Incidental Detection of Von Willebrand Disease: Can A Self-Assessment Anamnesis Questionnaire Protect From litigation And Minimize Complications?

Abstract Introduction: Surgical specialties are often involved in legal actions associated with inadequate or incomplete documentation. Case presentation: We report the case of a 22-year-old patient with gynecomastia who developed a unilateral hematoma after power-assisted liposuction and subcutaneous mastectomy performed in an outpatient setting under intercostal nerve block and monitored anaesthesia care. After revision surgery healing was uneventful. Further exams revealed a von Willebrand Disease. The patient had omitted a previous circumcision and the occurrence of a hematoma thereafter during the preoperative patient assessment. The specific and detailed anamnesis and the erroneous answer were documented on a structured self-assessment patient questionnaire for pre-surgical evaluation. Conclusion: Literature suggests that standardized risk assessment improves the quality of the anamnesis, the patients’ safety, the physician’s time management. This case illustrates that it may also help defend the surgeons in case of medical litigation. However, physicians need to be aware of the risk of response bias.Level of Evidence: Level V, case report