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“Superficial” Report Leads to “Deep” Problem
PERIOPERATIVE GRAND ROUNDS “Superficial” Report Leads to “Deep” Problem The Case: A 35-year-old woman presented to the emergency department with left foot and ankle pain. The patient denied any recent trauma to her leg and had no fever or respiratory symptoms. She had no other medical problems, and her only medication was an oral contraceptive. She reported smoking one pack of cigarettes daily and drinking alcohol occasionally. The patient’s mother had a history of a “blood clot,” but there was no other significant family history. The physical examination showed moderate pitting edema, mild erythema, and tenderness of the left leg from the foot to the mid calf area. The left calf circumference was 4 cm greater than the right calf circumference. There were no dilated superficial veins or palpable venous cords. The patient was able to bear weight on the affected leg but had an antalgic gait (ie, a limp adopted to avoid pain). A radiograph of the patient’s left foot and ankle was normal. The resident ordered a Doppler ultrasound to rule out deep venous thrombosis (DVT). The preliminary radiology report read, “thrombus left distal superficial femoral vein.” The resident and attending physician interpreted this as a superficial vein thrombus. Because superficial thromboses usually can be treated safely without anticoagulation, they diagnosed the patient with cellulitis with a superficial thrombophlebitis and prescribed oral antibiotics along with elevation and warm compresses to the affected leg.
The final report of the patient’s ultrasound, returned many hours later, read, “deep vein thrombosis of the left distal superficial femoral vein.” Two days later, the resident read the final report and recognized that the patient should have been treated with anticoagulation. The patient returned to the emergency department for treatment with low-molecular-weight heparin and warfarin. She completed three months of therapy, and a follow-up ultrasound showed resolution of her DVT.
Discussion: The clinicians appropriately considered DVT in a 35year-old woman who smoked and was taking oral contraceptives, had asymmetric lower extremity edema and pain, and had a family history of thrombosis. They ordered the appropriate test, but the action they took based on the results was incorrect. At least two reasons are possible: the clinicians were unaware that the superficial femoral vein (SFV) is a deep vein, or they were familiar with the anatomy but committed a cognitive slip. Results of studies suggest that faulty information processing, not inadequate knowledge or flawed data, is the principal contributor to diagnostic error.1,2 Whether the clinicians were unaware or forgot that the SFV is a deep vein, they are not alone. In a 1995 study with the scenario of an “occluding [acute] thrombus of the distal superficial femoral vein,” only 24% of (continued on page 377)
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 Gurpreet Dhaliwal, MD, and was adapted for this article by Nancy J. Girard, PhD, RN, FAAN, consultant/owner, Nurse Collaborations, Boerne, TX. (Citation: Dhaliwal G. “Superficial” Report Leads to “Deep” Problem. AHRQ Web M&M [serial online]. December 2009. http://webmm.ahrq.gov/case.aspx?caseID¼210. Accessed June 27, 2012.) 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.2012.07.008
462 j AORN Journal
October 2012 Vol 96 No 4
Ó AORN, Inc, 2012
PERIOPERATIVE GRAND ROUNDS (continued from page 462) clinicians recommended anticoagulation, the remainder chose nonsteroidal anti-inflammatory drugs and conservative treatment or reevaluation in three days.3 A 1996 survey found that only 26% of internists when presented with a thrombosis of the SFV advised anticoagulation.4 Virtually no one learns the term superficial femoral vein during basic anatomy instruction. Femoral vein (FV) is the preferred term for the venous segment that runs between the popliteal vein and the deep femoral vein. Most vascular specialists use the term SFV to distinguish the deep femoral vein from the common femoral vein.3 These specialists have no misconception that the SFV, the principal vein of the thigh that travels with the superficial femoral artery, is anywhere near the skin. However, clinicians who treat venous thrombosis in emergency, internal, and family medicine have limited daily interaction with this anatomy. For them, the potential confusion induced by the shared adjective in superficial venous thrombosis and SFV requires remembering a rule: every time you hear SFV, ignore the natural default (this “superficial” vein is not superficial) and remember that it is a deep vein! One solution to this terminology problem would be to initiate educational reviews about lower extremity vascular anatomy. However, this method relies on human memory, and the confusing nomenclature would still require remembering the rule given above. In this case, the DVT label in the final report either triggered recognition or generated new knowledge leading to appropriate management. A universal requirement that all lower extremity venous Doppler studies explicitly report thromboses as being in the deep or superficial venous system could provide clarity for physicians who are sifting through large amounts of data in real time. This solution still has the chance for misinterpretation, however, when the receiving physician sees or hears the word “superficial” among the reported information.5 As long as “superficial” remains in the name, there will continue to be individual- and systems-level problems. The most durable fix for this diagnostic problem would be to revise the anatomic terminology. Many vascular laboratories and radiologists have already
www.aornjournal.org
stopped using the term SFV. Many physicians have called for abandoning the term SFV in favor of FV,3,4,6,7 and an international committee on modern vascular anatomy has endorsed this change.8 Yet, the chasm between the consensus guidelines put in place by early adopters and the everyday habits of clinicians is substantial. Language is sustained or changed by those who use it daily; this requires a conviction and commitment among those who influence the word choice of others (eg, authors, editors, teachers, consultants). In the case of SFV, the period of change may be years, but the effort holds the promise of ensuring proper treatment for tens of thousands of patients each year who experience morbidity or mortality7 because of this predictable and persistent error grounded in nomenclature.
Perioperative Points: n Educational review can assist in reminding clini-
cians that the SFV is actually a deep vein of the lower extremity. n Chart prompts to identify FV versus SFV can facilitate clear communication. n Clarification and revision of confusing medical terminology has the potential to reduce error. References 1. Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13): 1493-1499. 2. Schiff GD, Kim S, Abrams R, et al. Diagnosing diagnosis errors: lessons from a multi-institutional collaborative project. In: Henriksen K, Battles JB, Marks ES, Lewin DI, eds. Advances in Patient Safety.Vol 2. Rockville, MD: Agency for Healthcare Research and Quality; 2005:255-278. 3. Bundens WP, Bergan JJ, Halasz NA, Murray J, Drehobl M. The superficial femoral vein. A potentially lethal misnomer. JAMA. 1995;274(16):1296-1298. 4. Riancho JA, Onta~ n on A. The superficial femoral vein: a cause of therapeutic error. Lancet. 1996;348(9042):1670. 5. Schreiber R. Superficial femoral vein thrombosis: a potentially confusing term. JAMA. 1996;275(6):445. 6. Hammond I. The superficial femoral vein. Radiology. 2003; 229(2):604-606. 7. Weiss MA, Weiss MM. Superficial thinking. AJR Am J Roentgenol. 2008;190(5):W318. 8. Caggiati A, Bergan JJ, Gloviczki P, Jantet G, WendellSmith CP, Partsch H. International Interdisciplinary Consensus Committee on Venous Anatomical Terminology. Nomenclature of the veins of the lower limbs: an international interdisciplinary consensus statement. J Vasc Surg. 2002;36(2):416-422.
AORN Journal j 377
The final report of the patient’s ultrasound, returned many hours later, read, “deep vein thrombosis of the left distal superficial femoral vein.” Two days later, the resident read the final report and recognized that the patient should have been treated with anticoagulation. The patient returned to the emergency department for treatment with low-molecular-weight heparin and warfarin. She completed three months of therapy, and a follow-up ultrasound showed resolution of her DVT.
Discussion: The clinicians appropriately considered DVT in a 35year-old woman who smoked and was taking oral contraceptives, had asymmetric lower extremity edema and pain, and had a family history of thrombosis. They ordered the appropriate test, but the action they took based on the results was incorrect. At least two reasons are possible: the clinicians were unaware that the superficial femoral vein (SFV) is a deep vein, or they were familiar with the anatomy but committed a cognitive slip. Results of studies suggest that faulty information processing, not inadequate knowledge or flawed data, is the principal contributor to diagnostic error.1,2 Whether the clinicians were unaware or forgot that the SFV is a deep vein, they are not alone. In a 1995 study with the scenario of an “occluding [acute] thrombus of the distal superficial femoral vein,” only 24% of (continued on page 377)
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 Gurpreet Dhaliwal, MD, and was adapted for this article by Nancy J. Girard, PhD, RN, FAAN, consultant/owner, Nurse Collaborations, Boerne, TX. (Citation: Dhaliwal G. “Superficial” Report Leads to “Deep” Problem. AHRQ Web M&M [serial online]. December 2009. http://webmm.ahrq.gov/case.aspx?caseID¼210. Accessed June 27, 2012.) 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.2012.07.008
462 j AORN Journal
October 2012 Vol 96 No 4
Ó AORN, Inc, 2012
PERIOPERATIVE GRAND ROUNDS (continued from page 462) clinicians recommended anticoagulation, the remainder chose nonsteroidal anti-inflammatory drugs and conservative treatment or reevaluation in three days.3 A 1996 survey found that only 26% of internists when presented with a thrombosis of the SFV advised anticoagulation.4 Virtually no one learns the term superficial femoral vein during basic anatomy instruction. Femoral vein (FV) is the preferred term for the venous segment that runs between the popliteal vein and the deep femoral vein. Most vascular specialists use the term SFV to distinguish the deep femoral vein from the common femoral vein.3 These specialists have no misconception that the SFV, the principal vein of the thigh that travels with the superficial femoral artery, is anywhere near the skin. However, clinicians who treat venous thrombosis in emergency, internal, and family medicine have limited daily interaction with this anatomy. For them, the potential confusion induced by the shared adjective in superficial venous thrombosis and SFV requires remembering a rule: every time you hear SFV, ignore the natural default (this “superficial” vein is not superficial) and remember that it is a deep vein! One solution to this terminology problem would be to initiate educational reviews about lower extremity vascular anatomy. However, this method relies on human memory, and the confusing nomenclature would still require remembering the rule given above. In this case, the DVT label in the final report either triggered recognition or generated new knowledge leading to appropriate management. A universal requirement that all lower extremity venous Doppler studies explicitly report thromboses as being in the deep or superficial venous system could provide clarity for physicians who are sifting through large amounts of data in real time. This solution still has the chance for misinterpretation, however, when the receiving physician sees or hears the word “superficial” among the reported information.5 As long as “superficial” remains in the name, there will continue to be individual- and systems-level problems. The most durable fix for this diagnostic problem would be to revise the anatomic terminology. Many vascular laboratories and radiologists have already
www.aornjournal.org
stopped using the term SFV. Many physicians have called for abandoning the term SFV in favor of FV,3,4,6,7 and an international committee on modern vascular anatomy has endorsed this change.8 Yet, the chasm between the consensus guidelines put in place by early adopters and the everyday habits of clinicians is substantial. Language is sustained or changed by those who use it daily; this requires a conviction and commitment among those who influence the word choice of others (eg, authors, editors, teachers, consultants). In the case of SFV, the period of change may be years, but the effort holds the promise of ensuring proper treatment for tens of thousands of patients each year who experience morbidity or mortality7 because of this predictable and persistent error grounded in nomenclature.
Perioperative Points: n Educational review can assist in reminding clini-
cians that the SFV is actually a deep vein of the lower extremity. n Chart prompts to identify FV versus SFV can facilitate clear communication. n Clarification and revision of confusing medical terminology has the potential to reduce error. References 1. Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13): 1493-1499. 2. Schiff GD, Kim S, Abrams R, et al. Diagnosing diagnosis errors: lessons from a multi-institutional collaborative project. In: Henriksen K, Battles JB, Marks ES, Lewin DI, eds. Advances in Patient Safety.Vol 2. Rockville, MD: Agency for Healthcare Research and Quality; 2005:255-278. 3. Bundens WP, Bergan JJ, Halasz NA, Murray J, Drehobl M. The superficial femoral vein. A potentially lethal misnomer. JAMA. 1995;274(16):1296-1298. 4. Riancho JA, Onta~ n on A. The superficial femoral vein: a cause of therapeutic error. Lancet. 1996;348(9042):1670. 5. Schreiber R. Superficial femoral vein thrombosis: a potentially confusing term. JAMA. 1996;275(6):445. 6. Hammond I. The superficial femoral vein. Radiology. 2003; 229(2):604-606. 7. Weiss MA, Weiss MM. Superficial thinking. AJR Am J Roentgenol. 2008;190(5):W318. 8. Caggiati A, Bergan JJ, Gloviczki P, Jantet G, WendellSmith CP, Partsch H. International Interdisciplinary Consensus Committee on Venous Anatomical Terminology. Nomenclature of the veins of the lower limbs: an international interdisciplinary consensus statement. J Vasc Surg. 2002;36(2):416-422.
AORN Journal j 377