Alphonse, a 50-year-old CEO of a large aerospace company with a family history of high cholesterol has come to your hospital for cardiac bypass surgery.

Scenario:  

Alphonse, a 50-year-old CEO of a large aerospace company with a family history of high cholesterol has come to your hospital for cardiac bypass surgery. He has been married to Sonia for 25 years, and they have three college-aged children.  The operating surgeon and anesthesiologist are both members of different multi-specialty physician groups that purchase their professional liability insurance from physician mutual insurance companies, and the hospital is self-insured. 

The hospital has recently purchased a new piece of equipment for blood administration during a surgical procedure. The anesthesiologist received training on the equipment and has used it in six surgical cases to date. The equipment is being used in this surgical case. Two units of blood have been administered during the case using the equipment. As the anesthesiologist administers the last unit of blood, the patient suddenly experiences cardiopulmonary arrest. 

The anesthesiologist suspects that Alphonse has an air embolus, and appropriate resuscitative measures are undertaken. He is successfully resuscitated but experienced a prolonged period of limited oxygen to the brain. Over the next few days, it is clear that he has suffered a significant brain injury due to the lack of oxygen. He is discharged to a skilled nursing facility with little prospects of ever returning to work. 

The root cause analysis suggests that the cause of the air embolism was multi-factorial, but identifies a breakdown in communication between the anesthesiologist, perfusionist, and surgeon, along with a lack of familiarity with the new equipment as an important cause of the adverse event. 

Please provide full disclosure. It should be exactly what you would say to Alphonse’s family, as his physician. Patients preferred disclosure containing  

1. How the provider will prevent the mistake future  

2. Meaningful and sincere apology (contain an apology & empathy)

3. Address bills or additional care  

4. Offer counseling and support