Protecting Against Malpractice Liability After Unauthorized Hemorrhoidectomy
Critical Actions to AVOID
Never attempt to minimize, dismiss, or deflect the patient's concerns about the unauthorized procedure—this is the single most damaging action from a medicolegal perspective and will strengthen any malpractice claim. 1
Documentation Pitfalls to Avoid
Never alter, amend, or "clarify" previous medical records after the patient raises concerns—any changes to documentation after a complaint will be viewed as evidence tampering and significantly strengthen the plaintiff's case 1
Never document defensive or accusatory statements about the patient (e.g., "patient is being difficult," "patient misunderstood consent")—these entries demonstrate poor professionalism and will be used against you 1
Never fail to document every interaction with the patient going forward—gaps in documentation after a complaint suggest avoidance or cover-up 1
Never document speculative statements about what "might have happened" or alternative explanations that weren't part of the original clinical decision-making 1
Communication Errors to Avoid
Never discuss the case with colleagues in non-privileged settings (hallways, nursing stations, electronic communications)—these conversations are discoverable and will be used as evidence 1
Never communicate with the patient without a witness present—all future interactions should include another healthcare provider who can document what was said 1
Never provide inconsistent explanations for why the procedure was performed—changing your story strengthens the claim of negligence 1
Never blame other team members (anesthesia, nursing, surgical assistants) for the unauthorized procedure—this demonstrates lack of accountability and suggests systemic problems 1
Clinical Management Errors
Never refuse to see the patient or provide follow-up care—abandonment claims will be added to the malpractice suit and are often easier to prove than the underlying negligence 1
Never recommend additional procedures without explicit informed consent documented by a witness—any further intervention without meticulous consent will compound the liability 2, 1
Never dismiss complications as "normal" or "expected" without thorough evaluation—hemorrhoidectomy has a 10% complication rate including bleeding, fissure, fistula, abscess, stenosis, urinary retention, soiling, and incontinence 3
Protective Documentation and Verbiage
Immediate Documentation Requirements
Document the following in every encounter note going forward:
Exact patient complaints and concerns using the patient's own words in quotation marks—this demonstrates you listened and took concerns seriously 1
Complete physical examination findings including digital rectal examination and anoscopy when tolerated—document if examination was refused or not tolerated and why 2, 4
Specific assessment of surgical site healing including presence/absence of complications: bleeding severity, pain level (numeric scale), signs of infection, sphincter function, continence status 2, 3
Detailed informed consent discussions for any recommended treatments, including risks, benefits, alternatives, and patient questions—have a witness present and document their name 1
Protective Verbal Communication Framework
Use this exact verbiage structure in all patient interactions:
"I understand you have concerns about the procedure that was performed. I want to make sure we address your current symptoms and any complications thoroughly. Can you tell me specifically what symptoms you're experiencing now?" 1
- This acknowledges concerns without admitting fault, focuses on current clinical needs, and demonstrates patient-centered care 1
For discussing the unauthorized procedure:
"I want to review what happened during your surgery and answer your questions. I recommend we have [witness name] present for this discussion to ensure we address everything thoroughly. Would that be acceptable?" 1
- Never have these discussions alone—always include a witness who documents the conversation 1
For recommending follow-up care:
"Based on your examination today, I recommend [specific intervention]. The risks include [specific risks], benefits include [specific benefits], and alternatives include [specific alternatives]. Do you have questions about this recommendation? I want to make sure you understand everything before we proceed." 2, 1
- Document patient's verbatim response and whether they accept or decline recommendations 1
Essential Clinical Assessments
Perform and document these evaluations at every visit:
Hemorrhoid-specific complications assessment: Check for bleeding (quantify amount), thrombosis, prolapse, sphincter function, continence status (any soiling or incontinence), anal stenosis, fissures, abscesses, or fistulas 2, 3
Systemic complications screening: Urinary retention, signs of pelvic sepsis (fever, severe pain, systemic symptoms), anemia symptoms (fatigue, pallor, shortness of breath) 2, 3
Functional outcomes: Pain level (0-10 scale), ability to defecate without straining, return to normal activities, quality of life impact 2, 3
Red flag symptoms requiring urgent evaluation: Severe bleeding with hemodynamic instability, fever with severe pain (suggests necrotizing pelvic sepsis), urinary retention, signs of sphincter injury or incontinence 2, 3
Protective Testing and Referrals
Order these investigations to document thoroughness and rule out complications:
Complete blood count if any ongoing bleeding—document hemoglobin/hematocrit to assess for anemia from hemorrhoidal disease (though rare at 0.5/100,000 population) 2, 5
Anoscopy at each visit when tolerated—document findings or document if patient refused/couldn't tolerate with specific reason 2, 4
Colonoscopy if bleeding persists or patient has risk factors for colorectal cancer—never attribute chronic bleeding to hemorrhoids without complete colonic evaluation 2, 5
Anorectal manometry and endoanal ultrasound if patient reports any incontinence symptoms—document sphincter integrity since hemorrhoidectomy causes sphincter defects in up to 12% of patients 2, 3
Medicolegal Consultation Verbiage
When discussing with your malpractice carrier/attorney, document:
"Patient seen today for follow-up regarding hemorrhoidectomy performed on [date]. Patient has expressed concerns about [specific concerns]. Current examination reveals [findings]. I have recommended [interventions] with informed consent discussion documented. Witness [name] present. Patient [accepted/declined] recommendations. Will continue close follow-up. Malpractice carrier notified on [date]." 1
- Notify your malpractice insurance carrier immediately—delayed notification can void coverage 1
Critical Follow-Up Protocol
Schedule frequent follow-up visits (weekly initially, then biweekly)—document that you offered close monitoring and document if patient declined 2, 1
Provide 24/7 contact information for urgent concerns—document that this was provided 1
Offer referral to another colorectal surgeon for second opinion if patient desires—document the offer even if declined 1
Monitor for late complications up to 6 months post-operatively including anal stenosis (0-6% incidence), delayed bleeding, and progressive incontinence (2-12% incidence) 3