A patient in her mid-sixties presented to her ENT physician with complaints of chronic sinusitis and a 3-month history of headache with facial pain and swelling, as well as purulent nasal discharge. A CT scan revealed a deviated septum, and a subsequent fiber optic exam identified a right-sided sinus blockage.
The patient agreed to a functional endoscopic sinus surgery at an ambulatory surgery center to drain the maxillary and ethmoid sinuses. Although the ENT physician conducted an informed consent discussion with the patient, not all risks were covered, including the risk of vision loss.
Postoperatively, the patient complained of left eye pain, blurred vision, and limited downward eye movement. A CT scan revealed an interruption of the left medial wall of the medial rectus muscle. The ENT physician stated later that the laceration was likely due in part to use of a microdebrider machine that she had not previously used. The patient was discharged with an appointment to be seen by an ophthalmologist and prescriptions for an antibiotic and prednisone.
Upon consultation with the ophthalmologist, an urgent surgical exploration was arranged. The lacerated muscle was initially repaired, but did not hold. As a result, the patient now has diplopia and recurring headaches, and she is unable to drive or work.
Risk Management Issues for This Claim
- Improper technical skill in relation to competency with surgical equipment
- Inadequate informed consent for the surgical procedure (failure to discuss all related risks)
- Failure to obtain a timely consult/referral