Exempt from public disclosure pursuant to offline a. § 13 cf. PAA. § 13, first paragraph. 1
Termination of supervision
Norwegian Board of Health has concluded that you have violated acceptability requirements of the Health § 4. However, we have not found it necessary to give you a warning.
Procedural process
Norwegian Board of Health received by letter dated XXXXXX from the County of XXXXXX submitted a supervision about your activities of physicians . Audit case concerns an operation you performed the XXXXXX XXXXXX on, born XXXXXX.
We oriented you by letter dated XXXXXX that we would consider giving you a warning. You stated you to this by letter dated XXXXXX.
We also considered whether XXXXXX has broken acceptability requirements of Specialized Health Services Act § 2-2, and declared our decision is attached.
The subject matter
You are educated in XXXXXX and received authorization as a doctor in Norway the XXXXXX, HPR no. XXXXXX. At the time of the incident were you doctor in specialization at XXXXXX.
XXXXXX (hereinafter referred to as the patient) have the lawyer XXXXXX, in a letter of XXXXXX to the County of XXXXXX complained that she should have been subjected to rough medical errors by XXXXXX.
The sequence of events
Below explanation of the current course of events as specified in the complaint, the patient’s note submitted in letter of XXXXXX to Norwegian Board of Health, your statements of XXXXXX and XXXXXX and journal notes. Norwegian Board of Health has considered the matter on the basis of the above documentation.
The patient contacted XXXXXX legesenter the XXXXXX, because she had growing pains after receiving incidert one anorectal abscess at XXXXXX some days earlier. Upon arrival the medical center she had an abscess in the right buttock. According to the doctor who examined her she was hasty injected into the skin prevalent in the buttock, and had an elongated abscess more central. Abscess was so big and widespread that the doctor believed it should incideres under anesthesia and entered drain afterwards. The patient was referred to the surgical ward, XXXXXX for treatment.
The patient was hospitalized at XXXXXX same day. Shifts doctor who accepted her, wrote in the journal XXXXXX that admission diagnosis was “ Anorectal abscess ” and that the patient had received incidert one perianal abscess at XXXXXX. It was further disclosed that she had increasing pain and swelling in the right seat of the ball. It does not appear admission journal about shifts doctor examined the area in question, but it says that tertiary guard examined the patient. Tertiary Guard (Chief XXXXXX, our note) wrote no medical record for the survey. It was planned incision and drainage of abscess same day. According printing operation program was the patient reported to the surgery department for drainage diagnosed with “ Perianal abscess .”
According to a report from the patient she came to the surgical ward lying on his stomach, because she was in pain if she had to lie on his back. Surgical nurse believed that the patient would lie in leg supports under the procedure and asked the patient lie on his back before anesthesia was initiated. Patients should have protested at this when she thought that it was not possible to reach the abscess if she were placed in regular gynecological rent. The patient, however, was placed on his back, placed under general anesthesia, and made ready for operation.
According to your statement did you get along with Chief XXXXXX at a trauma when it got a call from shifts doctor, and you agreed that superior should inflow patient with turnus. You show that you are LIS (doctor in specialization, our note) in orthopedics and that it was therefore natural that Chief XXXXXX examined the patient. You hit superior bit later and received verbal information about the abscess and what should be done. You were told that if you needed help, could consultant XXXXXX come on very short notice.
You describe that you missed to inflow patient before you were called up to the surgery department with the message that the patient lay in narcosis and was ready for operation. You read nor patient file. You had, according to your report, gained an understanding that it would operate one perianal abscess. In operation description of XXXXXX described you therefore that you expected to find it so patient lying; supine and leg supports. You saw a filling on the left side of the anus and palpated this without finding particular masses or clear flushing of the examined area. However, this was the only area that could be described as an abscess, and you inciderte therefore this. It can be seen as the operational description that you tried to palpate pus-filled pockets without success, you entered corrugated drainage and sutured this firm.
As the patient awoke from anesthesia, so the patient was very red on the right buttocks and that abscess sat there. The medical records and your statement stated that you explained to her that she had been incidert at fault localization. The patient still had severe pain from the area because of the abscess. You conferred with Chief XXXXXX. Then the patient was placed under general anesthesia again and superior came to the operating room and inciderte the correct abscess.
In your explanation you indicate that despite the fact that you know you may have difficulties in remembering this period directly after general anesthesia, you chose to inform the patient about what had happened. Patients should have replied clearly that she just wanted to get rid of the problem and you claim this can be confirmed by anyone who was in the operating room. You were fully clear that the patient probably would not remember the conversation, but felt it was appropriate to inform her considering how alert she appeared. The patient appeared to be awake and pain affected, and you perceived that the patient consented to a new intervention. She was in advance informed about what should be done. Your physician and XXXXXXs assessment was that it would impose an additional load on the patient to wait until the next day for a new intervention. She also had elevated infection parameters because of its abscess, and you said that it was medicine academically irresponsible not to perform the scheduled procedure correctly. Postoperatively, there were over XXXXXX which oriented the patient about what had happened and plans for further follow-up.
According to the patient’s explanation, she can not remember that she got this information or that she agreed to that last procedure. She got in the wake of the two interventions information about what had happened.
The patient was discharged XXXXXX. Of discharge summary states that the final diagnosis was ischiorektal abscess.
You state that this is a result of a mistake made by you. Because of parallel events sow not patient before she was sent to surgery. In retrospect, you can see that you should have demanded that the patient should be identified and examined by you, also because the place where you first inciderte probably would given the symptoms that was communicated to you. Did you add the patient before she was taken into the operating room, you would probably have wanted patient in another deposition than in the leg supports. Had you read referral letters from the emergency room, it says specifically where she had an abscess on the right buttocks.
Statement from the business
Clinic Director XXXXXX and health care adviser XXXXXX has XXXXXX explained XXXXXX its procedures for preoperative evaluation, how patients are reported to the surgery, using the checklist “Safe Surgery” and ensuring patients’ right to information and participation preoperatively and during treatment.
Preoperative assessment:
Management finds that the system of supervision by you as an operator in this case has failed something and should have been done differently in that tertiary guard with you as secondary duty had seen the patient together. Furthermore, reference to it in the report to ward is informed that the patient would get drained one perianal abscess. From whom and how this information has accrued surgical ward is not clear.
Message to operational tin holds:
According to the report from clinic manager are no written procedures for notification of patients to a surgical intervention. Clinic Director considers the lack of procedures as a system failure.
Safe Surgery:
Clinic Director notes that the checklist for “Safe Surgery” according to records documentation was used. It emerges, however, now in retrospect that Checklists first column, first and second classified; Preparation before induction of anesthesia, not implemented entirely as intended.
Marking of operation field is implemented in practice in all interventions except gynekologiske- and rectal / anal. It has been discussed various options to do this by this kind of intervention, but unfortunately did not have this discussion led to written procedures. Clinic Director believes this is a strong contributing factor to that in this case was committed an error.
clinic management has realized that the incident has revealed systemic failure in several areas both in terms of a message to the operation, marking of surgical patients and a clearer division of responsibilities in the preoperative preparation. Management believes, however, that this does not relieve you as an operator from the requirement for an independent investigation and information gathering, but that you’ve been put in a very unfortunate situation on the basis of many unfortunate factors. Management also points out that you, once the error was committed, has admitted and apologized for the inconvenience.
Legal basis for assessment
Information in supervision by the case to consider whether you have acted in contrary to the requirement of proper business in Health § 4, first paragraph:
health professionals must perform their work in accordance with the requirements of professional responsibility and diligent care that can be expected based on their qualifications, the nature of work and the situation in general.
The Health § 4 is a central provision. The provision requires professional responsibility and diligent care and health professionals’ professional practice.
What is justifiable is determined by an assessment of each case, and how health workers ideally should have acted.
We also assessed whether the patient’s right to consent to medical care in patient and user Rights Act chapter 4 is broken.
The individual health personnel’s duty to proper professional practice must be seen in connection with the duty health has to prudent operations, see Specialist Health Service Act § 2-2. The requirement to soundness in service legislation imposes a duty of business organization and establishment of practices and procedures that ensure adequate health services. The duty also means that the business owner and management has the responsibility to create conditions so that the individual health professionals to perform their duties in a proper way.
Norwegian Board of Health review
Norwegian Board has considered whether your patient management was prudent. To take a position on this, we have considered the following:
- The treatment that was given during the first procedure.
- Information for the patient and obtaining consent before the second surgery was completed.
1. The treatment was given during the first procedure
An indication of good practice
It is in line with good surgical practices that whoever shall conduct an operation, talking with the patient in advance and possibly also examines patient. This is to ensure that you know what to do, and that the patient understands the surgery. In practice, however, so that this is not always feasible. Then it is important that the person who will operate orient themselves thoroughly about what should be done by surgery. In this context, competent surgeon orient themselves in the register and request reports from other colleagues, primarily from the examining and talking with the patient.
In cases where the surgeon first come to the operating room when the patient is placed in narcosis, he must ensure that it is right patient lying on the operating table. If the patient has a marked operative site concerned must ensure that it is also in the area where the operation uncovering added. Abscesses in the skin around the anus or external genitalia is usually easily visible. There will be swelling and redness in the area as well as a fluctuating masses characterizes that it concerns an abscess. If such findings can not be identify when the operation is to be started, the operator must reconsider whether the diagnosis is correct, alternatively if the abscess is sitting somewhere else. If there are doubts about how it will be operated or what to do should the competent physician summon an experienced colleague or whoever has examined the patient preoperatively.
Abscesses around the rectum may have different localization, but is in most cases visible upon inspection of the surface. There can be a fistula from the abscess to the skin which can also be identified. For some women, it may be a low perineum (between the meat) that allows the distance between the anus and the vagina is short. Birth defects with scarring may therefore extend down toward the rectum and by examination, there may be thickened areas in the perineum. Sometimes these can be tender and therefore it may be difficult to assess whether there actually is an infection, or whether it solely revolves around scar tissue.
Surgical treatment of abscesses is incision and ensure good drainage .
Review
When you arrived in the operating room the patient was under general anesthesia, placed in gynecology and covered in terms of incision of perianal abscess. You had received oral report from the superior who had examined the patient. Norwegian Board of Health do not know exactly what information you received about the patient and the localization of abscess, but superior who informed you have stated that he gave the message that the patient should be reported to the surgery with a diagnosis of “ perianal abscess “. Same diagnosis was used in anesthesia form.
When you arrived in the operating room should you, after having ensured that it was the right patient lying on the operating table, having oriented closer to the patient by reading journal . There was an inpatient journal and an admission letter that could give important information. The risk that you had overlooked important information was great as you did not read the registry information. This was especially important because you nor herself had made the preoperative examination. If you had read the journal had you seen information from the admitting physician that the patient had an abscess in the right buttock. It was also disclosed that the patient was “ hasty injected into the skin prevalent in the buttock, and has an elongated abscess more central (…) abscesses are so big and widespread that I have little desire to incidere it here – it should probably be done with proper anesthesia and entered drained afterwards. “ On the basis of this information had you learned abscess localization and appearance. There is a clear deviation from good practice that you are not oriented on the patient’s chart before you would perform the surgery.
Then you would begin operation you saw no obvious signs of abscess in the area, thus no flushing in skin or mucosa. You did however one filling the left side of the anus. At this point you should have thought about the possibility that you had not found the right area for incision. Good practice had been to summon experienced colleague, or whoever had examined the patient, to ensure that you do not inciderte in the wrong area. You did not, however, but inciderte in the filling you could palpate. Norwegian Board of Health considers this departure from good practice.
After an overall assessment, we concluded that the patient received unjustifiable treatment of you by not oriented you sufficiently about the patient’s condition before you started the surgical procedure, and ended up adding incision in the wrong place. This constitutes a violation of the requirement for proper treatment.
Information and consent before the second surgery was performed
There is a requirements for patients and users Rights Act § 4-1, cf. § 4-2, the patient should be agreed before the health care being provided. For consent to be valid, the patient must have received sufficient information about their health status and content of health care. This means that patients must have received adequate information about the purpose, methods, anticipated benefits and potential hazards associated with health care.
There are not enlightened in the matter what information the patient received prior to the first surgery. The complication occurred in that particular case is, however, in our opinion beyond what was foreseeable risks of the intervention, and what the patient would normally be informed. It can not therefore be assumed that the original consent also included reoperation immediately after the first intervention.
You have stated that you understood that the patient was informed and agreed to the new operation, when she was about to wake after the first operation. This despite the fact that you knew that she would not remember anything afterwards. Norwegian Board considers, however, that patient at that time was not competent to give consent because of physical disturbance, ref. Patient and user Rights Act § 4-3.
Health care entailing a serious intervention for the patient, can according to the patient – and use Rights Act § 4-6 given despite the fact that the patient lacks consent if it is deemed to be in the interest of the patients, it is likely that the patient would have given permission for such help and the patient does not object to such care. Where possible must be obtained information from next of kin about what the patient would have wanted.
We would point out that good practice would be to confer with next of kin if this light was conducted. You have explained that you considered it to be the best option for the patient to do another operation there and then rather than wait. The reason for this was that the patient had a lot of pain and it was proven elevated infection parameters in blood. At this time conferred also with superior who then came to the operating room. Based on the information about the patient’s condition, we consider that there was a risk of further complications if you had exposed explant. Exposing reoperation patient was sufficiently alert to be able to provide a new informed consent could have caused additional burden for the patient, both as regards pain problems and a spread of the infection. The patient had consented to the operation that originally was to be implemented and there was nothing in the situation to indicate that the patient did not want the solution that was chosen.
We have not found that the provisions on consent to medical care is broken.
Summary
Norwegian Board of Health has found that you acted recklessly when you are not oriented you sufficiently about the patient’s condition before you started the surgical procedure, which contributed to the incision was placed incorrectly.
After an overall assessment, we have concluded that your treatment of the patient is a violation of the Health § 4.
Assessment of whether you should be given a warning
By violation of Health Personnel provisions we can give warning pursuant Health § 56 which reads:
The board can give a warning to health care professionals who willfully or negligently violates obligations under this Act or regulations issued pursuant to it, if the breach of duty is liable to endanger the safety of health and care services, to inflict patients and users a significant load or to substantially undermine confidence in healthcare or health and care services.
The board can give a warning to health care professionals who have demonstrated a behavior that is likely to significantly impair confidence in the profession.
Warning are individual decisions under the Public Administration.
To give warning is firstly a condition that you have acted negligently. In making this assessment, the Norwegian Board of Health to decide whether you can be blamed. In the assessment, we could focus on if you had action alternatives in the current situation. We find that you had courses of action when you were reading the journal prior to surgery.
Norwegian Board finds on this basis that you acted negligently.
The second condition that must be met is that the action is likely to endanger the safety of health and care services, inflicting patients or users a significant load or to substantially undermine confidence in healthcare or health and care services. It is not essential if the action in the present case actually received such consequences.
Norwegian Board of Health has determined that your actions were likely to cause patients a significant load. Failure to ensure a sufficient degree of patient’s condition, can cause patients not receiving treatment for the condition they have or that they are being subjected to unnecessary interventions, such as this case shows. In our opinion, the action is likely to cause patients considerable burdening
The main terms to give you a warning under the Health § 56 are met. The Board shall make a judgment on whether you should be given a warning. Such assessments are based on the purpose of giving warning that is responding to serious violations of Health. The reaction will help to promote quality in health, patient safety and help prevent future breach of duty.
In this case we found that XXXXXX had inadequate routines / procedures and that this has been a contributing factor to treatment was indefensible. You further acknowledged the breach of duty retrospectively and shown that you have insight into the mistakes you made.
Norwegian Board finds after an overall assessment that it is not appropriate to give you a warning.
Conclusion
Norwegian Board of Health finds that you have violated the Health § 4, but we have not found it necessary to issue a warning. Supervision The case against you is with this end.
Sincerely
XXXXXX XXXXXX
XXXXXX
XXXXXX
The letter is approved electronically and sent therefore without signature
Copy to:
Attorney XXXXXX XXXXXX
> County of XXXXXX XXXXXX
Police
Legal officer: XXXXXX
Health Academic coordinator: XXXXXX
Other letters in the case
Decision – termination of supervision – breach of duty for Specialized Health Services Act § 2-2 Letter to Health trusts in case
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