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kc_article_2007_surg_comm

Surgeons Fixing Communication Errors

By Tom A. Augello, CRICO

Related to: Communication, Surgery

Heightened role of attendings in new research provides focus for interventions.

Commentators

  • Atul Gawande, MD, MPH; Brigham and Women’s Hospital; Boston, MA
  • Caprice Greenberg, MD, MPH; Brigham and Women’s Hospital; Boston, MA

Transcript

In medical malpractice claims against surgeons, the second most common errors that lead to patient harm—behind technical mistakes—are those related to communication. New research is shining light on the DNA of those communication breakdowns, which may help surgeons prioritize interventions.

According to a Harvard study in the Journal of the American College of Surgeons in April 2007, most communication errors that lead to patient harm occur outside the operating room, either before or after a procedure. Attending surgeons are most likely to be involved.

Dr. Caprice Greenberg, an Instructor of Surgery in the Division of Surgical Oncology at Brigham and Women’s Hospital in Boston, was lead author of the study, based on data from an earlier investigation of nearly 450 surgical malpractice claims at four liability insurers in the U.S.

Dr. Greenberg and colleagues identified 60 claims that featured an injury to patients caused by flaws in communication.

“One of the things that has become obvious with the original study was that communication breakdown seems to play a major role in serious injury to surgical patients. And so what we wanted to do was try to look a little bit more in detail and try to understand a little bit about how and where these communication breakdowns were taking place, so that we had an idea of where to target intervention to start improving communication in the surgical realm.”

More than 90 percent of the errors involved oral communications. In looking at the character of the communication breakdowns, Dr. Greenberg’s team asked some questions: Was a typical surgical communication error like a game of “telephone,” where a single accurate message is relayed through several people in a series of misinterpretations? The answer to that one was ‘no.’ Most communication breakdowns occurred between a single transmitter and a single receiver.

Seventy-two percent of the cases involved just one communication breakdown. Where did these errors take place? Who was involved? In terms of focusing on potential interventions, some of the findings stood out.

“The main findings, perhaps the most striking, was the …pivotal role that the attending surgeons play in the communication breakdowns.  They were the most common person who was transmitting information that was lost and also the most common person who was supposed to be receiving information that was lost. And I think a lot of focus so far has been paid to the residents just because of the 80 hours work week and the natural need for increased hand offs that this is creating and our results suggest that it is really the surgical attending who is the keeper of so much information and really has to play the gate keeper in this complex system.”

Residents failing to contact an attending when the patient’s post-op condition warranted it, was the most common communication breakdown.

Still, Dr. Greenberg notes that communication errors were distributed almost evenly across the continuum of pre-op, intraoperative, and post-op periods. But most of the intraoperative problems involved sponge and instrument counts.

“Then when we took out things that were related to the count—because the counts are sort of a whole other issue—then we realized that the preop and the post-op seemed to be more frequent than the intraop. The reason that is interesting is because surgical errors in general that lead to injuries of surgical patients seem to be focused mostly in the operating room.  So, this is a little bit different.  I think so many of the initiatives are being undertaken now in regards to surgical communication are based on things like a time out and training like through crew resource management whereas what our results suggest that maybe we don’t need to focus so intently on the intraoperative course, but we also need to pay a lot of attention to the system that is getting patients into the operating room and the system that is taking care of them afterwards.”

Just where to start trying to fix communication problems is a question that has prompted the surgical chairs at four major Harvard teaching hospitals to form an extraordinary alliance. With the help of the Harvard malpractice insurer, CRICO/RMF, and researcher/surgeon Atul Gawande of Brigham and Women’s Hospital in Boston, the leaders have been meeting regularly to create a strategy across their competing institutions.

Dr. Gawande, a co-author on the Greenberg study, has authored some of the leading research in surgical errors, as well as best-selling books on human performance. Dr. Gawande says the data from the four malpractice insurers that formed the basis for the communication study has been key to the collaboration.

“That’s what is the remarkable thing about having the Harvard chiefs together.  You know when you start bringing together people four of the most competitive institutions in the city and all national reputation hospitals in and of themselves, and start asking them to share information about some of the most difficult problems in their hospitals, you don’t even know if they’re going to be willing to talk to one another and from the very beginning they’ve been sharing information, sharing ideas, being extremely insightful, and pushing very hard back on us the people in my group who are trying to help innovate some of the ideas that can help them and show them what the data shows and also on CRICO to help support the effort.”

Dr. Gawande says that the surgical leaders are collaborating on how to apply recommendations from the communication study to their institutions. These include standards to require residents to communicate patient problems to attendings, and structured hand-offs, including read-backs to ensure understanding.

“The suggestion in the paper was that if it could be established as a standard for critical events—and those range from a patient who codes or needs to be transferred to be transferred to the ICU or needs an unexpected blood transfusion—that the attending surgeon be notified promptly. And a second kind of standard would be that when attendings sign out that the attending who takes over knows the names of the patients who they are covering and some basic information about what they’re problems are, they can act quickly if a problem arises.”

According to Dr. Gawande, the difficulty is that people like those standards but believe they are happening anyway. He says the question is, how do you get from having the standards met 70 or 80 percent of the time, to making it happen 100 percent of the time?

The communication study authors reviewed the cases to see if certain interventions would have changed the outcome for the patient. One intervention already in use at some institutions is known as “triggers.” These are a list of conditions under which a resident or nurse must contact the attending surgeon during the patient’s recovery.

Dr. Greenberg explains:

“If we had a patient who had unrecognized hemorrhage, for example… and the patient got a number of units of blood transfused that the resident, and nursing taking care of the patient did not recognize that bleeding was the problem, but as soon as the attending arrived at the bedside they recognized what the problem was and were able to intervene and take the patient back for a reoperation for bleeding—had the triggers been in place that required the attendings to be notified when they’re patient was getting an unplanned blood transfusion, then the affects would have been mitigated and then the patient could have gone to the operating room earlier and there would not have been a delay in diagnosing the fact that the patient is bleeding. And so that case is one that you would then say, yes, this trigger could have mitigated the effects of this event.”

Dr. Gawande says the Harvard chairs are also considering ways to fool-proof systems so that attempts to reach attendings never fail. Ideas to ensure that an attending’s special knowledge and wisdom are available at the patient’s bedside for evaluations…or that hand-offs from attending to attending are always effective… will take time to test and adapt to individual institutions.

“We have to be able to absorb an enormous amount of know-how and turn it into practice in lots and lots of places. And I think that the chiefs getting together…by having an ongoing discussion every two-to-three months using benchmarks to ask, how far have we gotten in the last two-to-three months on the major issues we want to be working on?  Where are the roadblocks that we’re running into?  How have you overcome it at the Beth Israel Deaconess?  How have you overcome it at the Mass General?  That information is proving really helpful and the other thing that happens is you look around and you realize that, one of these places is actually doing something that is a lot better than everybody else and maybe we all should be doing it.”

 


September 1, 2007
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