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The patient underwent the decompression surgery. However, imme-
diately after surgery in PACU, she complained of a severe headache
and neurological changes. She was repeatedly given a narcotic to help
the pain, but continued to show a decline in her neurological status.
Eventually a CT head scan was ordered demonstrating an intraven-
tricular hemorrhage resulting in an obstructed fourth ventricle and
hydrocephalus (water on the brain). She underwent another emer-
gency surgery, but now permanently suffers from weakness in her left
arm and leg, numbness, and other neurological problems.
An expert evaluation of the case found that the patient was only
given a routine pre-op evaluation — despite the concern about her
known history of a high-risk coagulation disease — and no pre-op
hematology consultation or proper clearance was obtained. Instead, it
was discovered that the clearing anesthesiologist, who received only a
portion of the patient's hematology charts, reviewed only the informal
and outdated handwritten note in the margin of the flow sheet. Based
solely on this note, which did not clear the patient for the specific
neurosurgery planned, the doctor went forward with surgery without
any precautions.
In deposition, the hematologist said that the note in the margin was
not her final opinion and that the patient needed further testing. Most
critically, the hematologist said that if the hospital and doctors had
contacted her to clear the patient for the planned surgery, she never
would have given them the OK to proceed.
The importance of a written clearance
Unfortunately, this scenario is an all-too-common occurrence.
Miscommunication often happens because patients are made
responsible for collecting their own records or clearances from
