Operation well performed but insufficiently documented and not indicated

• Published in: Der Unfallchirurg Vol. 118; no. 3; pp. 271 - 274
• Main Authors: Greipel, J M, Deiler, S, Neu, J
• Format: Journal Article
• Language: German
• Published: Germany 01-03-2015
• Subjects: Documentation; Germany; Health Records, Personal; Humans; Male; Malpractice - legislation & jurisprudence; Medical Errors - legislation & jurisprudence; Middle Aged; Orthopedic Procedures - legislation & jurisprudence; Germany
• ISSN: 1433-044X
• DOI: 10.1007/s00113-014-2707-z

A 50-year-old patient presented with a lump in the main joint of the fourth finger of the left hand, which was suspected of being malignant, for an operation. Following surgery the lump was still present and, furthermore, the patient reported a wound resulting from surgery on the third finger accompanied by swelling, pain and a loss of mobility. The patient accused the physician of performing surgery without indications on the wrong finger together with failure to remove the lump. The surgeon stated that lysis had been performed on the flexor tendon in the area of the lump. An external expert admonished the cursory surgery report; however, the expert stated that removal of the lump at the tendon would have been medically indicated and the operation was performed according to professional surgical standards. The decision of the arbitration board differed from the expert opinion as the insufficient documentation presented at first could have been understood to mean that a tendon node on the fourth finger was to be removed which was not the case. Furthermore, the operation performed would only have been indicated if a "trigger finger" were present; therefore, the surgery as well as the resulting afflictions and follow-up treatment were to be assessed as faulty. The handwritten surgery report had several shortcomings as well and led to a reversal of the burden of proof.