Risk Management Tools & Resources


CASE STUDY: Improper Management of Bariatric Surgery Patient Leads to Suboptimal Outcome

Safety in Numbers: Improving Diagnosis Through Teamwork

Case Details

A patient underwent laparoscopic Roux-en-Y gastric bypass. During the immediate postoperative days, the patient experienced tachycardia and significant abdominal pain. An abdominal computed tomography (CT) scan revealed fluid in the abdomen, but the results were not immediately relayed to the surgeon.

Over the next 2 days, the patient’s condition deteriorated, but neither the nursing staff nor the lab directly notified the surgeon about the critical CT scan results. Ultimately, the patient required surgery after developing respiratory distress, metabolic acidosis, septic shock, and acute renal failure.

Surgery revealed that the gastrojejunostomy had failed. A third surgery was required 3 days later due to increasing pain. During the third surgery, a perforation in the transverse colon was discovered. The patient required multiple subsequent surgeries and suffered severe weight loss, skin breakdown, and permanent nerve damage as a result of malnutrition.


Appropriately managing patient care is a vital element of safe surgery and should include thorough communication among healthcare providers and careful patient monitoring during the postoperative period. MedPro Group closed claims data from 2006–2016 show that issues related to inadequate management of surgical patients occur in one-third of bariatric-related malpractice allegations.

In this case, numerous risk management and safety issues occurred that ultimately resulted in a poor outcome for the patient and liability exposure for the healthcare team and organization. These issues included:

  • Inadequate patient assessment, including failure to elevate concerns related to the patient’s deteriorating condition
  • Inadequate postoperative management of the patient due to the lack of a timely response to ongoing patient symptoms
  • Inadequate communication among providers regarding critical test results and deterioration of the patient’s condition
  • Lack of adherence to policies and procedures for reporting critical test results

To reduce the risks associated with these types of issues, healthcare organizations and providers should establish well-defined protocols for consistent postoperative patient assessments, ongoing patient monitoring, and discharge criteria and requirements. Policies related to documentation and communication of critical test results and care transitions also should be implemented, and routine monitoring should occur to ensure compliance with these policies.

More information and tools are available in the Agency for Healthcare Research and Quality’s (AHRQ’s) free Toolkit To Promote Safe Surgery and Toolkit To Improve Safety in Ambulatory Surgery Centers. AHRQ’s TeamSTEPPS® program also offers free education to improve teamwork and communication in various practice settings.

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