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Miscommunication in the OR Leads to Anticoagulation Mishap

Ian Solsky, MD, and Alex B. Haynes, MD, MPH | December 1, 2017
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The Case

A 63-year-old man with a history of coronary artery disease and diabetes was scheduled to undergo bilateral femoral artery embolectomy. Eight months previously, he had experienced a myocardial infarction and was started on dual antiplatelet therapy with aspirin and clopidogrel. Six days prior to surgery, as instructed by the surgeon, he stopped taking his aspirin and clopidogrel in order to decrease the risk of bleeding during and after the operation.

On the day of surgery, just prior to anesthesia induction, the team conducted a preoperative briefing, using the World Health Organization Surgical Safety Checklist. The patient's identity, the operation, the surgical site, and the anesthesia plan were verified. The surgeon told the anesthesiologist that the patient would benefit from epidural analgesia continued into the perioperative period. However, he failed to mention that postoperatively the patient would be therapeutically anticoagulated with enoxaparin for several days. The anesthesiologist was new to the hospital and unfamiliar with the postoperative management of patients undergoing femoral artery embolectomy. After surgery, no formal postoperative debrief was conducted. Unaware that the patient was going to be placed on enoxaparin, a blood thinning medication, the anesthesiologist continued orders for epidural analgesia and the epidural catheter remained in place.

The patient was started on enoxaparin per the surgeon's order. Five days later, the epidural catheter was removed. Fortunately, the patient did not experience bleeding, a potential and sometimes devastating complication of therapeutic anticoagulation in patients with epidural catheters.

The Commentary

by Ian Solsky, MD, and Alex B. Haynes, MD, MPH

As highlighted by this case, communication failures are complex and can occur at both the level of individual providers and the health care system. The surgeon did not share critical information, the newly hired anesthesiologist did not speak up about his unfamiliarity with protocol, and no operating room (OR) team member initiated a debrief. It is equally concerning that no safety checks at a systems level were in place to help providers identify this issue for 5 days postoperatively when a serious complication could have resulted and caused permanent patient harm.

Communication errors are common in surgical care. In one study exploring OR communication failures, researchers found that they were present in approximately 30% of team exchanges and that one third of these jeopardized patient safety.(1) Another study found that 43% of errors reported by surgeons at three teaching hospitals were partly due to communication breakdowns.(2)

Not only do communication errors occur frequently, but they are also pervasive across all stages of surgical care. A study of communication breakdowns reported in malpractice claims found that they occurred preoperatively in 38% of cases, postoperatively in 32% of cases, and intraoperatively in 30% of cases.(3) Contributing factors included steep hierarchy, conflicting roles and role ambiguity, and interpersonal power and conflict.(4)

To try to address these errors, interventions have been designed to strengthen teamwork and communication among providers to create a safer environment for patients. One of the most widely adopted interventions to improve OR communication is the World Health Organization Surgical Safety Checklist, which has been shown to reduce surgical morbidity and mortality. One study demonstrated that after implementation of the checklist in 8 hospitals in 8 cities, the rate of death was reduced from 1.5% to 0.8% (P=0.003) and inpatient complications fell from 11% to 7% (P<0.001).(5) Use of the checklist has also been associated with improved perceptions of teamwork and safety.(6)

Beyond the checklist, many other interventions have been developed and tested to prevent communication errors in the operative environment. These interventions include team-based training programs such as TeamSTEPPS (7), coaching focused on improving OR briefings and debriefings (8), and a variety of surgical handover instruments and frameworks.(9) Technology will undoubtedly also play a bigger role in the future and has already been used in the form of computerized handover templates (9) and clinical decision support systems such as those that alert providers to possible safety issues when administering critical medications.(10)

Although hospitals that have adopted such interventions are taking important steps toward building a culture of safety, the continued prevalence of communication-related errors suggests that these interventions may not be having their intended effects. This is potentially due to faulty implementation, as in the case above where the checklist was incompletely performed. If safety interventions are not implemented properly, they cannot be expected to prevent patient harm.

Serious barriers to checklist implementation have been noted, including challenges associated with integrating the checklist into the workflow of OR teams, conflicting priorities of various stakeholders responsible for implementation, and skeptical or negative perceptions of the checklist.(11) As underscored by a study across all acute care hospitals in Ontario, Canada, simply mandating that the checklist be used without providing proper training and support for those tasked with implementation will not result in improved postoperative outcomes.(12) The importance of staff engagement and proper implementation are not unique to the checklist but are applicable to any intervention attempting to bolster teamwork and communication. For example, while information technology–based interventions may be designed to improve patient safety, they may actually contribute to sentinel events if they are adopted too rapidly without sufficient staff training and resources.(13)

To prevent communication errors, health care organizations must dedicate themselves to building a safety culture that addresses both individual and systems-level factors. This is essential given that negative perceptions regarding the safety of surgical practice among OR personnel have been associated with hospital-level 30-day postoperative mortality rates.(14) However, building an optimal safety culture is challenging: no single intervention can address all communication-related failures and is generalizable to all settings. In light of the significant variability in perceptions of safety culture both within and between hospitals, interventions must be tailored to meet the needs of the particular clinical area or health care organization.(15)

Although use of a surgical safety checklist is an attractive starting point for a hospital trying to prevent communication errors in the operative setting, the challenges associated with effective implementation should not be underestimated. Hospital leadership must be prepared to modify the checklist to fit local practice, work with all OR stakeholders to ensure engagement, and have a system for psychologically safe error reporting and monitoring in place to have maximal impact. The same holds true regarding the implementation of a team-based training program or a new technology. Health care systems should also make efforts to onboard trainees and new staff to ensure a shared understanding of systems of care as they adapt to a new setting. Establishing and sustaining a culture of safety requires multifaceted interventions implemented effectively, thoughtful leadership, and staff engagement.

Take-Home Points

  • Miscommunication is common in health care settings and places patients at risk for complications. Interventions targeting both individual and systems-level factors to improve communication may prevent harm.
  • Although surgical safety checklists have been shown to reduce morbidity and mortality, they must be implemented properly to yield meaningful safety improvements.
  • Health information technology (IT) may play an important systems-level role in preventing harm, even when there is a communication failure between individuals. Targeted use of IT interventions such as safety alerts via the electronic health record should be used selectively, while accounting for alert fatigue.
  • Establishing a culture of safety requires the dedication of hospital leadership to continually promote patient safety interventions tailored to fit local practice and to ensure staff engagement in these efforts.

Ian Solsky, MD Research Fellow, Ariadne Labs Brigham and Women's Hospital Harvard T.H. Chan School of Public Health

Alex B. Haynes, MD, MPH Assistant Professor of Surgery Harvard Medical School Massachusetts General Hospital Associate Program Director, Safe Surgery, Ariadne Labs Brigham and Women's Hospital Harvard T.H. Chan School of Public Health


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This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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