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The Danger of Relying on Others to Review Meds Before Surgery

Hospitals and surgery centers operate with a number of individuals taking responsibility for a variety of tasks. A surgeon’s reliance on others, however, for the pre-surgery review of medications can expose a patient to catastrophic injury.

A 78-year-old retired chemical engineer was referred to Dr. PM, an interventional pain management specialist, for neck and left shoulder pain that she had been experiencing for several months. On the patient’s initial visit, Dr. PM noted that she was taking furosemide and insulin for diabetes but that she had no history of ischemic heart disease, MI, hypothyroidism, or cancer. On examination (and with the benefit of MRI images taken the previous month), Dr. PM diagnosed a left paracentral disc herniation with C6 radiculopathy. The patient denied any history of heart problems, stroke, or blood thinners to both Dr. PM and to his assistant. Dr. PM and the patient planned for a cervical epidural procedure to shrink the disc. The surgery center where the procedure was to be performed had a protocol for a pre-operative clearance, but such clearance was not pursued.

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When she arrived at the surgery center a week later for her procedure, the patient presented a printed list of her current medications to the staff. Using that information, the surgery center nurse listed “clopidogrel 75 mg” as a “blood pressure” medication. (Clopidrogrel is the generic name for Plavix, a blood thinner.)

Though Dr. PM did not review that day’s intake records, he asked the anesthesiologist if there was anything he should be aware of and was informed “no.”

With the patient under Propofol, Dr. PM performed the cervical injection using Marcaine and a solution of Decadron and Celestone under fluoroscopic guidance. He noted severe foraminal stenosis at C6 on the left side of midline but no complications at the time of the procedure.

Some 30 minutes after arriving in the post-operative care unit, the patient was awake and complaining of severe pain and shoulder numbness. She was advised that the numbness was normal.

Less than an hour later, however, the patient complained that “something was not right” and that the numbness had moved to her legs. About 30 minutes later, the patient’s anxiety triggered a call to Dr. PM, who arrived with the anesthesiologist. The patient received valium and an oxygen mask and began to rest comfortably, but later that day, she complained of pain and numbness in her legs. She refused Percocet and by early evening, Dr. PM requested a transfer to a local hospital ER, where she exhibited flaccid paraplegia.

By mid-evening, the patient reported no feeling from her trunk down to her legs and an MRI revealed a large epidural hematoma that was causing significant cord compression. An emergency laminectomy and evacuation of the hematoma by her new healthcare team did not prevent the patient from developing paraplegia. During that time, a previous hospitalization for stroke came to light.

The patient and her husband filed suit against the woman’s healthcare providers. Dr. PM, who had apologized to the patient when he discovered that she was taking Plavix, passed away before the litigation against him was resolved informally.

Whether other healthcare professionals should recognize certain risks to a patient and share that knowledge with a surgeon does not detract from those responsibilities on which the primary treater must gain assurance independently. Add in such factors as a patient’s advanced age and a surgeon’s lack of a significant history with a patient, and the risks of relying on others for key information can become acute.


Gordon Ownby is CAP’s General Counsel. Comments on Case of the Month may be directed to