Jan 17, 2016
Morbidity and mortality (M&M) rounds have historically provided an excellent opportunity for physicians to learn from adverse events, misdiagnosis and therapeutic misadventures. The below reanalysis of a previous presented case, highlights the shortcomings of single specialty peer based review. The AHRQ does a superb job promulgating cases and commentaries following a traditional M&M format. A case was presented and an expert clinician commented.
The following synopsis is provided
A 66-year-old man presented with worsening subacute abdominal pain. He reported relatively mild abdominal pain for the past 2–3 weeks, which was described as in his "mid-abdomen and crampy." The previous night he developed severe mid-abdominal pain that did not radiate and did not remit. He had never experienced abdominal pain of this severity. He reported no nausea, vomiting, diarrhea, fevers, chills, weight loss, or night sweats. On initial evaluation, the patient had stable vital signs, a tender abdomen without rebound or guarding, and unremarkable laboratory test results. A CT of his abdomen/pelvis noted mild dilation of the ascending, transverse, and proximal descending colon with associated air-fluid levels in the ileum and a possible "transition point concerning for stricture/mass or physiologic peristalsis." Because the patient appeared well, he was admitted to the medicine (instead of surgery) service for observation, pain control, and serial abdominal exams. Surgical consultation was not requested at time of admission. Approximately 48 hours into the hospitalization, the patient's abdomen became more distended, with increased abdominal pain and tenderness with rebound on exam. A surgical consultation was requested. After the surgeons reviewed the imaging and performed a physical examination, they took the patient urgently to the operating room, where an obstructive mass with associated perforation was noted. The patient had a prolonged postoperative course with intra-abdominal infection before ultimately dying.
A thorough clinical discussion by the expert surgeon followed the case.
As a patient safety analyst and radiologist several additional points, nonsurgical in nature, should be raised.
The radiology report is at a minimum nonspecific and not clear. A transition zone is the sine qua non of obstruction. If present, a patient with obstruction should be managed by a surgeon. The differentiation between peristalsis and a mass or stricture is critical. At no time was a repeat study, colonoscopy or laparoscopy to further evaluate the ambiguous finding explored. The radiologist could have recommended any of these in the report. A second radiologist over read was not requested. Multiple opportunities to alter the outcome were missed.
A systems solution adopting a protocol that all abdominal patients should be seen at admission by a surgeon is prudent. Any plan requiring serial exams should have a meaningful baseline by a surgeon. Hospitalists and internists are more than capable to manage patients with abdominal pain but surgical oversight is often desirable. When a surgical intervention ultimately is mandated, the surgeons always ask why there were not consulted earlier.
Organizational opportunities to address the management of abdominal pain and radiology reports that need further clarification are present in the case. The laboratory follow-up, nursing notes, physician notes and request for consults were not assessed. A detailed RCA warrants contribution by a multidisciplinary team who can bring many areas of expertise to the analysis.
The reason I am providing a second review of this case is to highlight the inherent weaknesses of single specialty traditional M&M. While the consulting expert brings superb clinical analysis there is no system analysis and no complete root cause analysis (RCA). A comprehensive nursing, radiology, medicine, ER, IT and systems analysis would bring multiple additional experts to the process. In the future the results of a multidisciplinary RCA should be presented with the expert peer review at all M&M conferences. When a tragic premature death is experienced, a comprehensive system based analysis is what we owe ourselves and future patients.
Nicolas Argy, M.D., J.D.Health/Business Consultant/Educator, Patient Safety, Quality, Risk Management, Public Health Advocate, Witness Prep