Swedish docs cleared over misplaced colon
David Landes · 1 Jul 2009, 11:06
Published: 01 Jul 2009 11:06 GMT+02:00
The faulty operation took place in January at Malmö University Hospital on a patient who had previously had surgery for an inflamed rectum following treatment for prostate cancer.
Doctors were planning to carry out a sigmoidostomy, a procedure whereby the patient is given an artificial anus through an opening in the sigmoid colon.
But following the procedure, the doctors managed to sew the man's lower intestine to his bladder.
After the operation, one of the doctors admitted he noticed a difference in the thickness of the intestinal wall and what turned out to be the bladder as he stitched the two together.
“I obviously misjudged the anatomy in the minor pelvis,” wrote one of the doctors in a post operative report cited in a ruling by the National Board of Health and Welfare (Socialstyrelsen).
“In hindsight there are signals that should have made me realize I was on the wrong track. I still can’t, despite going over things several times in my mind, really explain how I could have made such a serious misjudgment of the anatomy.”
The health board’s investigation also revealed that, for certain periods of the complex procedure, only one surgeon was at the operating table.
In addition, one of the doctors admitted that he was “weighed down with social problems” and as a result was “mentally out of sync” at the time of the operation.
The botched operation was repaired in a subsequent surgery four days later, but still resulted in a number of serious complications for the man, forcing him to endure a prolonged hospital stay.
While the health board was “highly critical” of the doctors for not taking a “time out” or asking a colleague for help in light of the operation’s numerous anomalies, it nevertheless elected not to sanction the surgeons for their mistake.
According to the agency, the blunder can be attributed to “the sum of a series of unfortunate circumstances” including a heavy workload for the doctors involved.
“There is nothing to indicate it was deliberate carelessness or that the professionals involved pose a risk to other individuals,” wrote the Board of Health of Welfare in its ruling.
In the future, the agency said it plans to keep close watch over how the workload of doctors at the hospital may affect patient safety.