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Haste Makes Care Unsafe
PERIOPERATIVE GRAND ROUNDS
Haste Makes Care Unsafe THE CASE An 80-year-old man underwent an elective coronary artery bypass graft (CABG) and Maze procedure (ablation of atrial fibrillation). A pulmonary artery (PA) catheter was placed to monitor the patient’s hemodynamic status and was to be pulled back from the PA into the right ventricle when the surgeon performed the ablation. During the surgery, the surgeon was informed that another patient in the cardiac intensive care unit (ICU) required an emergency CABG. The surgeon and anesthesia team were the only cardiac resources available that day, so they decided to begin the emergency CABG immediately after completing the current procedure. The team completed the remainder of the initial CABG without incident, and the patient was weaned off cardiopulmonary bypass, a process that took nearly another hour. By this time, the emergency patient had been taken to another OR. To speed up the initial case, the attending anesthesiologist refloated the PA catheter back into the PA, which required reinflating the catheter’s balloon. As soon as this was completed, the anesthesiologist rushed to the other OR to begin the emergency CABG after handing off the first patient to an anesthesia resident to take to the ICU. The ICU nurse immediately noticed the PA catheter waveform was flat and did not vary with the cardiac cycle. The nurse and the resident determined the PA catheter balloon was still inflated and likely had been so the entire time after refloating. Leaving it inflated could have caused catastrophic damage to the PA. Fortunately, the nurse recognized the situation and the resident deflated the balloon immediately and withdrew the catheter without the patient experiencing harm. The anesthesia resident realized that the PA catheter status had not been discussed with the attending anesthesiologist before the patient’s transfer to the ICU.
DISCUSSION Pulmonary artery catheter insertion and monitoring was very common in cardiac surgical cases 20 to 40 years ago, but today it is much less common. This is mainly because of the widespread adoption of intraoperative transesophageal echocardiography. Echocardiographic direct observation of cardiac
valvular function, volume of blood in the heart, and myocardial contractility allows evaluation of the surgical repair and also titration of anesthetic and hemodynamics-targeted medications in real time. Guidelines on PA catheters exist,1 but indications for PA catheter monitoring continue to be debated. Benefits include measurement of parameters (eg, PA occlusion wedge pressure, cardiac output, mixed venous oxygen saturation), which can give an objective assessment of the hemodynamic status. Preoperative PA catheter data can be helpful in determining whether it is safe to proceed with surgery for high-risk patients. Unfortunately, PA catheterization can also have adverse effects, such as arterial injury, hematomas, hemopneumothorax, and dysrhythmias. There can be a potentially fatal PA hemorrhage from balloon overinflation causing arterial rupture, endocardial damage, thromboembolism, or sepsis. The data provided by a PA catheter is also complex and subject to misinterpretation. It is a tribute to the ICU nurse that the danger was recognized and corrected. The main concern of this case is why the PA catheter balloon was inappropriately left inflated. Major accidents virtually always involve two or more variations from normal that occur in a situation not seen before by the involved personnel. This concept was articulated in Reason’s Swiss Cheese Model,2,3 in which the lining up of the holes in safety barriers allows continued on page 214 This content is adapted from AHRQ WebM&M (Morbidity & Mortality Rounds on the Web) with permission from the Agency for Healthcare Research and Quality. The original commentary was written by John H. Eichhorn, MD, and was adapted for this article by Nancy J. Girard, PhD, RN, FAAN, consultant/owner, Nurse Collaborations, Boerne, TX. (Citation: Eichhorn JH. Haste makes care unsafe. AHRQ WebM&M [serial online]. http://webmm.ahrq.gov/ case.aspx?caseID¼340. Published January 2015. Accessed October 20, 2015.) Dr Girard has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. http://dx.doi.org/10.1016/j.aorn.2015.11.005 ª AORN, Inc, 2016
262 j AORN Journal
www.aornjournal.org
Perioperative Grand Rounds
continued from page 262 progression to patient injury, thus failing to stop the injurious flow of events. In this case, attention to detail by both the surgeon and the attending anesthesiologist was diverted by continuous reports of the emergency patient status. The attending anesthesiologist did not give complete hand-over information to the resident. Whether the resident was experienced enough to recognize the dangers of a permanently wedged PA catheter is unknown, but there could have been a knowledge deficit. Having clinicians thrust into an emergency situation should be a red flag that leads to recognition of dangers. Rather than hurrying, clinicians should slow down their pace, becoming more deliberate as they complete the current task before turning to the new one. Communication interruptions are a frequent cause of surgical errors and adverse events.4 The attending anesthesiologist should have given a complete report to the resident, but some human error is inevitable. The purpose of communication tools in such circumstances is to help prevent human errors, including oversights and knowledge deficits. Cognitive aids in the past have included mnemonics5 for hand-over protocols, but more recent strategies involve formal checklists. The efficacy and value of checklists is well known. A medical hand-over checklist can be completed rapidly and covers patient demographics, past care, current status, and care plans and can be critical for safe patient care.6 Checklists of the type applicable to this case have been published.7,8 Using a handover checklist at the time of turning over responsibility to the resident would have revealed the PA catheter error and prompted early correction. The World Health Organization’s Surgical Safety Checklist9 is another example. This comprehensive 19-item list has sections for three key time points in the patient’s surgical experience: before induction of anesthesia, before skin incision, and before the patient leaves the OR. The efficacy of this specific checklist in preventing adverse patient events has been demonstrated.10 Resistance by personnel in the surgical arena to the adoption and use of any checklist can be expected, but it takes only one patient saved from an injury
214 j AORN Journal
February 2016, Vol. 103, No. 2
to convert health care workers into believers. The integration of hand-over checklists, combined with a strong safety culture, can ensure patient safety, even when time is tight.
PERIOPERATIVE POINTS If a PA catheter balloon remains inflated accidently, it can cause severe PA or lung injury. Unplanned emergency demands can distract practitioners and disrupt practices and lead to adverse patient outcomes. The World Health Organization Surgical Safety Checklist is a tool proven to reduce patient morbidity and mortality from oversights or knowledge deficits. Resistance to the implementation of checklists can occur if not planned correctly.
References 1. American Society of Anesthesiologists Task Force on Guidelines for Pulmonary Artery Catheterization. Practice guidelines for pulmonary artery catheterization: an updated report by the American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization. Anesthesiology. 2003;99(4):988-1014. 2. Reason JT. Understanding adverse events: human factors. Qual Health Care. 1995;4(2):80-89. 3. Reason JT. Human error: models and management. BMJ. 2000; 320(7237):768-770. 4. Nagpal K, Vats A, Lamb B, et al. Information transfer and communication in surgery: a systematic review. Ann Surg. 2010; 252(2):225-239. 5. Porteous JM, Stewart-Wynne EG, Connolly M, Crommelin PF. iSoBARda concept and handover checklist: the National Clinical Handover Initiative. Med J Aust. 2009;190(11 suppl):S152-S156. 6. Kalkman CJ. Handover in the perioperative care process. Curr Opin Anesthesiol. 2010;23(6):749-753. 7. Zavalkoff SR, Razack SI, Lavoie J, Dancea AB. Handover after pediatric heart surgery: a simple tool improves information exchange. Pediatr Crit Care Med. 2011;12(3):309-313. 8. Craig R, Moxey L, Young D, Spenceley NS, Davidson MG. Strengthening handover communication in pediatric cardiac intensive care. Paediatr Anaesth. 2012;22(4):393-399. 9. World Alliance for Patient Safety. WHO surgical safety checklist and implementation manual. World Health Organization. http://www.who .int/patientsafety/safesurgery/ss_checklist/en/. Published 2008. Accessed October 20, 2015. 10. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491-499.
www.aornjournal.org
Haste Makes Care Unsafe THE CASE An 80-year-old man underwent an elective coronary artery bypass graft (CABG) and Maze procedure (ablation of atrial fibrillation). A pulmonary artery (PA) catheter was placed to monitor the patient’s hemodynamic status and was to be pulled back from the PA into the right ventricle when the surgeon performed the ablation. During the surgery, the surgeon was informed that another patient in the cardiac intensive care unit (ICU) required an emergency CABG. The surgeon and anesthesia team were the only cardiac resources available that day, so they decided to begin the emergency CABG immediately after completing the current procedure. The team completed the remainder of the initial CABG without incident, and the patient was weaned off cardiopulmonary bypass, a process that took nearly another hour. By this time, the emergency patient had been taken to another OR. To speed up the initial case, the attending anesthesiologist refloated the PA catheter back into the PA, which required reinflating the catheter’s balloon. As soon as this was completed, the anesthesiologist rushed to the other OR to begin the emergency CABG after handing off the first patient to an anesthesia resident to take to the ICU. The ICU nurse immediately noticed the PA catheter waveform was flat and did not vary with the cardiac cycle. The nurse and the resident determined the PA catheter balloon was still inflated and likely had been so the entire time after refloating. Leaving it inflated could have caused catastrophic damage to the PA. Fortunately, the nurse recognized the situation and the resident deflated the balloon immediately and withdrew the catheter without the patient experiencing harm. The anesthesia resident realized that the PA catheter status had not been discussed with the attending anesthesiologist before the patient’s transfer to the ICU.
DISCUSSION Pulmonary artery catheter insertion and monitoring was very common in cardiac surgical cases 20 to 40 years ago, but today it is much less common. This is mainly because of the widespread adoption of intraoperative transesophageal echocardiography. Echocardiographic direct observation of cardiac
valvular function, volume of blood in the heart, and myocardial contractility allows evaluation of the surgical repair and also titration of anesthetic and hemodynamics-targeted medications in real time. Guidelines on PA catheters exist,1 but indications for PA catheter monitoring continue to be debated. Benefits include measurement of parameters (eg, PA occlusion wedge pressure, cardiac output, mixed venous oxygen saturation), which can give an objective assessment of the hemodynamic status. Preoperative PA catheter data can be helpful in determining whether it is safe to proceed with surgery for high-risk patients. Unfortunately, PA catheterization can also have adverse effects, such as arterial injury, hematomas, hemopneumothorax, and dysrhythmias. There can be a potentially fatal PA hemorrhage from balloon overinflation causing arterial rupture, endocardial damage, thromboembolism, or sepsis. The data provided by a PA catheter is also complex and subject to misinterpretation. It is a tribute to the ICU nurse that the danger was recognized and corrected. The main concern of this case is why the PA catheter balloon was inappropriately left inflated. Major accidents virtually always involve two or more variations from normal that occur in a situation not seen before by the involved personnel. This concept was articulated in Reason’s Swiss Cheese Model,2,3 in which the lining up of the holes in safety barriers allows continued on page 214 This content is adapted from AHRQ WebM&M (Morbidity & Mortality Rounds on the Web) with permission from the Agency for Healthcare Research and Quality. The original commentary was written by John H. Eichhorn, MD, and was adapted for this article by Nancy J. Girard, PhD, RN, FAAN, consultant/owner, Nurse Collaborations, Boerne, TX. (Citation: Eichhorn JH. Haste makes care unsafe. AHRQ WebM&M [serial online]. http://webmm.ahrq.gov/ case.aspx?caseID¼340. Published January 2015. Accessed October 20, 2015.) Dr Girard has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. http://dx.doi.org/10.1016/j.aorn.2015.11.005 ª AORN, Inc, 2016
262 j AORN Journal
www.aornjournal.org
Perioperative Grand Rounds
continued from page 262 progression to patient injury, thus failing to stop the injurious flow of events. In this case, attention to detail by both the surgeon and the attending anesthesiologist was diverted by continuous reports of the emergency patient status. The attending anesthesiologist did not give complete hand-over information to the resident. Whether the resident was experienced enough to recognize the dangers of a permanently wedged PA catheter is unknown, but there could have been a knowledge deficit. Having clinicians thrust into an emergency situation should be a red flag that leads to recognition of dangers. Rather than hurrying, clinicians should slow down their pace, becoming more deliberate as they complete the current task before turning to the new one. Communication interruptions are a frequent cause of surgical errors and adverse events.4 The attending anesthesiologist should have given a complete report to the resident, but some human error is inevitable. The purpose of communication tools in such circumstances is to help prevent human errors, including oversights and knowledge deficits. Cognitive aids in the past have included mnemonics5 for hand-over protocols, but more recent strategies involve formal checklists. The efficacy and value of checklists is well known. A medical hand-over checklist can be completed rapidly and covers patient demographics, past care, current status, and care plans and can be critical for safe patient care.6 Checklists of the type applicable to this case have been published.7,8 Using a handover checklist at the time of turning over responsibility to the resident would have revealed the PA catheter error and prompted early correction. The World Health Organization’s Surgical Safety Checklist9 is another example. This comprehensive 19-item list has sections for three key time points in the patient’s surgical experience: before induction of anesthesia, before skin incision, and before the patient leaves the OR. The efficacy of this specific checklist in preventing adverse patient events has been demonstrated.10 Resistance by personnel in the surgical arena to the adoption and use of any checklist can be expected, but it takes only one patient saved from an injury
214 j AORN Journal
February 2016, Vol. 103, No. 2
to convert health care workers into believers. The integration of hand-over checklists, combined with a strong safety culture, can ensure patient safety, even when time is tight.
PERIOPERATIVE POINTS If a PA catheter balloon remains inflated accidently, it can cause severe PA or lung injury. Unplanned emergency demands can distract practitioners and disrupt practices and lead to adverse patient outcomes. The World Health Organization Surgical Safety Checklist is a tool proven to reduce patient morbidity and mortality from oversights or knowledge deficits. Resistance to the implementation of checklists can occur if not planned correctly.
References 1. American Society of Anesthesiologists Task Force on Guidelines for Pulmonary Artery Catheterization. Practice guidelines for pulmonary artery catheterization: an updated report by the American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization. Anesthesiology. 2003;99(4):988-1014. 2. Reason JT. Understanding adverse events: human factors. Qual Health Care. 1995;4(2):80-89. 3. Reason JT. Human error: models and management. BMJ. 2000; 320(7237):768-770. 4. Nagpal K, Vats A, Lamb B, et al. Information transfer and communication in surgery: a systematic review. Ann Surg. 2010; 252(2):225-239. 5. Porteous JM, Stewart-Wynne EG, Connolly M, Crommelin PF. iSoBARda concept and handover checklist: the National Clinical Handover Initiative. Med J Aust. 2009;190(11 suppl):S152-S156. 6. Kalkman CJ. Handover in the perioperative care process. Curr Opin Anesthesiol. 2010;23(6):749-753. 7. Zavalkoff SR, Razack SI, Lavoie J, Dancea AB. Handover after pediatric heart surgery: a simple tool improves information exchange. Pediatr Crit Care Med. 2011;12(3):309-313. 8. Craig R, Moxey L, Young D, Spenceley NS, Davidson MG. Strengthening handover communication in pediatric cardiac intensive care. Paediatr Anaesth. 2012;22(4):393-399. 9. World Alliance for Patient Safety. WHO surgical safety checklist and implementation manual. World Health Organization. http://www.who .int/patientsafety/safesurgery/ss_checklist/en/. Published 2008. Accessed October 20, 2015. 10. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491-499.
www.aornjournal.org