[Foreign body retention after soft tissue laceration. A case of insufficient inspection and documentation].
A 52-year-old man sustained a laceration to his left eyebrow after a fall in his bathroom. His plastic glasses shattered upon impact. The patient was referred to a local emergency department. After a quick exploration by the physician on call, the wound was closed by a nurse using the Steri-Strip Wound Closure system. No further exploration or imaging was performed. Four weeks after the incident the patient presented to a dermatologist with a "foreign body sensation" at the site of the laceration. Assuming a foreign body granuloma, he was referred to a maxillofacial surgeon who removed plastic debris (parts of the glasses worn by the patient). The wound subsequently healed without further complications.The patient filed a complaint for inadequate treatment in the emergency department. No detailed patient and accident history had been obtained, the wound exploration performed by the physician was superficial, and the wound closure was performed by a nurse. The expert opinion of the arbitration board ascertained a medical malpractice in terms of insufficient history, examination, and a lack of documentation. Specific questioning of the accident history would have led to the suspicion of possible foreign bodies, thus, leading to a more thorough exploration and likely further imaging. The arbitration board concluded that obtaining a detailed accident history and an accurate examination would have revealed the foreign bodies and/or led to further imaging. Complying with this, the patient could have been spared further harm and secondary surgery would have been unnecessary.
Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar, Technische Universität, Ismaninger Straße 22, 81675, München, Deutschland, lisa.kempf@tum.de.
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D003951:Diagnostic Errors / Q000331:legislation & jurisprudence*; D004282:Documentation / Q000592:standards*; D005129:Eye Foreign Bodies / Q000175:diagnosis* / Q000601:surgery*; D005858:Germany; D006801:Humans; D008297:Male; D008318:Malpractice / Q000331:legislation & jurisprudence*; D008875:Middle Aged; D017695:Soft Tissue Injuries / Q000175:diagnosis* / Q000601:surgery*