Clinical AdvisorScheduling Error and Communication Failure Result in Infertility

A 36-year-old infertility patient underwent hysteroscopy with endometrial ablation instead of polyp removal due to scheduling errors and inadequate informed consent processes. The hospital’s nurses failed to explain the procedure in plain language, allowing a fertility-ending surgery to proceed despite multiple verification opportunities. The appellate court reinstated the case against the hospital, emphasizing nurses’ independent duty to ensure patients understand procedures beyond obtaining signatures.

⚖️ Professional Impact Points

• Informed consent requires verification beyond signature collection: Nurses must confirm patient comprehension in lay terms, not simply witness consent forms, creating shared liability between physicians and facilities.
• Electronic health record reliance without chart review creates vulnerability: Physician entered procedure order based solely on hospital system data rather than patient records, missing the scheduling discrepancy.
• Preoperative timeout protocols demand procedure confirmation with patient: Failure to verbally verify the planned surgery with patient before proceeding eliminated final safeguard against wrong-site/wrong-procedure error.
• Documentation changes post-procedure raise red flags: Physician’s alteration of operative notes 9 days post-surgery to reflect intended rather than actual procedure complicates defense and suggests awareness of error.
• Scheduling communication gaps between office and hospital systems require redundant verification: Phone-based scheduling without written confirmation or read-back protocols allowed procedure name corruption during data entry.

🏥 Practice Management Considerations

• Documentation Strategy: Implement verified read-back protocols for all surgical scheduling with written confirmation sent to ordering physician; maintain contemporaneous operative notes without post-hoc alterations that undermine credibility.
• Patient Communication Protocols: Require nursing staff to explain procedures in plain language during consent process (e.g., “this destroys uterine lining and ends fertility” rather than “endometrial ablation”); train reception staff to provide procedure verification sheets at check-in.
• Legal Risk Assessment: Wrong-procedure cases carry significant liability even with signed consent forms when informed consent process is inadequate; appellate court ruling establishes nurses’ independent duty to ensure comprehension creates facility exposure.
• Staff Training Requirements: Educate surgical schedulers on critical procedure verification steps; train perioperative nurses on lay-language consent confirmation requirements that go beyond form completion.

HCN Medical Memo
Review surgical scheduling workflows to eliminate single points of failure—implement electronic confirmations with procedure name verification by ordering physician before hospital entry. Mandate preoperative huddles where nurses confirm procedure details with patient in non-technical language, documenting patient’s understanding. Consider wrong-procedure sentinel event protocols even for near-misses to identify system vulnerabilities.