Patient Safety Scenario #5: Communication
This essay is the fifth 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.
Scenario
A patient needed a trigger release and the surgeon filled out a surgery request form, asking for 30 minutes under a MAC anesthesia. The form was transmitted to the surgery scheduler, who duly entered the data. However, due to a recent update to the software in the surgery scheduling office, as the data got transferred from the scheduling software to the surgery center EMR system, the case got changed to two hours under a general anesthetic, but the change was not noticed by the scheduler.
On the day of surgery, the surgeon re-examined the patient, signed the site next to the patient’s mark, and went to the room to check instruments. The anesthesiologist read the OR schedule and saw that the case, a trigger finger, was scheduled for two hours under a general. He knew the surgeon well and figured it must have been scheduled this way for a reason, with some kind of complication not reflected in the coding as a “trigger finger”. He consented the patient for a general and went to the room to prepare his drugs.
The patient was brought to the room, the surgical pause was performed properly, and the patient was transferred to the table. As the anesthesiologist was about to put the patient to sleep, the surgeon noticed that an LMA had been laid out. He asked, “Why an LMA for a 10 or 15 min case?” The anesthesiologist replied, “Well, it is booked for two hours.” A discussion ensued and the scheduling error was discovered.
Analysis
The fact that communication errors are a major factor in medical errors that lead to patient harm has been documented by many studies. The Joint Commission annually reviews sentinel events and has found that communication is often the number one cause, and is rarely not in the top four. 1 A study by the medical malpractice insurance company that provides coverage for 26 Harvard-affiliated hospitals found that communication failures were linked to 1,744 deaths in five years. 2 A study by Woolf, et al., released in 2004 showed that communication errors were frequently the root cause of medical errors. 3 A four-year study in six Danish hospitals found that verbal communication errors were present in 52% of patient safety incidents 4 The American Hospital Association has identified communication as a key skill for health professionals.5
You are a good communicator, right? You have no real need for improvement, correct? Yet if we ask our spouses if we are a good communicator, we are likely to get a different answer. Communication is a skill that can be developed, but you have to work at it. Communication, or the lack of it as the scenario above demonstrates, in the OR can easily go wrong. How often have you asked the circulator to get something, they leave the room without verifying that they heard you, and come back with the wrong item? A simple readback would solve that problem. Open communication within the OR team does not necessarily come naturally and must be learned, taught, and encouraged. This problem has been studied by many industries where the stakes for miscommunication are high (military, aviation, nuclear power) and techniques for improved communication have been developed and are now advocated by the Joint Commission through the TeamSTEPPS program, which is also advocated by the AAOS 6. Communication is one of the four key teachable/learnable skills of the TeamSTEPPS program. 7
Root Cause Analysis
Communication Error
Suggestions
The surgeon should encourage open communication with the team. It is good practice to speak to each team member by name, including the anesthesiologist, scrub tech, circulator, and anyone else who is involved. A “huddle” is a way to accomplish this quickly and efficiently. The surgeon should discuss the case with them, highlighting any special aspects of the case and special equipment, supplies, or procedures that are relevant. They should be encouraged to speak up if they have a concern, using the CUS (concern, uncomfortable, safety issue) format and all orders should be given in the Check Back format (see TeamStepps, 8). The surgeon should, at a minimum and in every case, review the planned procedure and anesthetic with the anesthesiologist.
References:
1. The Art of Handoff Communication https://www.jointcommission.org/quality_reliability__leadership/the_art_of_handoff_communication/
2. Communication failures linked to 1,744 deaths in five years, US malpractice study finds. Online article, https://www.statnews.com/2016/02/01/communication-failures-malpractice-study/ Accessed 8/4/18
3. Woolf, SH, et al., A String of Mistakes: The Importance of Cascade Analysis in Describing, Counting, and Preventing Medical Errors. Ann Fam Med. 2004 Jul; 2(4), 317-326. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1466697/
4. Rabol L, et al. Republished error management: Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals. Postgrad Med Journal 2011 Nov; 87(1033):783-9.
5. Focusing on Teamwork and Communication to Improve Patient Safety, website of the American Hospital Association https://www.aha.org/news/blog/2017-03-15-focusing-teamwork-and-communication-improve-patient-safety accessed on 8/5/18
6. AAOS TeamSTEPPS webpage, https://www.aaos.org/Education/TeamSTEPPS/ accessed on 8/5/18
7. Joint Commission, TeamSTEPPS (Microsoft PowerPoint version) https://www.ahrq.gov/teamstepps/instructor/essentials/index.html
8. Joint Commission, TeamSTEPPS , PocketGuide https://www.ahrq.gov/teamstepps/instructor/essentials/pocketguide.html#cus accessed 8/5/18