A system analysis of a suboptimal surgical experience

Table 1 Incidents that occurred during the process of care

Step in process	Department	Incident	Outcome
Preoperative assessment	Surgery/Urology	Failure to warn or notify patient to stop gabapentin*	Hemorrhage, purpura (after surgery)
Surgery	Surgery/Urology	Failure to stop bleeding	Hemorrhage, swelling, pain, worry
		Failure to install drains	Swelling, pain
Post-operative process	Emergency	Failure to be seen by physician	Delay, swelling, pain, worry
		Failure to call urology resident	Delay in being seen
		Failure to triage and to recognize ongoing bleeding	Near syncope
	Surgery/Urology	Lack of beds	Waiting without supervision (risky for many reasons)
	Emergency, Surgery/Urology	Inexperienced residents recommending overly conservative "watch and wait"	Continued swelling, purpura, pain, worry
		Attending not seeing patient	Expert assessment not provided
Second preoperative assessment	Surgery/Urology	Released without being seen	Expert assessment not provided
Second surgery	Anesthesia	Failure to warn or notify patient to stop gabapentin	Longer recovery
	Surgery/Urology	Inexpert IV insertion	Hemorrhage, purpura (in arm)
		Long wait for surgery	Swelling, pain, worry

*Note that gabapentin can increase vasodilation and purpura in 1% of patients. The health system of interest appropriately asks patients at multiple points in the process of care as to what medications they take; however, there was never a suggestion that the patient should stop taking this drug.

ISSN: 1754-9493