A 36-year-old woman with a significant history of postpartum hemorrhage is to undergo a laparoscopic tubal ligation at a freestanding ASC that requires minimal pre-procedure testing. The only test required of this patient is a pregnancy test, which was negative. The anesthesiologist and admitting nurse both elicit the history of postpartum hemorrhage, but are unconcerned given the circumstances. Following the vaginal delivery of her fourth child three years ago, the patient lost two liters of blood, caused by retained products of conception. She wasn't transfused at that time, although her hemoglobin on discharge had fallen to 6.8 grams.

Uncontrolled bleeding
Toward the end of the ligation, the surgeon notes a bleeding point on the right tube. Each attempt to control the bleeding with cautery only worsens it.

Exasperated, the surgeon asks the circulating nurse for the patient's platelet count. The nurse responds that a count hadn't been performed. "I specifically ordered a platelet count," the surgeon seethes. They place a stat call to the surgeon's office. Uh-oh. A member of his staff reports that the patient's platelet count was extremely low. The lab had called the surgeon's office with the results, but his staff neglected to share the results with him.

Despite aggressive attempts to staunch the bleeding, the patient continues to hemorrhage. The surgeon performs an exploratory laparotomy and eventually controls the bleeding. An ambulance transfers the patient seven miles to the hospital without incident; the anesthesiologist accompanies her. The patient's hospital course is complicated by anemia requiring the transfusion of seven units of blood, two units of fresh frozen plasma and 30 units of platelets.

A year later, Hepatitis C
About a year after her discharge from the hospital, the patient discovers that she has acquired hepatitis C, presumably from the transfusion. She brings suit against the surgical center, surgeon, nurses and anesthesiologist, claiming that they negligently failed to notice her decreased platelet count and never should have performed her procedure in a freestanding setting. Had the procedure been performed in a hospital, the patient contends in her lawsuit, there'd have been less of a delay in controlling the bleeding and transfusion wouldn't have been necessary. She also claims that she never consented to a transfusion.

The surgical center staff counter that they were unaware that a platelet count had been ordered. Besides, they add, since a platelet count wasn't part of the required workup, how could they have been expected to evaluate the results before surgery? The surgery center argues that the patient had met all the facility's criteria.

When it became apparent that the surgeon was the sole member of the operating team who had been aware that a platelet count had been ordered, he settled the case against him early into the trial. But what about the ASC, nurses and anesthesiologist?