Ms V, a 49-year-old secretary, saw Dr L, a gynaecologist, because of problems with an ovarian cyst. Ms V was listed for hysterectomy and bilateral oophorectomy. During her consultation, Ms V told Dr L that she had a family history of thrombosis. Dr L didn’t record this.
Ms V’s surgery was routine and uncomplicated, but she was readmitted to hospital two weeks after her operation with a pulmonary embolus. It transpired that she had not received any form of thromboprophylaxis in the perioperative period. Ms V sued Dr L, alleging that he was negligent in not prescribing thromboembolic prophylaxis.
Dr L acknowledged that he’d been at fault for not documenting the relevant family history. He noted that, even without this information, according to the guidelines used in his hospital, Ms V should have received thromboprophylaxis on the basis of her age and the fact that she was undergoing major gynaecological surgery.
Dr L agreed that Ms V was at high risk of venous thrombosis and accepted that it was unlikely she would have had a pulmonary embolus if she’d received such prophylaxis.
The standard pre-admission form, which Ms V brought to her preoperative assessment, had contained her family history. It was seen by her anaesthetist, Dr B, and a junior member of the gynaecology team. Dr B had recommended Ms V receive tinzaparin as part of her preoperative preparation.
The pre-med. was written up by another anaesthetist and didn’t include this. Dr B carried out the anaesthetic and didn’t prescribe tinzaparin postoperatively.
There was uncertainty between the gynaecological and anaesthetic teams as to whose responsibility it was to ensure patients received appropriate thromboprophylaxis. It seems, in Ms V’s case, that it was everybody’s job and so nobody did it. We settled the case.
Patients having inpatient surgery are universally at risk of thrombotic complications.
The assessment and amelioration of this risk should form a standard part of preoperative assessment. It should consider the optimal type of thromboprophylaxis, the timing of its administration, the type of anaesthetic being used, the type of surgery and any patient-related factors that may influence how it is carried out. It is essential that a team-based approach, involving surgical, theatre and anaesthetic staff, is used.
Perioperative thromboprophylaxis is a good example of an area of practice where it pays to have agreed protocols and procedures, with defined responsibilities, to ensure that patients receive the treatment recommended in clinical guidelines. The use of integrated care pathways (ICPs) to facilitate this is becoming more common. For details of the principles and practicalities of ICPs, see http://pathways.nice.org.uk/.
The absence of such a system in this case, combined with human error, led to a potentially life-threatening complication that could have been easily avoided. We recommend finding local guidelines for perioperative thromboprophylaxis and ensuring that your procedures comply with the advice given.
A recent Cochrane review examines the evidence-base for thromboprophylaxis in women having gynaecological surgery. It is published in The Cochrane Library, Issue 1, 2004, John Wiley and Sons Ltd. Chichester, UK. [This review has subsequently been withdrawn. September 2008]
Comprehensive guidelines published by the Scottish Intercollegiate Guidelines Network (SIGN) on venous thromboembolism prophylaxis. Section four considers advice for patients undergoing general/ gynaecological surgery. A summary of recommendations derived from the SIGN guidelines is produced by the National Guidelines Clearing House.