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September 14, 2021
Wrong Eye Injections
It was ophthalmology that actually introduced us to wrong site surgery. Our initial interest in surgical timeouts and checklists stemmed from a root cause analysis on an ophthalmology incident. That incident led to the development of one of the first formal surgical timeout policies, which later became a model for New York State’s first foray into surgical timeout policies. Also, during a lull at one of the meetings of the statewide NYPORTS (New York Patient Occurrence and Report Tracking System) committee we asked attendees if they had ever seen implantation of incorrect lenses during cataract surgery. One hand after another shot up! Probably a third of attendees had experienced this at their hospital. John Simon and his colleagues at Albany Medical College subsequently analyzed all such cases in the NYPORTS database and an ophthalmology malpractice claims database. His work and the references are summarized in our March 11, 2008 Patient Safety Tip of the Week “Lessons from Ophthalmology”.
Note that we use the term ”wrong site surgery” to include not only a procedure on the wrong body part but also procedures on the wrong patient, wrong side, or wrong procedure.
But it’s not just ophthalmologic surgery that runs the risk of wrong site errors. Intravitreous injections have become a very frequent ophthalmologic procedure and a recent report described several cases of errors related to such injections (Vora 2021). While the overall incidence of errors in such cases was very low, Vora et al. identified some important lessons from the four cases they found. Two cases involved injections in the wrong eye, one injection of the wrong medication, and one the wrong dose of the correct medication.
The 2 cases of wrong eye injection involved failure to use (or failure to review) a surgical checklist and failure to perform a pre-procedure timeout. Timeouts and surgical safety checklists should be required not only for “surgery”, but also for any procedure being performed regardless of site of service. See our June 6, 2011 Patient Safety Tip of the Week “Timeouts Outside the OR” for a good discussion on that issue. And, of course, this also raises the question of how organizations that do have policies for use of timeouts and checklists for non-OR procedures actually audit adherence to those checklist and timeout procedures.
Also, in both cases, a new consent form was not obtained because the EMR contained an “active” consent form. Since age-related macular degeneration is commonly bilateral, it is not surprising that a patient might be scheduled for injections in each eye at one time or other. So, the presence in the EMR of consents for injections in both eyes may be a factor contributing to wrong eye errors. Also, since patients are likely to need recurrent injections, the issue of how long a consent should be “active” in the EMR is a serious consideration. How many of you have a process for “closing” a consent once the patient has the first procedure for which that consent was obtained? We’ll bet probably none of you. We really need to develop a standard for somehow flagging in the EMR those consents that are no longer valid because the patient has already had the procedure for which that consent pertained. Just because a patient consented to a procedure the first time does not automatically mean they have consented to the repeat procedure.
The case in which the wrong medication was injected was interesting. This was a patient who had received previous injections of 3 anti-VEGF agents. There had been successful response to only one of those agents. “Active” consents for all 3 agents were present in the electronic medical record. Instead of reviewing the most recent medical record, the surgeon reviewed a past note where the patient received one of the failed medications. He then ordered that medication rather than the one that had been successful. Once again, the procedure team had not relied on a surgical checklist and it is unclear if a pre-procedure timeout was completed.
The fourth case involved injection of the wrong concentration of an anti-VEGF agent. At this site, all anti-VEGF agents were stored together in a refrigerator. The medical assistant, who was new to the service, erroneously pulled a box containing the higher concentration of the intended anti-VEGF agent and the surgeon injected that higher dose. As in the other cases, no checklist was used and there was no pre-procedure timeout performed.
The Vora study does not comment on two significant factors we’ve seen in ophthalmologic “wrong site” cases in the past – daily volume of cases and throughput pressures. Some of those cases involved ophthalmologic surgeons performing many procedures during a session and unexpected changes in the schedules on the day of the procedures. Distractions and interruptions are other factors leading to wrong-site errors. Since many of these procedures are being performed in the office, one wonders how often the surgeon gets interrupted or distracted by other activities in the office setting (phone calls, other patients, requests from other staff, etc.). In one of these cases, where the decision to inject an eye was made during a “routine” appointment, it was noted that the surgeon “re-entered” the room. Was he/she distracted by whatever he/she was doing outside that room?
Apparently, none of these patients suffered harm from these errors. But the authors note these errors did have the potential to cause substantial ocular morbidity, particularly if a complication such as endophthalmitis might occur. They also comment on how such errors can diminish trust in the treating physician and harm the physician-patient relationship.
The authors propose that retina surgeons standardize the injection pathway, with the following considerations:
One of the most important facets in avoiding “wrong site” errors is a strong scheduling policy and procedure (see our October 30, 2012 Patient Safety Tip of the Week “Surgical Scheduling Errors”). At the time of scheduling a procedure, the appropriate primary source documents (including any relevant imaging studies) and current consent forms should be submitted along with a request delineating the exact procedure to be performed and laterality if appropriate. Requests for special equipment or supplies required should also be part of the scheduling process. We also recommend that the scheduling process include a comment or checkbox as to whether a surgical specimen for pathological examination is anticipated. That should be the process when a procedure is scheduled for an OR or facility-based procedure room. But many or most of these intravitreous injections are performed in the office. We suspect that such a formal scheduling process is not routinely performed for office-based procedures like these.
One problem we see during timeouts, whether they are in the OR or elsewhere, is failure of all staff to review primary source documents. All too often, staff merely nod agreement to items on the timeout checklist without themselves reviewing those documents.
Two other important opportunities to avoid wrong-site procedures are the pre-procedure “huddle” and the site marking. In cases being done in a hospital OR or an ambulatory surgery center, the pre-op huddle is done prior to the team entering the OR or procedure room. But we doubt such “huddles” are being done in most office-based procedures. The Vora study does not indicate whether site marking was used in any of these cases or whether it is routinely used during intravitreous injections in their organization. Our May 14, 2019 “Wrong-Site Surgery and Difficult-to-Mark Sites” had comments about site marking in eye procedure cases.
One important consideration in avoiding wrong-site procedures is involvement of the patient in the processes. But, since the majority of patients receiving intravitreous injections are elderly, problems with hearing, eyesight, and/or cognition may preclude full participation by the patient in those processes.
Lastly, how the anti-VEGF agents are stored may be important. Each office (or other site) should have a process in place to clearly segregate these medications to minimize the risk that the wrong one will be procured for a procedure. In the Vora paper there is a photo of the similar appearance of the medication-filled syringes for the two different doses of one of the anti-VEGF agents. Note that this is a similar problem to primary care practices storing multiple vials of different vaccines in their refrigerators.
While the incidence of such “wrong-site” procedures was low in this study, the increasing frequency of intravitreous injections will likely lead to occurrence of similar cases. The Vora study provides valuable lessons to avoid such incidents.
Some of our previous patient safety columns involving ophthalmology issues:
June 5, 2007 “Patient Safety in Ambulatory Surgery”
March 11, 2008 “Lessons from Ophthalmology”
June 8, 2010 “Surgical Safety Checklist for Cataract Surgery”
June 2012 “Tailored Timeouts for Ophthalmologists”
May 20, 2014 “Ophthalmology: Blue Dye Mixup”
September 2014 “Another Blue Dye Eye Mixup”
May 17, 2016 “Patient Safety Issues in Cataract Surgery”
December 5, 2017 “Massachusetts Initiative on Cataract Surgery”
Some of our prior columns related to wrong-site surgery:
September 23, 2008 “Checklists and Wrong Site Surgery”
June 5, 2007 “Patient Safety in Ambulatory Surgery”
July 2007 “Pennsylvania PSA: Preventing Wrong-Site Surgery”
March 11, 2008 “Lessons from Ophthalmology”
July 1, 2008 “WHO’s New Surgical Safety Checklist”
January 20, 2009 “The WHO Surgical Safety Checklist Delivers the Outcomes”
September 14, 2010 “Wrong-Site Craniotomy: Lessons Learned”
November 25, 2008 “Wrong-Site Neurosurgery”
January 19, 2010 “Timeouts and Safe Surgery”
June 8, 2010 “Surgical Safety Checklist for Cataract Surgery”
December 6, 2010 “More Tips to Prevent Wrong-Site Surgery”
June 6, 2011 “Timeouts Outside the OR”
August 2011 “New Wrong-Site Surgery Resources”
December 2011 “Novel Technique to Prevent Wrong Level Spine Surgery”
October 30, 2012 “Surgical Scheduling Errors”
January 2013 “How Frequent are Surgical Never Events?”
January 1, 2013 “Don’t Throw Away Those View Boxes Yet”
August 27, 2013 “Lessons on Wrong-Site Surgery”
September 10, 2013 “Informed Consent and Wrong-Site Surgery”
July 2014 “Wrong-Sided Thoracenteses”
March 15, 2016 “Dental Patient Safety”
May 17, 2016 “Patient Safety Issues in Cataract Surgery”
July 19, 2016 “Infants and Wrong Site Surgery”
September 13, 2016 “Vanderbilt’s Electronic Procedural Timeout”
May 2017 “Another Success for the Safe Surgery Checklist”
May 2, 2017 “Anatomy of a Wrong Procedure”
June 2017 “Another Way to Verify Checklist Compliance”
March 26, 2019 “Patient Misidentification”
May 14, 2019 “Wrong-Site Surgery and Difficult-to-Mark Sites”
May 2020 “Poor Timeout Compliance: Ring a Bell?”
References:
Vora RA, Patel A, Seider MI, Yang S. Evaluation of a Series of Wrong Intravitreous Injections. JAMA Ophthalmol. Published online August 26, 2021.
https://jamanetwork.com/journals/jamaophthalmology/fullarticle/2783398
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September 21, 2021
Repeat CT in Anticoagulated Patients After Minor Head Trauma Not Cost-Effective
One topic that has remained controversial over the years is how often delayed intracranial hemorrhage occurs in anticoagulated patients who suffer blunt head trauma. In several of our columns we have described cases where patients did develop subdural hematomas after they had an initially negative CT scan. But most case series have demonstrated that the overall risk is quite low.
A new study (Borst 2021) identified patients in a trauma registry who were on antithrombotic (anticoagulant and antiplatelet) medications during a 5-y period and who underwent a head computed tomography for blunt trauma. Per their institution protocol, patients with an initial negative head computed tomography underwent repeat imaging 6 hours after their initial head computed tomography. All patients were admitted to the trauma service and observed for 12 to 24 hours with neurologic checks every 2 hours.
The initial head computed tomography was negative in 82% of 1,377 patients. Of those with an initial negative head computed tomography, 12 patients (0.9%) developed an intracranial hemorrhage that was identified on the second head computed tomography (6 had intraventricular hemorrhage, 3 had subdural hematoma, 2 had subarachnoid hemorrhage, and 1 had an intraparenchymal hemorrhage). None of the patients with delayed intracranial hemorrhage developed a change in neurologic status, required an intracranial pressure monitor, or underwent neurosurgical intervention.
Although delayed intracranial hemorrhage was more common in patients on anticoagulants than on antiplatelet agents, the study was not powered to detect a difference between these two groups. The authors also note that, given the small percentage of patients with known INR’s in the supratherapeutic range, their results may not apply to patients with supratherapeutic INR levels.
The estimated total direct cost of the negative head computed tomography scans was $926,247. Applying their findings to a hypothetical case where a delayed intracranial hemorrhage is missed, they estimated the ICER per QALY at $132,321, not meeting the generally accepted criteria for cost-effectiveness.
We’ll note that the methodology used likely overestimated the potential cost savings. The authors estimated the cost of negative head CT’s by multiplying the average charge for a noncontrast head CT scan ($2,179) by the Healthcare Cost and Utilization Project cost-to-charge ratio. If you are a trauma center (the study institution was a Level 1 Trauma Center) and have round-the-clock radiology staffing, your actual marginal cost for doing that second non-contrast CT scan is actually quite small. Even if you have to call in a radiology tech, the marginal cost is probably considerably lower than their calculated value. Nevertheless, we all like to avoid any study that adds little value.
Based on the findings of their study, the institutional protocol at the study institution was updated. Repeat head CT scans are no longer performed unless the patient has an INR
>3.5 or a mental status decline on neuro checks performed every 2 hours during their 12- to 24-hour admission for observation.
The results of the study are reassuring. One question still unanswered is the optimal timing of the initial CT scan. Perhaps it might make sense to delay the initial scan in patients who are alert, not drowsy, and having no neurological signs to 6 hours. But a key to clinical management of these patients was that they did observe the patients for 24 hours, with neuro checks performed every 2 hours.
We should also note that the many clinical decision rules on deciding which patients with minor head trauma should get CT scans do not apply to patients on anticoagulants.
Some of our previous columns on head trauma in the anticoagulated patient:
April 16, 2007 “Falls With Injury”
July 17, 2007 “Falls in Patients on Coumadin or Heparin or Other Anticoagulants”
June 5, 2012 “Minor Head Trauma in the Anticoagulated Patient”.
July 8, 2014 “Update: Minor Head Trauma in the Anticoagulated Patient”
August 21, 2018 “Delayed CT Scan in the Anticoagulated Patient”
Some of our previous columns on CT scans in minor head trauma:
April 16, 2007 “Falls With Injury”
July 17, 2007 “Falls in Patients on Coumadin or Heparin or Other Anticoagulants”
March 2010 “CATCH: New Clinical Decision Rule for CT in Pediatric Head Trauma”
November 23, 2010 “Focus on Cumulative Radiation Exposure”
June 5, 2012 “Minor Head Trauma in the Anticoagulated Patient”.
July 8, 2014 “Update: Minor Head Trauma in the Anticoagulated Patient”
January 2017 “Still Too Many CT Scans for Pediatric Appendicitis”
March 2017 “Update on CT Scanning after Minor Head Trauma”
September 2017 “Clinical Decision Rule Success”
August 21, 2018 “Delayed CT Scan in the Anticoagulated Patient”
References:
Borst J, Godat LN, Berndtson AE, et al. Repeat head computed tomography for anticoagulated patients with an initial negative scan is not cost-effective. Surgery 2021; 170(2): 623-627 Published online: March 26, 2021
https://www.surgjournal.com/article/S0039-6060(21)00117-3/fulltext
Print “Repeat CT in Anticoagulated Patients After Minor Head Trauma Not Cost-Effective”
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September 2021
In our November 1, 2016 Patient Safety Tip of the Week “CMS Emergency Preparedness Rule” we discussed hospital emergency plans or disaster plans. But most such plans have dealt with acute emergencies that are of limited duration. How many of you have updated your emergency preparedness plan or disaster plan for dealing with pandemics?
Disaster plans may take into account potential sudden influx of patients and need to rapidly mobilize excess staff for disasters such as a mass casualty accident or a mass hazardous material exposure. But those are limited to short timeframes. The COVID-19 pandemic led to massive influx of patients for long periods of time and resulted in significant workload burdens and staff shortages over the long haul.
Wei and colleagues recently published “Nine Lessons Learned From the COVID-19 Pandemic for Improving Hospital Care and Health Care Delivery” (Wei 2021). It includes a valuable table containing elements to include in a hospital disaster plan for dealing with increased volume of patients or workforce shortages. Elements in that table are:
The table and text outline considerations for each of those elements.
Given that the COVID-19 pandemic may not be over yet and there may well be a surge this fall (or a new pandemic in the future), you really need to address all these elements in your emergency preparedness or disaster plans.
Go to the Wei paper for its excellent recommendations, not only on the disaster plan elements, but also on each of their 9 lessons learned from the COVID-19 pandemic:
And, if you are a teaching hospital, you also need to consider how a long pandemic will impact your training programs. A timely “Checklist Framework for Surgical Education Disaster Plans” (Matthews 2021) provides good recommendations for surgical residency programs but many of the recommendations could apply equally to other residency programs as well.
References:
Wei EK, Long T, Katz MH. Nine Lessons Learned From the COVID-19 Pandemic for Improving Hospital Care and Health Care Delivery. JAMA Intern Med 2021; Published online July 23, 2021
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2782429
Matthews JB, Blair PG, Ellison EC, et al. Checklist Framework for Surgical Education Disaster Plans. Journal of the American College of Surgeons 2021; Published online: July 12, 2021
https://www.journalacs.org/article/S1072-7515(21)00493-2/fulltext
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Wu and colleagues recently did a systemic review of systemic reviews on deprescribing in the elderly (Wu 2021) and it serves as an excellent introduction or primer on the topic. They conclude that the evidence suggests deprescribing is safe and feasible as a management strategy in patients at risk of medication-related problems. The literature shows that deprescribing can reduce the number of potentially inappropriate medications and rarely causes adverse drug withdrawal events. However, the authors note there is actually limited evidence of its effects on global and geriatric outcomes, such as falls, hospitalization, cognitive and physical function decline. Though common sense dictates that patient outcomes will be improved by deprescribing potentially inappropriate drugs in the elderly, studies on deprescribing have been limited by small sample sizes, confounding factors, and the lack of long-term follow up.
The review has a nice table listing the challenges and solutions of implementing deprescribing at the patient, healthcare professional, and health system levels. We just discussed many of those challenges in our June 29, 2021 Patient Safety Tip of the Week “Barriers to Deprescribing”.
Patient challenges include poor health literacy, reluctance to discontinue medications based on false beliefs, and fact that patients are often not involved in decision making about the use of medications. At the healthcare professional level, time constraints, lack of formal training on deprescribing, and the complexity and multiple comorbidities of the geriatric patient are challenges. At the health system level, fragmentation of care and poor communication between providers is the primary challenge.
They discuss the role of educational solutions at each of those three levels. While educational interventions are necessary, we’ve always pointed out that they are generally among the weakest solutions to any problem. Wu et al. do note that provision of deprescribing protocols and use of explicit criteria to guide medication review have proven to be effective in achieving deprescribing. And they discuss the role of computer clinical decision support tool, noting that most studies have demonstrated CDS tools do result in reduction of potentially inappropriate medications in the elderly. But, again, even those studies have yet to demonstrate improvement in hard patient outcomes. They also discuss the use of quality indicators, which may be tied to financial incentives, public reporting, accreditation, or continued professional development. However, they note that use of some quality indicators, particularly when tied to financial incentives, may have unintended consequences (such as healthcare providers turning away specific types of patients that might reduce their quality indicator scores). They provide a table with the New South Wales (Australia) Therapeutic Advisory Group (NSW TAG) Polypharmacy Quality Use of Medicines (QUM) Indicators as an example of the kinds of quality indicators you might consider.
The Wu review is a good place to start for those just getting started with deprescribing and has a good bibliography to help you identify relevant studies. It also points out the dearth of research linking results of deprescribing to actual patient outcomes.
We hope you’ll go back to our June 29, 2021 Patient Safety Tip of the Week “Barriers to Deprescribing” and the multiple other columns we’ve done on deprescribing and potentially inappropriate medications in the elderly..
Some of our past columns on deprescribing:
Some of our past columns on Beers’ List and Inappropriate Prescribing in the Elderly:
References:
Wu H, Kouladjian O'Donnell L, Fujita K, et al. Deprescribing in the Older Patient: A Narrative Review of Challenges and Solutions. International Journal of General Medicine 2021; 14: 3793-3807
Print “September 2021 A Primer on Deprescribing”
Our May 4, 2021 Patient Safety Tip of the Week “More 10x Dose Errors in Pediatrics” discussed multiple examples of errors leading to 10-fold (or higher) overdoses of medications and discussed many factors contributing to such errors.
A recent case from New Zealand (Connor 2021) highlights yet another factor contributing to such events. A 4-year-old boy with cerebral palsy was admitted to a New Zealand hospital for a surgical procedure intended to reduce his lower extremity spasticity. At one point during his recovery from the surgery he became confused and looked angry. Staff gave him morphine, thinking his symptoms may have been secondary to pain. However, he became lethargic, then obtunded, with his tongue “hanging out” and snoring. Despite his mother’s pleas that something was terribly wrong, “it took three-and-a-half hours for them to agree that there was something really wrong - and that's when he coded”.
Staff originally suspected the morphine as the reason for his deterioration. But his mother insisted the changes had begun to take place prior to administration of morphine. That finally led to a review of all his medications.
At the time of admission, hospital policy required his mother to hand over any of the medicines she gives her son while he is at home. One of those was baclofen, which he took for his spasticity. The staff used the baclofen from his home supply. But, at some point, they got the pharmacist in the hospital to make up his medicine and switched to the hospital supply. The concentration of the patient's personal supply of baclofen was 1 mg/ml and that of the hospital pharmacy supply was 10 mg/ml. Up until then they'd been giving 7 ml out of the home supply bottle and it was supposed to swap to 0.7 ml out of the hospital supply bottle. "The poor nurse had gone away and checked, and he was told that 7 ml was right, came back and gave it” according to the mother. Thus, he had received a 10-fold overdose of the baclofen. He required transfer to the Pediatric ICU but ultimately recovered fully.
Hospitals in the US generally do not allow administration of medications brought in from home while a patient is an inpatient. However, occasionally a patient might be taking a medication that is not on the hospital formulary. In such cases, hospital staff may temporarily use the patient’s home supply, as was done at the New Zealand hospital. The time of subsequent transition to a hospital’s supply of a medication is obviously a period of vulnerability.
It’s not really surprising that a nurse, used to administering 7 ml from a vial, would expect to continue administering that amount. We assume there was a new order when the switch to the hospital supply occurred. But even that may have been confusing. Would one use the same size syringe (or whatever instrument was used for administration) for the new dose was supposed to be less than 1 ml? The nurse apparently did some sort of check about the amount to be given, but concluded that 7 ml was still appropriate, not recognizing the disparity in concentration of the preparation.
A second lesson learned here is not to ignore the observations and concerns of a patient’s family member. There are many incidents, including the Josie King case that was a seminal event in the patient safety movement, in which concerns of a parent went unheeded as clinical deterioration was occurring.
We suggest you go back to our May 4, 2021 Patient Safety Tip of the Week “More 10x Dose Errors in Pediatrics” for many more details on factors contributing to 10-fold overdoses.
Some of our other columns on 10-fold medication dose errors:
March 12, 2007 “10x Overdoses”
September 9, 2008 “Less is More and Do You Really Need that Decimal?”
January 18, 2011 “More on Medication Errors in Long-Term Care”
April 17, 2012 “10x Dose Errors in Pediatrics”
May 4, 2021 “More 10x Dose Errors in Pediatrics”
Some of our other columns on pediatric medication errors:
November 2007 “1000-fold Overdoses by Transposing mg for micrograms”
December 2007 “1000-fold Heparin Overdoses Back in the News Again”
September 9, 2008 “Less is More and Do You Really Need that Decimal?”
July 2009 “NPSA Review of Patient Safety for Children and Young People”
June 28, 2011 “Long-Acting and Extended-Release Opioid Dangers”
September 13, 2011 “Do You Use Fentanyl Transdermal Patches Safely?”
September 2011 “Dose Rounding in Pediatrics”
April 17, 2012 “10x Dose Errors in Pediatrics”
May 2012 “Another Fentanyl Patch Warning from FDA”
June 2012 “Parents’ Math Ability Matters”
September 2012 “FDA Warning on Codeine Use in Children Following Tonsillectomy”
May 7, 2013 “Drug Errors in the Home”
May 2014 “Pediatric Codeine Prescriptions in the ER”
November 2014 “Out-of-Hospital Pediatric Medication Errors”
January 13, 2015 “More on Numeracy”
April 2015 “Pediatric Dosing Unit Recommendations”
September 2015 “Alert: Use Only Medication Dosing Cups with mL Measurements”
November 2015 “FDA Safety Communication on Tramadol in Children”
October 2016 “Another Codeine Warning for Children”
January 31, 2017 “More Issues in Pediatric Safety”
May 2017 “FDA Finally Restricts Codeine in Kids; Tramadol, Too”
August 2017 “Medication Errors Outside of Healthcare Facilities”
August 2017 “More on Pediatric Dosing Errors”
September 2017 “Weight-Based Dosing in Children”
February 19, 2019 “Focus on Pediatric Patient Safety”
June 2020 “EMR and Medication Safety: Better But Not Yet There”
December 2020 “Guidelines for Opioid Prescribing in Children and Adolescents After Surgery”
May 4, 2021 “More 10x Dose Errors in Pediatrics”
References:
Connor F. Young boy 'almost killed' after 'accidentally' given 10 times normal dose of medication at Starship Hospital. Newshub 2021; July 26, 2021
Print “September 2021 Another Unusual Cause for a 10-Fold Overdose”
Our January 5, 2016 Patient Safety Tip of the Week “Lessons from AirAsia Flight QZ8501 Crash” discussed the crash of AirAsia Flight QZ8501 into the Java Sea on December 28, 2014, killing all 162 people aboard. Though there were multiple contributory factors, there were several ambiguous communications that were significant factors in failure to avert the crash.
A series of serious miscommunications occurred once the stall alarm triggered. The pilot in command shouted “level…level…level” (repeated 4 times). But it was not clear whether he meant to level the wings or level the “attitude” or orientation of the plane to the ground. Then he followed with the command to “pull down…pull down” (repeated 4 times). As above, this order is ambiguous because if you pull the level/stick down, the plane goes up and accentuates a stall.
It should come as no surprise that use of ambiguous language in the OR can be dangerous and contribute to adverse events and poor patient outcomes. Liu et al. (Liu 2021) reviewed video recordings of six surgical procedures performed by residents under the supervision of specialist physicians. In all, there were 319 minutes of surgery recorded and reviewed. Overall, they found 3912 examples of potentially ambiguous language, a rate of 12.3 per minute. Of these, they identified 131 near misses associated with potentially ambiguous language.
Unfortunately, this paper is replete with words and concepts that, quite frankly, are foreign to us! Words like “deixis” and “anaphora” may be part of the lexicon of linguists but are hardly part of the vernacular of your typical clinician. (Fortunately, they do provide a table with definitions of the linguistic phenomena, along with examples). Also, the focus of the study is on the impact of ambiguous language on teaching and training of surgeons. But the important lesson of the study is that our failure to use precise language in the OR can lead to unintended consequences.
It does have a table that provides examples of how the various types of ambiguous language led to near misses and what alternative language might have been used.
Of interest to us is lack of comment on other forms of communication that should have taken place. Of course, we are talking about “hearback”. The Liu article does note that airline pilots must repeat safety messages back to the controller but does not go into detail about use of hearback in the OR.
Back in that January 5, 2016 Patient Safety Tip of the Week “Lessons from AirAsia Flight QZ8501 Crash” we noted another miscommunication that was one that did not take place but should have. When the pilot in control began to manipulate his stick/lever, standard operating procedure would have been to call out “I HAVE CONTROL” and responded by the other pilot transferring the control by call out “YOU HAVE CONTROL”. Had that happened, perhaps the cancelling action of operating to sticks/levers simultaneously would not have occurred. Perhaps the analogy in the OR would be communication between the surgeon and anesthesiologist regarding when it is safe to use electrocautery once oxygen flow has been stopped. It might go something like this: surgeon “READY TO USE ELECTROCAUTERY”, anesthesiologist “YOU MAY USE ELECTROCAUTERY”.
The Liu paper also does not focus another communication-related factor contributing to adverse events in medicine or other industries - language/cultural disparities. As our healthcare workforce is becoming more diverse, we do encounter some difficulties ensuring everyone understands the words we use. That is particularly problematic when we use idioms and slang terms.
Hierarchy in the OR may also affect communication. Liu et al. acknowledge that ambiguous language use between teaching and training surgeons has the potential to lead to catastrophic surgical outcomes, “especially when the training surgeon is junior”.
There is much more to language than the actual words. The way the words are spoken is critical. Tone and inflection count as well. We always tell the story about the copilot saying softly in a monotone voice “We are running out of gas” several times before a plane crashed because it ran out of gas. He obviously should have been shouting it out loudly. The hierarchical nature of that cockpit probably prevented the copilot from speaking up. How many times has that happened in the OR? Lots.
And you’ve heard us often remind everyone that 90% of communication is nonverbal. While body language may be somewhat obscured in the OR due to masks and gowns, it still occurs. People can convey an awful lot of information with their eyes.
Though the Liu article has the problems we noted above, it does have some thoughtful and useful recommendations for improving communication in the OR and avoiding ambiguity. Some are very practical. For example, defining a directional frame of reference at the start of a procedure may be very useful (eg. left-right from the patient’s perspective or the surgeon’s prospective, use “toward the head” rather than “up/down”, etc.). It’s worth having not only your surgeons, but your whole OR team, look at these recommendations.
References:
Liu C, McKenzie A, Sutkin G. Semantically Ambiguous Language in the Teaching Operating Room. Journal of Surgical Education 2021; Article in press 23 April 2021
https://www.sciencedirect.com/science/article/abs/pii/S1931720421000738?via%3Dihub
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