Observed an Unconsented surgery performed

[mochilover]

I'm new to OR and is currently undergoing periop101 training at a teaching hospital.

This week during my first clinical rotation, I observed a surgery being performed on a patient without consent (pt was consented for R side ovarian cyst removal and surgeon removed Right ovarian cyst but also proceeded to remove the Left one)!

My preceptor (who's a highly experienced and respected preceptor) reminded the surgeon that we do not have consent on the other side but surgeons did not stop the surgery due to "medical necessity". My preceptor then called the charge nurse and asked her to report up the chain of command and inform that we would filed an incident report (which we did).

I wasn't with the pt in preop so I don't know if the possibility of bilateral removal were even discussed but it was definitely not written on consent. And I honestly did not know what/or if anything happened in the surgery that led to "medical necessity" of the other side removal (I was charting behind computer and grabbing supplies so I didn't really see what's going on when it happened). When I called the family for update, my preceptor said to inform family surgery is still going but do not mention anything about another side being performed...it's surgeon's responsibility to speak with the family and patient afterward.

However, I have an uneasy feeling all weekend thinking about this...how else things could be done differently? Why didn't my preceptor or anesthesia or scrub tech or charge nurse do anything to halt the surgery? Or does this happen more often in OR than I think? Should i have stopped the surgeon and have him scrub out to speak with the family? Also, Should I be freaking out about liability and losing my job/license? I know I'm technically in training but I do have an RN license and my name was on the OR documentation...

[klone, MSN, RN]

Ovarian cyst removal is necessary

Actually, in the vast majority of cases, ovarian cysts are not a big deal and do not require removal. Women get cysts on their ovaries every month. That's where the egg comes out, and it forms a cyst called a corpus luteum, the function of which is to provide hormones to the growing embryo.

Now, that's not to say they're not sometimes painful or uncomfortable. But in the vast majority of cases, they're not a big deal, and they go away.

[KelRN215, BSN, RN]

Sometimes the surgeon doesn't know what he's going to find when he gets in there and when he opens the patient, the situation is different than was originally thought.

[FurBabyMom, MSN, RN]

Sometimes the surgeon doesn't know what he's going to find when he gets in there and when he opens the patient, the situation is different than was originally thought.

This is absolutely true. The surgeons I work with have an extensive discussion with patients about a lot of potentialities. We do cases where the "ideal" plan is ABC but due to the invasive nature of a cancer or neurovascular status (ex graft sites) - we have to go with plan DEF. In most of these cases patients or their families can identify the primary plan and have an idea about some of the potential contingencies.

I've seen procedures added and completed secondary to a change in the patient's condition - and it is what it is. These have been things like an emergent trach on a known (or unknown/surprise) difficult airway. Planned endoscopic or laparoscopic cases convert to open secondary to changes in condition or complications. Other things I've heard of from coworkers include patients crashing onto bypass or leaving on ECMO or a balloon pump.

We're a Level 1 trauma center - and we OFTEN have no consent for procedures performed as emergencies (okay, often sounds really bad, but it is kind of true). If a patient is an inpatient - there is usually an attempt to reach HCPOA / family / next of kin. This is obviously limited by patient condition - we are not going to keep a patient who needs an emergency procedure from that procedure to reach the family if the surgeons/anesthesia team are saying it is a life threatening emergency. We also have patients who arrive via air transport and come basically straight to the OR and our only identifier is the (unique) "fake" name we assign patients who are transported in without identification. No way to know who to contact and we proceed with life sustaining care including emergency surgery.

Others have mentioned the clause in the consent form about other procedures medically necessary. That probably applies here. It may not - it may be that the patient and surgeon discussed the potential that there may be more than one or bilateral cysts. Not being in clinic or there when consent was obtained it's hard to say. I've been present while surgeons I work with have obtained consent for procedures - I've heard the whole speech the surgeons I work with give. I love working with the surgeons I work with, they are very thorough, very good with patients and families but I hope like hell never to need them to take care of me or my family (but if my family members or I did need that kind of care - I wouldn't dream of not having them take care of me or my family).

I always write up incident reports for many things - incorrect counts, procedures performed without expressly being on the consent forms, emergency cases, codes, delay(s) in care - all kinds of things. Our facility looks at the whole scenario to see what can be fixed. A sick as all get out patient is going to be sick as all get out and probably be more likely for complications, but policy issues and issues like instruments, equipment malfunctions etc can be tracked and potentially corrected.

[Foggy14]

I would give the surgeon the benefit of a doubt here. Surgical consents always include some kind of wording about "and indicated procedures" for cases like this where they don't always know what they're going to find before they open the patient up. I've had orchiopexies turn into orchiectomies, closed reductions turn into open reductions, and so on. Discussing complications/additional procedures is part of obtaining informed consent, which is the surgeon's job. I trust them to do their ethical/professional duty in that respect, but that does need to be balanced with an awareness of what is going on and the ability to raise questions if something seems "off." That being said, the situation you describe doesn't raise any red flags for me unless the patient was fertile and the surgeon removed both ovaries. Or if he just went ahead and did a tubal ligation. Now THAT would be sketchy.