In Sect. 3.1.3 it is already described that utilization of an epidural after a bloody insertion has to be viewed critically. Whether such utilization is actually malpractice is unclear. Nevertheless, utilization of the epidural with a local anesthetic immediately before removal of a neuroendocrine tumor is medically questionable.

Continuous CVP measurements were not performed.

While checking the chart on the ward, Dr. Constantine couldn’t find a blood pressure measurement for Mr. Anderson. Furthermore, one may assume that the high-quality radiographic images should have localized the tumor at the adrenal gland. However, further investigation into the localization of the tumor was not carried out. The initial diagnosis of an ileus was never questioned.

There was no intraoperative measurement of lab values. When the PVCs occurred, hematocrit and electrolytes should have been checked.

Informed consent requires a discussion between the physician and the patient concerning the risks, benefits, and alternatives to treatments. It is an ethical obligation of the practice of medicine and a legal requirement in the U.S. in all 50 states [7]. The patient must have “competence” and “capacity” to provide informed consent. Competence refers to the patient’s legal authority to make decisions. Adult patients, generally patients who are 18 or older, are presumed legally competent unless otherwise determined by a court. Capacity refers to a determination made by medical professionals that a patient has the ability to make a specific decision at a specific time. The informed consent discussion should focus on the indications for the proposed treatment, description of the procedure in terms a layperson can understand, and an explanation of viable alternatives. Disclosure of material risks of the recommended and alternate treatments is required. Material risks are risks that occurred frequently (e.g., backache, spinal headache, or failure after an epidural) as well as those that are rare but may result in serious morbidity or mortality (e.g., nerve injury/paralysis, seizures, coma, death). Some states also require disclosure of all persons anticipated to be involved in the patient’s anesthetic care. Some hospitals and some states require a separate written anesthesia consent form. In other places, a written surgical consent form suffices, with a verbal informed consent discussion about anesthesia risks. Specific risks described in the discussion, such as persistent numbness or paralysis from the epidural, should be charted on the preoperative evaluation or anesthetic record.