Cases & Commentaries

On O.R. Off?

Commentary By Michael Leonard, MD

The Case

An elderly man was admitted to the vascular
surgery service with rest pain in his leg. Angiography demonstrated
peripheral artery disease with anatomy suitable for
revascularization. A consulting cardiologist recommended a stress
echocardiogram to evaluate the patient's risk for surgery. While
awaiting those results, the vascular surgery service tentatively
scheduled the patient for surgery the next morning after obtaining
informed consent. Shortly after making their decision, the surgeons
learned that the stress echocardiogram showed marked abnormalities
warranting a cardiac catheterization and delay of surgery. The
surgeons contacted the operating room and informed them that the
case was canceled. When the team rounded on the patient later that
evening, he was asleep, so the surgeons chose to defer their
discussion of the new course of action with him until the morning.
The surgeons documented the change of plans in the patient's chart,
but failed to inform the nursing staff. The patient remained "NPO"
overnight in anticipation of the cardiac catheterization. Due to
unexplained events, the operation was not canceled on the

The next morning the patient was taken to the OR
holding area as the first case of the day. Meanwhile, the vascular
surgery team rounded on the patient only to discover him missing
from his bed. They assumed he was undergoing cardiac
catheterization. Due to time restrictions and the desire to start
promptly, staff did not ask surgeons to mark the operative site in
the holding area outside the OR. The patient was taken to the
operating room, intubated, and given a general anesthetic. When the
OR staff contacted the vascular surgeon to start the case, he
stated that it had been canceled. The patient awakened without
event and suffered no adverse consequences from the error. Cardiac
catheterization and peripheral arterial bypass surgery were later
completed successfully.

The Commentary

Five years ago, the Institute of Medicine's
landmark report on medical errors raised national awareness about
the scope of the epidemic. However, common clinical failures that
put patients and providers at risk continue to exist. Sadly, this
case will not sound unfamiliar to many providers: a complex process
of care, multiple communication failures, and numerous lapses in
basic safety procedures. These represent common and recurrent
elements in unanticipated adverse events.(1) As a practicing anesthesiologist, I have had the wrong
patient brought to the operating room for surgery, not once, but
twice in the same day! Additionally, a colleague related the story
of a patient whose coronary bypass operation was canceled, but
showed up at the hospital "on schedule" to have his operation. The
patient managed to make it all the way through admissions, pre-op
and into the OR, where he received an arterial line and a pulmonary
artery catheter. The mistake was discovered only when the surgeon
was called to start the operation—thankfully before the
induction of general anesthesia.

Let's examine the multiple processes that failed
for this patient, leading to him being mistakenly anesthetized in
the operating room.

Walking through a Series of

First and foremost in this case, there was a
fundamental lack of patient involvement or informed process. The
patient was determined to be at significant cardiac risk,
precluding surgery and requiring further evaluation, but
appropriate communication never occurred. The surgeons obtained
informed consent for the surgery, but failed to inform the patient
of the cancellation. What about communication with other family
members? If the patient and/or family had been actively engaged
during the care process, this error would have been prevented. To
echo the mantra of patient-centered care, "Nothing about me without

Second, the role played by the cardiology
consultant illustrates another missed intervention opportunity.
Cardiologists are frequently asked to evaluate cardiac risk for
patients undergoing peripheral vascular bypass. Based on risk
stratification, subsequent testing is often required to guide
peri-operative management. In certain cases, such test results will
lead to delay, or even cancellation, of surgery. In this case, the
cardiologist likely estimated a high risk for coronary disease
(given the existing peripheral artery disease) and recommended a
stress echocardiogram. Despite the concerning findings and the
decision to pursue cardiac catheterization, the type of
communication that ensued is unclear. Most physicians and nurses
may recall similar scenarios in which crucial test results,
recommendations, and plans are "discussed" only through the chart.
This case illustrates the importance of active communication. A
simple call from the cardiologist to the surgeon—saying, "We
need to cath this guy tomorrow"—would have prevented the
subsequent events.

Think for a moment about the gravity of the
clinical changes: surgery was canceled and a coronary angiogram
scheduled, all while the patient remained symptomatic. How
remarkable, then, that neither the patient, the nurse caring for
the patient, nor the OR staff was informed of the change in plans,
a dearth of communication that allowed the "error chain"—a
series of mistakes linked together—to remain
This type of miscommunication—or more accurately, lack of
communication—runs counter to the dynamic of team-based care.
The care process here favors "action" despite clear and compelling
reasons to hold-off. Overall, this lack of response and
documentation in the face of important clinical changes can likely
be attributed to a "normalization
of deviance," where shortcuts and other activities that are
inherently risky are considered acceptable because "we've never had
a problem."(4) The
fact that the patient remained NPO reinforced the concept that he
was having the surgery.

Third, we turn to the role of the surgical team,
which attempted to cancel the case—attempts that failed both
in the operating room and on the surgical ward. Due to the error,
what is arguably the most expensive resource in the hospital (a
fully-manned operating theater) remained poised for a canceled
procedure. Holding onto available OR time in order not to lose
access "normalizes" the practice of cases being changed around
frequently. This leads to greater challenges in catching the
mistake, and the lack of predictability makes it harder to detect
errors. As the plan of care changed, multiple caregivers were
acting the same roles but appeared to be acting in different
movies. Health care delivery represents such a complex and dynamic
process that simple but regimented communication mechanisms play a
critical role in keeping "everyone on the same page," especially in
the face of changing dynamics.

Finally, we see a system primed for speed more
than safety. For instance, although site marking is required by
JCAHO and advocated as a standard of care by professional surgical
societies, this crucial step failed to occur due to time-saving
efforts. Site marking is one tool to prevent communication mishaps.
Along similar lines, this patient received preparations for surgery
prior to the arrival of the operating surgeon. Once again, the
motivation behind the ragged process revolved around time-saving
goals. The tendency to take shortcuts and save time is a very human
one, but it also increases the risk of a mistake.(4) If providers are routinely taking shortcuts and doing
"adaptive work" to provide the best care, then the care process
needs to be examined and quite likely re-designed. Safeguards, like
briefings, can be very time efficient investments, as they
dramatically reduce the frequency of getting in the middle of an
operation or procedure and discovering the necessary equipment or
personnel are not available.

The ideal process to have prevented this error
would have been a clear model of communication with patient and his
family as to what the plan of care was, telling the nurses what to
expect, clearly telling the operating room when the case had been
canceled, and not taking a patient into surgery until the surgeon
has been present in the operating room and seen the patient. The
difficulty here is that the rules seemed quite variable, and the
practice of keeping the OR time invites mistakes. Lack of
predictability greatly increases the risk of mistakes.

Typically, when a surgical case is "booked,"
orders are written in the patient's chart on the ward, the OR desk
is consulted (often verbally), and consent is obtained from the
patient. The system is now primed for action. Given the dynamic,
ever-changing nature of patient care, basic communication
mechanisms can keep everyone on the same page. A structured process
for adding and canceling cases with the OR would have confirmed the
cancellation, and ideally notified the surgical floor. That's a
reliable system fix. If the surgical team and the nurses on the
ward had spent 5 minutes briefly discussing the plan for each
patient that day, everyone would have known the surgery had been
canceled, and the patient would have never gone to the operating
room. When the anesthesiologists were presented with a patient with
severe cardiac risk, communication between the two groups would
have quickly caught the error. In the OR area, a short briefing
prior to induction of anesthesia between the team members would
have caught the problem also. The combination of a reliable
scheduling system along with structured communication to keep the
team aware of the plan of care would have provided many
opportunities to preclude what happened.


This error was the result of a complex system
with multiple communication failures, which is how most medical
mistakes happen. No one had the big picture of what was supposed to
happen. Many things had to go wrong for all these mistakes (ie, the
"holes in the This error was the result of a complex system with
multiple communication failures, which is how most medical mistakes
happen. No one had the big picture of what was supposed to happen.
Many things had to go wrong for all these mistakes (ie, the "holes
in the Swiss
cheese") to line up.(5)
Given the complexity of medical care, the combination of effective
communication, teamwork, and reliable systems of care are essential
to providing safe and high-quality care.

As we mark the five-year anniversary of the IOM
report, an opportunity to reflect on our progress in reducing
medical errors exists.(6) My
feeling is that we must aim to transform medicine from a culture of
the expert provider to one of a team-based model of care. This
takes time. Many organizations are adopting a strategy to promote
pre- and post-procedure briefings to ensure everyone "stays in the
same movie" as we provide patient care, the use of critical
language to "stop the line" when there is a concern, and the
promotion of situational
awareness, where all the team members know what is going to
happen and what to expect.(7)
Most critically, medicine is moving toward the realization that
some basic safety procedures cannot be optional—they simply
must become integral parts of medical citizenship.

Take-Home Points

  • Actively engage patients and their
    families about their care. They're the most invested in "getting
    things right," so use them to partner in delivering safe and
    quality care.
  • Use effective and active communication
    with members of a surgical team (or any service) when planning
    procedures based on contingencies.
  • Engage in formal mechanisms for
    communicating changes in patient plans: orders, checklists, and
    briefings, including notification of relevant providers (eg,
    nursing staff or OR staff).
  • Consider specific processes with double
    checks for adding or canceling cases in the operating room as these
    mistakes can be costly and dangerous.

Michael Leonard, MD
Physician Leader for Patient Safety, Kaiser Permanente
IHI Faculty


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immune to errors. New York Times. February 23, 2003:sect. 1.
Available at: [ go to related site ]. Accessed February 14,

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Achieving safe and reliable healthcare: strategies and solutions.
Chicago, IL: Health Administration Press; 2004:81-92.

3. Gaba DM, Maxwell M, DeAnda A. Anesthetic
mishaps: breaking the chain of accident evolution. Anesthesiology.
1987;66:670-6.[ go to PubMed ]

4. Vaughn D. The Challenger launch decision:
risky technology, culture and deviance at NASA. Chicago, IL:
University of Chicago Press; 1996.

5. Reason JT. Managing the risks of
organizational accidents. Burlington, VT: Ashgate Publishing
Limited; 1998.

6. Wachter RM. The end of the beginning:
patient safety five years after 'To err is human'. Health Aff
(Millwood). 2004:W4-534-45.[ go to PubMed ]

7. Leonard M, Frankel A, Simmonds T.
Achieving safe and reliable healthcare: strategies and solutions.
Chicago, IL: Health Administration Press; 2004.