Case Vignette – April 2021

The Wrong Pathology

I usually draw upon cases that I have seen to structure this section of The Medicolegal Mind newsletter.

On this occasion, I am sourcing a dream I had recently. I was with a group of colleagues discussing the performance of another colleague. It related to a surgical procedure performed on a hip.

It transpired that the Surgeon under investigation had performed the subject operation perfectly. The problem was that it was the wrong operation!

He had performed an iliopsoas tendon release, believing that the patient suffered with intractable pain as a result of iliopsoas tendinopathy.

The real pathology however was not related to the psoas tendon but rather, to a labral tear, detachment and chondral anomaly within the hip joint itself.

There is no real need for the reader to bother about the precise pathology. Instead, attention should be focussed upon doing the right thing at the right time, for the right reason on the right patient. Without this combination of correctness, adverse outcomes are likely to be witnessed.