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Assumptions, Lack of Structure in Surgery Handoffs


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Assumptions, Lack of Structure in Surgery Handoffs

By Tom A. Augello, CRICO

Related to: Communication, Cures Act: Opening Notes, Surgery, Teamwork Training


Conference attendees were quickly engaged in analyzing a malpractice case, based on closed claims in the Harvard medical system. They were asked to identify system flaws and suggest changes in how care is organized to prevent future cases, based on the following facts:

Twenty-year-old Patrick Dwight suffered from multiple birth defects, an undescended testicle, and mild diabetes insipidus. Diabetes insipidus is also known as water diabetes, a rare disease in which the kidneys produce abnormally large volumes of diluted urine. Patrick depended on family members for all aspects of daily life. He could not talk, but he communicated with facial expressions, and to a limited extent, was able to use a computer translator. Patrick’s water diabetes was managed at home by careful attention to his fluid intake, and he was not on any medications.

Patrick was admitted for right hip replacement surgery by a surgeon who’d done his left hip three years prior. That first surgery resulted in an extended admission due to hypernatremia, or high sodium. Before the second surgery, the patient’s mother reminded the surgeon and the resident who would assist him about Patrick’s diabetes insipidus and previous complication, and she was told to remind the anesthesiologist.

That day she talked directly with the anesthesiologist about it. She also made sure that a nurse practitioner included the condition on his pre-op anesthesia assessment form. When the anesthesiologist called the Endocrine Service to evaluate Patrick’s testosterone levels, the mother mentioned the diabetes insipidus again. The endocrinologist recommended intravenous hydrocortisone during the surgery.

Halfway through the six-hour operation, the resident was called to another case, and an orthopedic fellow completed the surgery uneventfully. Immediately after the surgery, the attending surgeon left for vacation. The fellow discharged Patrick from the OR, but—unfamiliar with Patrick’s history—he did not include serial labs or monitoring for adequate fluid intake in his post-op orders.

When Patrick was transferred to the floor, the nurse was unaware of his diabetes insipidus. The next day, Patrick’s mother told a second nurse about it and gave her a worksheet of what his hour-by-hour fluid intake should be. This nurse did not follow up on it, because she assumed that the physician’s orders covered the patient’s needs. Endocrinology did not follow up postoperatively. Four days post-op, Patrick became somnolent, began having seizure-like activity, slipped into a coma, and developed aspiration pneumonia.

His sodium levels had gone unchecked for three days, and were seriously elevated. His electrolyte and fluid imbalance were corrected, but an MRI showed significant brain damage. Patrick was discharged to a long-term nursing home, and he can no longer communicate in any fashion. The case was settled through mediation for more than $1 million.

After hearing these case details at the Harvard patient safety conference in Boston, clinician attendees generated numerous insights and ideas for improvement.

[…room noise…]

[male voice] It is my observation that the critical error was the lack of communication between the surgical team and the postoperative team. The underlying problem was one of communication, and that came from a series of assumptions. The surgeon assumed the anesthesiologist would take care of it. The anesthesiologist assumed the surgeon knew what was going on. The surgeon assumed the endocrinologist was going to do it. It’s all the assumptions, but nobody followed through. So perhaps one solution to this could be any of us would be to have a postoperative huddle between the surgical team and the postoperative team to solve that problem.

[male voice] It depends what you mean by systems.  I mean, some expectations of communication requirements can be at least mandated by policy and then modeled by leaders and instructed.  I mean, there are some institutions that have started a system of obligatory consultation, and this might be one of those conditions that would have required it.  They had it preoperatively for endocrinology.  There might be some expectation like there was, as somebody mentioned, of the post-anesthesia visit, that’s an expectation.  It is a policy that most people are now doing.  That might be one.

[female voice] I think that you have this patient moving from essentially four different sites. You have preop, you have intraop, you have postop and you have the recovery floor. You have the PACU and you have the recovery floor, and those are four different teams and there really ought to be a care plan that travels with the patient as they transition from one area of care to another such that all of the patients’ medical problems are addressed and passed on to the next team that is taking over their care.

[female voice] One of the main distinctions we need to make in medicine is the distinction between a patient’s chief complaint and their main concern, and in this case the chief complaint was an orthopedic procedure, but the mother’s main concern was that the diabetes insipidus not be overlooked. If we can orient ourselves to what the family member or the patient’s main concern is rather than what the procedure is that this person is going to get or what they are admitted to the hospital for, then we can start orienting ourselves around what is the most significant thing that this family member or this patient is telling me, whether it is an allergy to penicillin, whether it’s that they are on anticoagulant medication and how recently that was stopped before the surgery or that it is a metabolic condition. The main concern has to be flagged somewhere on the chart so that these things are not missed.

[male voice] Common sense is the most difficult thing to – you can’t teach common sense. Why did the orthopedist schedule probably his most complicated patient for an elective hip replacement the day he was going on vacation? If he had done it the day he came back from vacation, conceivably none of this would have happened, and he wouldn’t have identified all these systems problems. But the first decision was made: why schedule this case which has to be one of the most complicated patients he is going to operate when he knows he is leaving?

[female voice] We talked about the slide that I think is two slides back, the communication slide that showed all of the individual caregivers communicating in a very individual fashion with one another, and I just want to second a couple of  peoples’ remarks. Where are the huddles or the team? Was there a preop meeting with the team? Was there a periop team meeting which would have included the PACU and then another postop meeting that would have included the floor with the PACU, which hopefully would have increased communication amongst many caregivers but also would have introduced some redundancy into the communication that was being given. I do appreciate what Dr. Ives said in terms of the scheduling of this case before a major vacation, but at the same time, a system should be put in place so that if anything happened to any caregiver, there is a level playing field where the patient gets the care that they should get and the communication is such that someone could go away on a vacation or someone could be taken ill in an emergent fashion and still have the same level of communication that is needed, whether it is a simple case or a complicated case. 

March 1, 2006
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