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Case Study
Leadership for Health Professionals: Theory, Skills, and Applications
Third Edition
Gerald R. Ledlow
C3
When you’ve worked in medical centers as long as I have and been involved in various situations, every once in a while, you
think you witness a miracle. This is one of those cases where I think a miracle happened. One day, a general surgeon came
to my office and told me that we had a problem. Now, when a physician has a problem, he or she generally has the attitude
that the hospital also has that problem. This is because the hospital is legally responsible for whatever a physician does in
that hospital, including malpractice. During surgery, he had left a sponge in a 16-year-old developmentally disabled patient.
As a rule, the surgical team makes three counts of the sponges used—one count by the surgeon before he or she stitches
the incision closed, one count by the circulating nurse, and one by the technician. How this got by all three of them is unexplainable, but it did, and the boy developed gangrene. The general surgeon told me that the child was going to die, and he
wanted to know what we should do. I answered, “Well, the first thing we’re going to do is advise the parents what happened
here. And then after we tell the parents, you will not talk to your attorneys, but I’ll go talk to our attorneys.”
So, as the child laid dying in the Intensive Care Unit, we took the parents aside for this very difficult conversation. We
went to what we call the quiet room, which is where physicians have private discussions about the condition of patients with
families. The general surgeon told them the truth. He told them he had left a sponge in their child during surgery. Because
of that mistake, the child had developed gangrene, and the child was going to die, probably within the next 2 weeks.
Now, if that had been my child, I think I would have been quite upset with the surgeon. So, I was expecting the parents to
respond with great emotion and possibly even anger. Surprisingly, when the surgeon told the mother and father the truth
about what had happened in this case, they were very calm. They said they did not fault the surgeon, and they actually would
pray for him. Both of us were totally shocked by their reaction. The miracle of this story is that the boy walked out of the ICU
and the medical center about 12 weeks later and continued his life. This was one of the few miracles that I think I witnessed
during my 25 years in the hospital setting.
Content Link:
Ledlow & Stephens, Leadership for Health Professionals: Theory, Skills, and Applications, 3rd Edition, Jones & Bartlett Learning,
2017
Chapter 5: Cultural Competence
Copyright © 2018 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
2 ❚ Case Study
Name:
Date:
Section:
C3. Case Study Questions
1. Should the surgeon and I have discussed this matter with the parents before discussing it with our legal counsel?
2. What would you do to the privileges of the general surgeon who made the surgical error?
3. What new procedures would you develop in your operating room to prevent this from happening again?
Copyright © 2018 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
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