This essay is the tenth 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

Patient Safety and Developing a Culture of Communication

By Julie E. Adams, MD

Patient Scenario:

A 37-year-old healthy woman presents to you for elective hand surgery after failing nonoperative treatment. You discuss the planned surgery and she wishes to proceed. She has had a thorough preoperative assessment, which presents no concerns. The attending anesthesiologist is experienced and dedicated, as is the CRNA. The plan for anesthesia is for a general with a LMA in the operating room. Your patient’s husband, who is a pilot, and her two young children, drop her off at the surgery center and go to run errands, planning on seeing her later that day.

The induction is performed, but the anesthesiology team has difficulty establishing an airway. Initial attempts with a laryngeal mask are not successful. The anesthesia team then attempts to intubate her, unsuccessfully.  The patient’s oxygen saturations continue to drop to 40% and less. Attempts to ventilate with 100% oxygen and an oral airway/ face mask are unsuccessful. A call for help is made, and now a second anesthesiologist joins the operating room, and 2 CRNAs, an ENT surgeon, and 2 nurses are now in the room. Repeated attempts are made to intubate the patient. She appears grossly cyanotic, and her oxygen saturations are at the lower limit of normal that the machine reads. One nurse, unsolicited, leaves the room, then returns, announcing she has secured a tracheostomy tray. The OR staff persist, unsuccessfully, in attempting intubation. You stand by, feeling helpless, but knowing something is terribly wrong, yet feeling uncomfortable about speaking up; after all, you are just a hand surgeon and not an expert in airway management. You leave the room, and call the ICU to let them know your patient–here for an elective “simple” surgery(!)–will be coming to the ICU, to give them a “heads up.” You return to the room and announce that you’ve called the ICU attending to let them know about the patient. You receive a look from the team that says, “What for? You are overreacting.”  Confused, you call back the ICU and tell them things are under control. Over 35 minutes passes, and the team is struggling. The anesthesia staff tell you that the procedure should be abandoned, and an attempt is made to awaken the patient. Ultimately, she is transferred to the ICU. She never regains consciousness, and 13 days later, she dies.

This is a fictional scenario, based upon a real patient’s case, Elaine Bromiley. The scenario highlights many issues associated with the challenges of spoken and unspoken communication, the team culture, and the authority gradient in the room.

No one argues that communication is essential to optimal patient safety.  A PubMed search of “patient safety AND communication” yields 9071 results! Not only do we need to communicate well with our patients and their families, but also with our colleagues and support staff. However, communication is not just the words we use, but also relates to nonverbal communication, the factors related to the environment and atmosphere, as well as the cognitive load and past experience of those receiving communications. Furthermore, as the saying goes “we may all be speaking English, but we aren’t talking the same language.” In this Patient Safety moment, we explore issues associated with communication culture and with our team.

Operating rooms particularly are a high stakes, high intensity environment, and are hierarchical in nature. Additionally, issues with workplace environment and culture can be an issue that impairs communication.  Recently the American Academy of Orthopaedic Surgeons surveyed members asking about work environment and culture (Van Heest & Weber). Over 50% of all survey respondents – both sexes and members of all races and ethnicities — reported they had experienced discrimination and bullying! The Royal Australian College of Surgeons also found nearly half of surgeons had experienced discrimination, harassment or bullying in the workplace, and in response launched an initiative aimed at “Let’s Operate with Respect” and “Building Respect and Improving Patient Safety.” If practicing surgeons experience this cultural issue, imagine the environment that our trainees, surgeons new in practice, our new nursing and clinical support staff might experience. Thus, a person who feels that they are less trained, lower in status in the hierarchy, or are more in a support role than a leadership role may feel particularly uncomfortable speaking up. Past experiences and relationships, and feelings of intimidation can be a driver such that certain individuals may not feel comfortable telling the surgeon that they feel there may be a problem. Furthermore, the concept of “cognitive load” incorporates the individual’s ability to receive process and act upon information or a message received. Specifically, in a stressful situation or in which a lot of information is coming at a person at once, they may not have the ability to process that information and act upon it.  It is therefore imperative that we as surgeons try to make ourselves approachable and make the environment one that welcomes questions and everyone feels comfortable speaking up.

Bromiley et al. and Paterson et al. described a tragic case in which a patient, Elaine Bromiley, died after a failed intubation for an elective surgical procedure. During the course of an attempted oxygenation for an elective procedure, Mrs. Bromiley became hypoxic. Highly experienced, dedicated, and skilled staff focused upon trying to intubate the patient. They persisted despite repeated failures to intubate and oxygenate the patient. The patient’s status deteriorated progressively as time passed. A nurse brought in a tracheostomy tray (without being asked) and stated it was ready, attempting to transmit concern about lack of oxygenation and the need to seek alternative means of ventilation, but the staff remained focused upon intubation. Another nurse (without being asked) called and requested an ICU bed, and announced that this was done, attempting to transmit to the team her concern about the emergency status and the patient’s further deteriorating status. In this situation, it has been suggested that the medical staff were attempting to intubate the patient and were focused upon that task; they were overwhelmed by a rapid sequence of events and were unable to understand or receive the messages transmitted to them. Ultimately, Mrs. Bromiley expired.

Later, her husband, Martin Bromiley, requested an inquest into the factors contributing to his wife’s demise. The result of that investigation prompted Martin Bromiley, trained as a pilot, to found the Clinical Human Factors Group (https://chfg.org/), an organization focused upon improving safety in healthcare. According to the analysis of this event, it has been suggested that some of the patient safety communication failures in this situation and in others may be related to differing communication styles, the authority gradient in the room, and the cognitive overload (Wachter and Patterson et al.). The authority gradient in the room discouraged staff from directly asserting that the patient was becoming hypoxic and this was an emergency, and that an alternative method of ventilation should be sought; rather there was a “hint and hope” dialogue. Wachter notes that nursing or support staff communication styles may avoid direct or confrontational communication, while physicians are trained to be direct and succinct. The nurse that called the ICU and the one that brought in the tracheostomy tray were trying to “hint” that this was an emergency situation, and that they had concerns about the patient’s deteriorating status, without overtly stating that. The physicians and anesthetists didn’t receive or understand that communication due to the lack of direct communication and the stress of the situation causing cognitive overload.

How can we as hand surgeons make sure we are communicating optimally in our own practice and operating rooms?

 Firstly, we can try to make our operating room a place that our staff feel comfortable speaking up when they are concerned and be aware of “authority gradients”. It may be helpful to tell the occasional self-deprecating (and true!) story about a time you were wrong or the time you learned from someone (a nurse, a tech, an intern) something “new” or something that helped your practice or your patient. Be aware of your body language, your expression, and your nonverbal communication. Set yourself up for success to avoid potentially getting trapped by hierarchy.  In my operating room, I prefer to have the time out proceed in a “reverse hierarchical” fashion, in which the surgeon is the last to state the planned procedure.  Imagine a new OR staff member doing the time out.  I want that new person to feel comfortable saying what they think we are doing in the case, rather than potentially feeling intimidated “correcting” the surgeon, as they might if I went “first” in the time out.

Additionally, we can be aware of the communication style differences that may exist, particularly with the indirect communication styles such as “hope and hint”.  One strategy that has been suggested is teaching individuals to use and recognize key “CUS” words to use with progressive escalation if the message is not received, with “I’m concerned…”, then “I’m uncomfortable…” and finally “this is a safety issue” (Wachter 2012).  If you hear these terms, then pay attention!

Lastly, be aware of your own cognitive load as well as those in your operating room. Be aware that if your colleagues or staff seem frazzled, they may not be able to receive the message you are trying to transmit. We all know how this works in our own situation! Each of us can recall a time when we were at a tenuous portion of a surgical procedure or in the middle of a case that wasn’t yet going the way we planned, when we were hard at work and thinking intently about the case.  Someone ”interrupts” you to ask about something not crucial to that portion of this particular case; maybe it is information about the last patient or about a patient in clinic, or even a question like “what suture do you want to close with?” but you can’t give them a good answer or maybe you have to take a second to pause and redirect your attention towards that information.  Perhaps you ask them to ask you again later.  In any case, your cognitive load doesn’t permit you to process that information or answer that question at that point in time without redirecting your own attention.  It is important to recognize this and understand when you might “miss” important information.   Likewise, be aware of the “cognitive load” of your team – the anesthesia care provider, the tech, the nurse and your assistant and if they can process your messages.

References:

Ann Van Heest & Kristy Weber: An Assessment of Culture in Orthopaedic Surgery. AAOS Now, December 2018.

https://www.surgeons.org/media/22260415/RACS-Action-Plan_Bullying-Harassment_F-Low-Res_FINAL.pdf

http://fpm.anzca.edu.au/documents/prod-david-watters-racs-cultural-change-and-teachi.pdf

JG Paterson, J Reid, M Bromiley. Clinical human factors: the need to speak up to improve patient safety. Nursing Standard.  Issue: Volume 26(35), 2 May 2012, p 35-40

Martin Bromiley & Lucy Mitchell: Would you speak up if the consultant got it wrong? And would you listen if someone said you’d got it wrong? October 2009 Vol 19, Issue 10 AfPP.

Martin Bromiley. The Husband’s Story: From Tragedy to Learning and Action. BMJ Quality & Safety. 2015; 24:425-427.

Robert Wachter: Understanding Patient safety.  McGraw Hill Professional, 2012.

The Clinical Human Factors Group: https://chfg.org/

http://simpact.net.au/bromiley.html

Lessons from the Bromiley Case