Case Studies

Lesson learned

Failure to Diagnose and Treat Postoperative Complications

Case Summary

A 52-year-old morbidly obese female presented to the hospital's emergency department during the late evening complaining of acute abdominal pain that had begun a few hours earlier. The initial lab work returned several abnormalities, including a high white blood count and bands. A CT scan of the abdomen/pelvis suggested free intraperitoneal air. Following a surgical consult, the patient was brought to the operating room in the morning. During surgery, a small perforation was found in the sigmoid colon. The surgeon performed a Hartmann's procedure and a sigmoid colostomy. The operation seemed to go without any apparent complications.

On post-op day #1, the patient complained of pain in her lower abdomen localized to the areas of the incisions. There was no nausea or vomiting. Bowel sounds were present. Her abdomen was distended. The stoma was retracted a “little bit” and appeared viable. Her WBC remained elevated. Her heart rate throughout the day was in the 90s.

On post-op day #2, the patient complained of heartburn/acid indigestion but denied nausea. She also complained of lower abdominal pain. She was essentially afebrile with relatively normal vital signs. She had reduced bowel sounds. The stoma was recessed but appeared viable. Her WBC was elevated. The surgeon felt the patient's pre-surgical peritonitis was resolving but still required antibiotic coverage. He charted that the patient needed to increase her activity level, but he also documented that the nurses were having a difficult time getting the patient to do so. He stated that she was very “resistant” to moving or walking and that they would have to “fight” that to get her active.

On post-op day #3, the patient said that she felt awful. She complained of nausea. She was afebrile. There was no output from the stoma, which was still somewhat recessed but appeared viable. Her abdomen was noted to be slightly distended, and there were minimal bowel sounds. The surgeon's impression was that there were no indications of a bowel obstruction. He felt the patient had a persistent ileus with no resumption of bowel function that was contributed to by the patient's resistance to increase her activity, “which is, of course, difficult anyway with her as obese as she is.” His plan was to ask the patient to increase her activity, and check abdominal films the following day, along with CBC and electrolytes.

On post-op day #4, the patient stated that she felt miserable. The surgeon documented that she was not being at all cooperative and was refusing to get out of the bed. On examination of her abdomen, he documented that it was difficult to determine to what extent it was distended given her obesity. Some bowel sounds were present. The stoma was starting to put out air. It was noted that the patient had a high fever during the overnight and the morning. An abdominal/pelvic CT scan was felt to demonstrate an ileus and apparent free fluid in the abdomen and subcutaneous tissue. A couple of images showed bubbles of air, but it was difficult to determine if they were within the small bowel or colon. The WBC was at the upper end of normal range. Throughout the day and night, the patient's heart rate was in the 100s with a couple of readings into the 120s and 130s. The surgeon's plan was to continue IV fluids, do nasogastric suctioning and continue broad spectrum antibiotics.

On post-op day #5, the patient was tachycardic throughout the day and night, with her heart rate mostly in the 140s. She was afebrile. There was a substantial amount of output from the nasogastric tube. Her urine output had decreased. There was still very little air out of the stoma and no appreciable stool. Her abdomen remained distended. Her elevated creatinine was felt to be due to dehydration from the NG suction. A workup was done due to concern for a possible DVT/PE. A perfusion scan showed low probability for PE. The plan was to continue enoxaparin and antibiotics. The surgeon also wanted there to be continued attempts to get the patient up and ambulating, and he charted that the patient was being resistant to the requests that she get up and ambulate.

On post-op day #6, the patient's urine output appeared to be improving, but she was continuing to put out a fair amount of bilious fluid from the NG tube. The surgeon felt that she was very close to needing parenteral nutrition. He charted that “her abdomen continues to be huge. A lot of it is herself. Some of it is distension for sure.” He felt that there were no signs of infection or evidence of peritonitis. She was tachycardic throughout the day and night. Her stoma had some superficial, patchy, mucosal necrosis at the surface. His assessment was that she was continuing to be “an extremely difficult patient particularly with her resistance to help herself. I discussed the situation with her PCP, and we are being quite forceful and insistent that she cooperate and get out of bed to walk.”

On post-op day #7, the patient was short of breath and complained of lower abdominal pain. Her blood pressure was elevated, and she continued to be tachycardic with increased respirations. The ostomy was noted to be ischemic on the surface. There was still increased output from the NG tube, and the plan was for a KUB and upright to check the position of the tube and evaluate the gas pattern of the small bowel. The surgeon's assessment was that the patient was afebrile, nontoxic, and hemodynamically stable. The patient coded later that day. They were able to resuscitate her, but it was felt that she suffered anoxic encephalopathy. She expired less than 12 hours later. The autopsy findings included generalized severe fecal peritonitis with dehiscence and a perforation of the colon with extensive leakage of fecal material.

The patient's family brought a malpractice suit against the surgeon. The case was settled relatively early in the litigation process.


Expert defense support could not be obtained for the postoperative care provided by the surgeon. The patient was exhibiting concerning signs, including significant tachycardia, fever, elevated WBC, increased drainage, and increased pain. It was felt by experts who reviewed the case that the patient should have been taken back to the operating room, certainly by post-op day #4 or #5.

The surgeon appeared to have a bias against this patient because of her morbid obesity. He described her as uncooperative, resistant and difficult when the nurses attempted to ambulate her and attributed this lack of activity to her obesity. He documented that her symptomology was related to an ileus as a result of the patient “not wanting to help herself.” Fundamental attribution error is the tendency to be judgmental and blame patients for their illnesses rather than examine the circumstances that might be responsible. While the patient was exhibiting concerning signs, the surgeon did not evaluate her full clinical picture and only saw her obesity as the reason for her symptoms.

While this patient was clearly deteriorating, the nursing staff did not advocate for her. They documented their findings such as abnormal vital signs, increased pain and increased NG drainage, but took no steps to bring concerns to the surgeon or up the chain of command.

Risk Management Takeaways

  • Provide clinical staff education around obesity bias in healthcare.
  • Offer physicians and other healthcare personnel a self-assessment to gauge their attitudes towards weight bias.
  • Offer providers education on reducing diagnostic errors, including different types of bias that lead to errors such as confirming bias, cognitive bias, and fundamental attribution errors.
  • Develop a chain of command policy and educate staff on when and how to use it.
  • Implement team training to empower staff to speak up for patient safety.