Sometimes a danger warning can, quite literally, get in the way of patient safety.
A 45-year-old gentleman visited Dr. CR, a colorectal surgeon, for complaints of irritation, pain, and difficulty cleansing his rectal area because of hemorrhoids and skin tags. A recent Pap test revealed a low-grade squamous intraepithelial lesion and other atypical squamous cells. Dr. CR recommended doing a high-resolution anoscopy (HRA) while also performing a hemorrhoidectomy.
Because the procedure was scheduled for the surgery center, Dr. CR arranged to provide his own acetic acid required for the HRA. Placement of the acid in the anal canal turns the areas of concern white, helping visualization and removal. On his request, Dr. CR’s medical assistant and his scheduler sought out the medication and placed a small brown bottle on the physician’s desk.
Dr. CR took the bottle with him to the surgery center and handed it to the scrub nurse. Dr. CR performed the hemorrhoidectomy without incident and when he was ready for the acetic acid, the nurse handed him a soaked sponge. Though the acid is normally clear, the soaked sponge was brown.
Dr. CR placed the soaked sponge into the anal canal and removed the speculum to allow the sponge to remain in position. Within 10 seconds, the sedated patient began bucking in pain, causing the acid to squirt out of the anal canal onto the testicles, thighs, and tip of the penis. Dr. CR wiped away the solution, irrigated the area with saline, and noted superficial chemical burns in the perianal, scrotal, and inner thigh areas. Dr. CR infiltrated the burned areas with local anesthetic and applied topical lidocaine gel and Telfa gauze. When the patient recovered from anesthesia, Dr. CR told him what happened and referred him to a dermatologist.
What Dr. CR discovered when he examined the small brown bottle was that a skull-and-crossbones warning sticker overlapped the label describing the bottle’s content. So, instead of the acetic acid that Dr. CR had requested, the bottle contained bichloroacetic acid, a highly caustic solution normally used to remove warts. The skull-and- crossbones label had obscured the letters “bichloro.”
Dr. CR and the patient, who suffered severe burns requiring a long course of treatment, resolved the matter informally very early in litigation.
Looking at such a course of events, one can identify several junctions at which the patient’s injury could have been avoided. Should retrieval of the medication have been more closely supervised by a physician? Does the application of a medication to the mucosal lining merit an extra step in confirming the solution? Should the brown soaked sponge have been reason enough for the physician to raise a question before proceeding? Would one expect a bottle of actual acetic acid to even have a skull-and-crossbones sticker on it?
Author Gordon Ownby is General Counsel for the Cooperative of American Physicians, Inc. (CAP).
If you have questions about this article, please contact us. This information should not be considered legal advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.