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  Communication errors are a major contributor to the development of adverse events. 6 sentinel cases are presented and analyzed as a learning tool for communication improvement in the perioperative setting

  
  
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  Adherence tp proven communication protocols in the surgical planning, pre-operative briefing, surgical checklist, post-operative evaluation, and transfer of care will decrease communication failures and improve patient outcomes

The Joint Commission defines a sentinel event as “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.”¹ The examination of such events has been used to improve patient safety and quality of care. Although rare, sentinel events still occur in surgery. This chapter examines 6 case studies based on actual malpractice claims data from a medical professional liability insurer. Each case highlights events occurring during the perioperative process, which includes preoperative, intraoperative, and postoperative care. The root causes of such events are examined and solutions for improvement are offered that can be used to improve patient outcomes in surgery and beyond.

Patients may categorize unanticipated outcomes as malpractice, suggesting negligence or incompetence on the part of a professional. However, for physicians and healthcare providers, unanticipated outcomes and even some adverse events from the patient perspective are often viewed as known complications in the practice of medicine. Yet, this view is not always shared by patients and their families. In the United States, these disputes may be settled in court. Unfortunately, the civil tort path to resolution typically takes 4 to 5 years to resolve. It is extremely costly and it leaves an indelible mark on the surgeon or hospital. Because cases are often settled confidentially, we are unable to fully learn from the event.

When looking at adverse events through a lens of patient safety, rather than litigation, the ambiguity of blame that is the hallmark of medical liability tort cases becomes clearer. Ways to improve quality of care for patients, healthcare teams, systems, and individual practitioners emerge.

In 1996, The Joint Commission coined the term “sentinel event” as a source of investigation for patient safety. Sentinel events are unanticipated events that have caused permanent or severe temporary harm or result in the death of a patient. These events signal the need for immediate investigation and response.

Today, accredited organizations voluntarily report sentinel events with their root cause analysis to The Joint Commission. Together with The Joint Commission’s supplemental analysis, these events are collected and categorized to assess the reasons for failure and find sources for improvement.

Reporting of such events has become a primary mechanism for improving quality and safety. Robert Wachter, MD, Professor, Associate Chair of the Department of Medicine at the University of California, San Francisco, states:

Dr. Wachter’s comments emphasize the importance of reporting errors so we can use them as a learning tool.

In 2015, The Joint Commission reported the sentinel events catalogued over the previous 10 years. Many of the sentinel events occurred in the operating room and during perioperative patient experiences. The report illustrates there are often multiple root causes that underlie a single sentinel event, with communication breakdowns ranked as a top factor throughout the analysis.² See Figure 17.1.

In this chapter, I use sentinel event cases to stress the importance of team communication at all levels to improve patient outcomes. The cases represent a mix of more than 30,000 events that COPIC, the Colorado Physician Insurance Company, has in its claims database. Names and places of those involved have been changed, but the nature of the event remains consistent with the error. Although the cases are surgical in nature, it is hoped that anyone providing patient care will learn from these sentinel events.

Case Study 17.1

Outline of the problem: Wrong side/equipment.

The hypothesis: To assure effective and efficient outcomes for surgical patients, it is essential that all personnel involved in patient care be fully informed of the intended procedure. Communication breakdown at any level can lead to poor patient outcomes.

The story: Dr. Hunk is a well-trained orthopedist who limits his practice to joint replacements. He has a great reputation, and performs 450 to 500 arthroplasties per year.

Mrs. Verna Lewis is a 78-year-old woman with a history of multiple joint replacements for rheumatoid arthritis. Both artificial hips, implanted 23 (right) and 25 (left) years ago, need revision. After discussing his plan with Mrs. Lewis and her husband, Dr. Hunk sends them to his surgery scheduler with a surgical form that includes the following:

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  Operation: bilateral revision, staged, R/L

  
  
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  Time: 5 hours

  
  
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  Equipment: cement remover, revision set

  
  
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  Rep to be present. Call and template.

On the day of surgery, Dr. Hunk confirms with Mrs. Lewis that he will be revising the older, left hip. She and her husband agree. As is his custom, Dr. Hunk uses an indelible marker to outline the posterior incision and sign his initials. As is his routine, he adds a smiley face at the end of the surgical site.

Following induction of anesthesia and lateral positioning of the patient, the operation proceeds smoothly. The prosthetic stem and cup are removed. Dr. Hunk begins preparing the femoral canal and asks for the revision broach. The operating room nurse hands him a broach for a right stem, and reports that all stems and trial components are for a right femur. Dr. Hunk calls the manufacturing representative, but per hospital policy, the representative is not allowed in the operating room. The following conversation transpired:

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  Dr. Hunk: Do you have a left revision set?

  
  
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  Rep: I was told it was a right revision.

  
  
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  Dr. Hunk: Back to my question. Do you have a left revision set?

  
  
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  Rep: Yes. Unfortunately, it will take at least 3 hours to get it here.

The patient’s outcome: Dr. Hunk washed out the wound and closed the hip without prosthesis. Later that day he apologized to Mrs. Lewis, explained the error, and informed her of his plan to return her to the operating room to complete the operation within 2 to 3 days. Unfortunately, Mrs. Lewis developed postoperative atelectasis, which delayed the second surgery. She then experienced a deep venous thrombosis that required 6 weeks of anticoagulation therapy. Because of her inability to walk with a walker, she required a 3-month nursing home stay. She and her husband sought the services of another orthopedist who told them that Dr. Hunk committed malpractice. Mrs. Lewis files a lawsuit, and Dr. Hunk subsequently settles out of court for several hundred thousand dollars based on pain, suffering, and the need for ongoing medical and nursing home care.

What went wrong? A number of factors led to this event. To start, the scheduling form was ambiguous. Mrs. Lewis needed both hips revised, and the scheduler assumed that the right side would be performed first because it was written first. The scheduler never discussed the surgery with Dr. Hunk. Because she believed the right hip would be revised first, this is what was communicated to the manufacturing representative.

The manufacturer’s representative made templates from the x-rays. Because both hips were to be revised, the rep marked both the right and left side, sizing the prosthesis for each side accordingly. Dr. Hunk never spoke directly to the representative but placed the marked x-rays on the operating room view box. Hospital protocol did not allow the representative to be in the surgical suite, so he was not allowed to view the revision set of hip instruments as the operating room was opened. Finally, preoperatively, the surgical technician was counting and organizing the hundreds of pieces of equipment needed for a revision hip surgery. The scrub nurse never knew she had the wrong equipment until she was asked for the femoral broach.

Hindsight evaluation of any wrong-side or wrong-site surgery is relatively easy to understand. Yet despite major efforts, these errors continue.

In 2004, The Joint Commission published the Universal Protocol designed to eliminate wrong site/side/procedure/patient surgery.⁴ The protocol consists of 3 parts:

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   Patient verification of the procedure to be performed

   
   
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   Surgical site marking

   
   
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   A time-out before starting surgery

Yet several authors have confirmed surgeries on the wrong patient, wrong site, and wrong procedure continue to occur despite the Universal Protocol.⁵ It must be remembered that such sentinel events are rare, occurring at an estimated 1/113,000 surgeries for wrong-site events. Reviewing more than 27,000 incidents in the COPIC taxonomy, Stahel et al found 107 wrong-site and 25 wrong-patient surgeries between 2003 and 2008.⁶

Unfortunately, the persistence of such events despite nearly 13 years of using the Universal Protocol attests to the difficulty of eradicating such errors. Systems analysis shows that these events involve more than just a surgeon operating on the wrong body part or without the proper equipment. The patient experience begins well before the physician-patient encounter. A phone call to the office may trigger a problem list, and language barriers are magnified by phone conversations where nonverbal cues are masked. Receptionists and office aides often help complete forms that might create an anchoring bias for diagnosis and treatment. The patient’s journey through the hospital and operating room is guided by the surgeon, who relies on his or her team to help throughout this journey. The team is large and involves receptionists, nursing assistants, surgical schedulers, physician assistants, perioperative personnel, manufacturers’ representatives, anesthesiologists, residents, radiologists, pathologists, and others.

How to prevent this error in the future? Had the team taken a surgical time-out, the outcome may have been different. The surgical time-out represents the last check before starting the procedure. The immediate members of the surgical team including the surgeon, anesthesiologist, circulating nurse, and surgical technician must participate in a standardized, controlled process.

In 2009, the World Health Organization (WHO) used its experience to publish the WHO Surgical Safety Checklist and implement it in 8 diverse institutions.⁷ Significant reductions in morbidity and mortality were noted. Despite such observations, utilization of the perioperative checklist remains inconsistent. In a 2015 article, Walter Biffl, MD, explored the inconsistencies surrounding use of these protocols in an observational study of 854 cases involving 10 Colorado hospitals that had mandated use of the WHO checklist.⁸ Dr. Biffl observed significant suboptimal compliance with the checklist, and he suggested a lack of surgeon leadership about the issue was a major contributor to noncompliance.

Lesson learned: Surgeons need to be aware of the areas of high risk this case study exemplifies. Special attention needs to be paid to communication in these areas:

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  Surgical schedulers, whether in the office or operating room, are part of the perioperative team. Accurate communication between surgeon and scheduler is imperative.

  
  
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  Complex operations involving equipment not routinely found in the hospital or surgery center require accurate communication between the supplier and the surgical team.

  
  
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  Preoperative briefings should confirm the correct patient, site, operation, medicine, labs, and equipment needed for a successful surgery.

Case Study 17.2

Outline of the problem: Wrong-patient surgery.

The hypothesis: Operating on the wrong patient is a nightmare for surgeon and patient. Despite recognition of this problem by all healthcare providers, wrong-patient surgery will persist until healthcare teams develop fail-safe systems of care assuring that the right surgery is being performed on the right patient.

The story: At age 72 and recently widowed, Ms. Hua Wong had emigrated from China to the western United States to join her 7 children and 22 grandchildren. She never learned English, and continued to speak exclusively Mandarin. The family lived in an area with a large Chinese population, and Ms. Hua Wong was quite comfortable staying almost exclusively within her Mandarin circle. As the years went by and her health declined, she relied exclusively on her children to translate all interactions with any non-Mandarin-speaking healthcare worker.

Following a heart attack, Ms. Hua Wong lost a significant amount of weight. She complained of jaw pain while eating, and her primary care physician determined she suffered from temporomandibular joint dissociation. A CT scan and a subsequent visit with an oral maxillary surgeon resulted in a planned 2-hour surgery scheduled for the following Tuesday at noon. Her eldest daughter told the surgeon that she would take the afternoon off to be with her mother on the day of this planned surgery. The other siblings would arrange their schedules to be with their mother during the expected 3-day hospital stay. Because of her multiple comorbidities, Ms. Hua Wong was admitted to The Medical Center Hospital on Monday night, with surgery scheduled for Tuesday.

Meanwhile, on Monday night, neurosurgeon fellow Dr. Brash performed a consult on a woman of Chinese origin who spoke no English, Ms. Huan Wong. From the history given by Ms. Huan Wong’s children, Dr. Brash determined that Ms. Huan Wong suffered from a subdural hematoma as a consequence of a fall.

Dr. Brash performed the initial evaluation on Ms. Huan Wong. His professor, Dr. Nuevo, was an American-trained, Nicaraguan-born neurosurgeon. He had fled Nicaragua in 1979 during the Sandinista revolution and had received his U.S. citizenship after serving 4 years in the Air Force as a neurosurgeon. He enjoyed a great reputation and had developed a very busy practice. As 1 of 7 neurosurgeons on the faculty at The Medical Center Hospital, he allowed the chief residents and fellows to initially evaluate consults and emergency department patients. As a professor of neurosurgery, Dr. Nuevo believed this was part of his teaching responsibility.

As was his routine, Dr. Nuevo listened to the history and reviewed the pertinent films involving consults and emergency department visits with Dr. Brash during evening sign-out rounds. Both Dr. Nuevo and Dr. Brash agreed with the CT interpretation for Ms. Huan Wong:

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  Nondisplaced fracture in the right temporal area.

  
  
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  Accompanying subdural hematoma, perhaps old, with mild midline ventricular shift noted.

Dr. Nuevo discussed with Dr. Brash the need for surgical evacuation. He suggested Dr. Brash prepare to place an interventricular shunt if the patient had a history of multiple falls. Dr. Nuevo told Dr. Brash that he would be willing to add Ms. Huan Wong as his fourth surgery on Tuesday if she was medically ready. As was his custom for in-house consults and emergency department cases scheduled to go to the operating room, Dr. Nuevo planned to meet the patient and her family in the surgical preoperative holding area immediately before the operation.⁹

Dr. Brash returned to Ms. Huan Wong’s bedside, where several of her children were present. Each wanted to serve as translator for their mother. Dr. Brash patiently answered all questions about the risk and benefits of the procedure. All agreed to the plan for surgery on Tuesday, and Ms. Huan Wong’s daughter signed the consent form.

Dr. Brash added the craniotomy procedure as Dr. Nuevo’s fourth case for the next day.

At 10:00 pm on Monday, Dr. Brash received a call from the anesthesiologist doing preoperative evaluations. Dr. Nuevo’s first case, an anterior cervical decompression and fusion, needed to be cancelled due to the patient contracting pneumonia. The anesthesiologist asked Dr. Brash if it would be okay to move Dr. Nuevo’s fourth case up to the first case. This would allow the second and third case, both outpatient lumbar discectomies, to continue as scheduled. Dr. Brash agreed, and he sent a text message to Dr. Nuevo informing his professor of this change.¹⁰

Tuesday morning: At 6:00 am on Tuesday, operating room attendants arrived on the ward to take Ms. Huan Wong to the operating room. The unit secretary went through the charts provided for Tuesday’s surgical cases, and gave the attendants the hospital chart for Ms. Hua Wong. The attendants mistakenly picked up Ms. Hua Wong.

Upon arrival to the busy preoperative holding area, a nurse verbally confirmed with the attendants that the patient was Ms. Huan Wong and that the chart contained lab work and consent for craniotomy. The nursing and anesthesia staff did not read the preoperative history and physical exam.

In the preoperative holding area, Dr. Nuevo quickly scanned Ms. Hua Wong’s chart, which contained Dr. Brash’s note and consent form. No family members were present, and Dr. Nuevo asked the nursing staff to call the family to inform them of the surgical time change. Aware of the language barrier, Dr. Nuevo warmly greeted Ms. Wong with a smile and a gentle handshake and introduced himself in English. He marked Ms. Wong’s right temporal area, and signed his intended incision site. Per hospital policy, he made an interpreter available by phone. Through his phone interpreter, Dr. Nuevo told Ms. Wong that he was the surgeon. He asked her if she had any questions about her surgery. She asked why her family was not present, and Dr. Nuevo, speaking through the phone interpreter, told her that the operating room schedule had changed. He added that in his experience, it is an advantage for an older patient to have an earlier surgery schedule. He hoped she understood. Ms. Wong smiled and said she had no more questions.