical Professionals Reference (MPR)Multiple Physicians Sued After Patient Mistakenly Cleared for Surgery

This malpractice case demonstrates critical failures in perioperative communication when multiple specialists cleared a high-risk patient for elective surgery despite documented respiratory concerns. The patient died from postoperative hypoxia, with autopsy revealing undiagnosed sleep apnea and undertreated asthma as contributing factors.

⚕️ Key Clinical Considerations ⚕️

• Respiratory risk stratification failed. Patient had obesity (BMI 42), possible sleep apnea, and asthma, yet no formal pulmonary evaluation was obtained before proceeding with airway surgery.
• Communication breakdown occurred. Cardiologist explicitly documented concerns about respiratory status as primary risk factor, but this information wasn’t acted upon by surgical team.
• Pre-anesthesia assessment inadequate. Anesthesiologist identified difficult intubation risk but conveyed concerns only verbally, creating no permanent documentation of airway management strategy.
• Surgical clearance process flawed. Multiple physicians assumed others were reviewing and acting on consultative recommendations, leading to collective oversight of critical risk factors.
• Perioperative monitoring insufficient. Patient with multiple risk factors for respiratory compromise was discharged without appropriate monitoring protocols for sleep-disordered breathing.

🎯 Clinical Practice Impact 🎯

• Patient Communication: Establish clear protocols for discussing perioperative risks with high-BMI patients, ensuring they understand sleep apnea screening importance and postoperative positioning requirements for airway protection.
• Practice Integration: Implement systematic review processes where operating surgeons personally verify all consultative clearances before proceeding, rather than delegating this responsibility to surgical centers or anesthesia teams.
• Risk Management: Develop mandatory sleep study requirements for patients with BMI >40 undergoing airway procedures, and establish formal pulmonary consultation protocols when respiratory concerns are documented by any team member.
• Action Items: Create standardized documentation requirements for all pre-anesthesia assessments, mandate written communication of airway concerns, and establish interdisciplinary sign-off processes for high-risk surgical candidates.

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