This essay is the ninth installment of the monthly Patient Safety essays, produced by the Patient Safety Subcommittee of the Ethics and Professionalism Committee. The essays are written in the spirit of the aviation industry’s “Black Box Thinking” in order to inform and improve our medical safety record. To read earlier essays and learn how to contribute, please click here.

Patient Safety incident by Kevin Malone and David Nelson
ASSH Ethics and Professionalism Committee

Scenario 1

The surgeon arrived at the ambulatory surgery center, ready to start a busy day: 9 cases.  He looked over the OR schedule that was posted in the pre-op area and noticed that the last 2 cases on his schedule seemed to be out of sequence, based on his orders from the day before.  He checked with the front desk staff. The staff was aware of the change he had made and they assured the doctor that the master schedule that had been distributed reflected the correct order. The schedule hanging in the preop area was an earlier version of the schedule. 

The busy day went well. After finishing the 7th of 9 cases that day, the doctor met the 8th and 9th patients in preop and completed the consent process for both patients. Each was having a soft tissue procedure under local anesthesia. 

The circulating nurse went to get the next patient for the room and came back to the room with patient #9 as opposed to patient #8.  She indicated that the preop nurses told her that #9 was next, based on the schedule posted in the preop area.  This error was identified as soon as the patient was brought into the room.  The doctor decided to proceed with patient #9, as the instrument sets were already opened, and the sets were the same for both cases. He then completed #8. 

Following completion of the day’s schedule the surgeon investigated further how this error occurred.  The schedule hanging in the preop area was the one that the nurses use to make the preop phone calls the day before surgery.  His changes were made after the preliminary schedule had been printed. The final schedule was always printed out on the morning of surgery, and correctly reflected the case order.  The old, incorrect, schedule has not been discarded and ended up being posted in the preop area and was used as a reference on the day of surgery.  Identification of this error has changed the process of schedule distribution on the day of surgery to avoid this issue.

Scenario 2

A surgeon was to perform a rather difficult case, so she was careful to make sure that the instrumentation that she needed was available: the Acumed hand set. She asked the circulator and the scrub if the Acumed set was available, and was glad to hear that it was. She had her mind focused on the procedure.

She had a bit of time, so she popped in the room of her partner, who was doing a knee. The case had just started, the instruments were being opened and laid out. Happy that all was well, she returned to her room. The patient was brought in, the time-out was conducted properly, and the patient was given anesthesia. As patient was positioned, the surgeon happened to look over at the instrument table. Instead of the Acumed set, they had opened an Acufex knee set. She was appalled at the error, and the staff apologized, they had misread the name on the set. She raced to her partner’s room: patient was already asleep and the final instruments were opened and just now were being laid out.

She could not do her case without the Acumed set, and her partner could not do his case without the Acufex set. Both cases had to be cancelled after the patients had been anesthetized because once instruments are opened in a room, they are not sterile and cannot be used in another room. She looked at the schedule: the wrong sets were listed for the rooms. To someone in the scheduling office, Acumed and Acufex looked alike.

Analysis

The first mistake did not lead to any patient harm, but could have. This is the very definition of a sentinel event.  In a sense, it is a “free lesson” in patient safety, but only if we pay attention to it. In the second case, it did lead to both patient harm and liability exposure for the surgeons and the hospital.

The book Black Box Thinking: Why Most People Never Learn from Their Mistakes–But Some Do, is based on the “black box” (a double misnomer: there are two boxes, not one, and they are painted international orange, for ease in locating the devices) used in aviation to record voice data from the cockpit and mechanical data from the airframe. The book makes the case quite solidly that we need to take an aggressive approach to sentinel events. While every error may seem like a once-in-a-lifetime sequence of events, it is not. The chances are very high that similar episodes will be repeated. In these two scenarios, schedules contributed to the errors.  In the first, there were two different schedules, in the second, the error was in the schedule itself.

The printed schedule is a form of communication. Human factors engineering has found that the most common form of error is a communication error, and almost all fatal mistakes in a hospital involve communication errors at some point.

We each think we are great communicators, and what we say is clearly understood by our colleagues. If you think that, just ask your spouse if you are a good communicator! When the laughter dies down, consider again: communication errors lie at the base of many medical errors. Observe your own OR closely and you will see the truth of this maxim.

The OR schedule is a very important form of communication and errors in the schedule will have cascading affects on the performance of many parts of the team, from transport techs to sterile processing to which instrument sets get opened. All preliminary schedules and final schedules must be clearly differentiated in a way that easily prevents confusion. In aviation, the location, shape, and feel of controls, switches, buttons, etc, are differentiated. In the OR, preliminary schedules and final schedules will both be circulating, no matter how carefully they are distributed and collected. It is an error waiting to happen. A simple change, such as different colors for the two kinds of schedules, will make a significant difference: all staff will be able to tell at a distance if they are using the correct schedule for their purpose. With time, the color recognition will become second nature, and the two schedules will not likely be confused. A second principle is that there should never be two versions of the schedule posted on the day of surgery. Each preliminary schedule must be removed.

Instrument sets need to be opened prior to the patient coming into the room, and must be inspected by the surgeon prior to any anesthesia being administered. Good leadership in the OR will help the team to understand the importance of these checks, and team members must understand defense in depth, with multiple people accepting responsibility to check and cross-check.

 Reference
Black Box Thinking: Why Most People Never Learn from Their Mistakes–But Some Do, by Matthew Syed.
https://www.amazon.com/Black-Box-Thinking-People-Mistakes-But/dp/1591848229

Managing the Risks of Organizational Accidents, by James Reason.
https://www.amazon.com/Managing-Risks-Organizational-Accidents-Reason/dp/1840141050