Risk Management

Reviewing Preoperative Tests and Studies

By Byron H. Demorest, MD

Argus, June, 1991

If you ask ophthalmic surgeons about the need for preoperative chest films or blood studies, you will get different opinions. With the emphasis now on outpatient surgery, however, most surgeons feel that few, if any, preoperative tests are warranted. From a risk management viewpoint, therefore, how important are such studies? Very! Particularly if such tests have been routinely ordered and then reveal a positive finding which is not followed up on.

Consider this scenario:

A patient enters the hospital for repair of a retinal detachment. The hospital requires a preoperative chest x-ray and certain blood studies. The chest file is done and the blood studies completed, but neither the surgeon nor the anesthesiologist giving the “stand-by” anesthesia reviews the patient’s chart preoperatively to see the report of the chest x-ray. The anesthetist does note a normal hemoglobin and blood potassium.

The surgery is only temporarily successful, and after a few months another chest file is done routinely prior to a second surgery on the eye. At this time, it is noted that the patient has lung cancer! A comparison with the first x-ray shows that the cancer has progressed significantly.

Why was the first x-ray not reviewed at the time of the first surgery? Although it was properly reported and read by the radiologist, a breakdown in protocol allowed the report to be returned to the patient’s file “unflagged.” Thus, it was overlooked by both the surgeon and the anesthesiologist.

The patient sues and is awarded a large settlement when an oncologist testifies that had the carcinoma been attended to at the time of the first x-ray report, the patient’s chances for survival would have been far better than they were by the time of the second x-ray.

The lesson here is that all reports of x-rays, laboratory work and pathology studies must be reviewed by the attending physician. Ophthalmologists may consider such tests to be redundant. Nevertheless, it is essential that the ophthalmologist personally review all tests, routine or otherwise. Failure to do so most certainly increases liability of the physician and causes complications for the patient.

Remember to set up a system in your office so that all reports are placed on your desk with the patient’s chart. Results of such tests should never be entered into the chart by your staff until you have had an opportunity to review each report, discuss positive findings with the patient, and place your initials on the report indicating that you have seen it.