Chapter 17: Nontechnical Errors in Surgery: Communication Breakdown

INTRODUCTION

• 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

• 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

BACKGROUND

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.

PERSPECTIVES AND UNEXPECTED EVENTS

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.

USING SENTINEL EVENTS AS A LEARNING TOOL

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: