Get her to the OR, she's herniating!

Dr. Johnson (ED): "CT back yet?" (God, I've got six patients in the back room and at least two of them are ICU material.) Pre-occupied, hurry.

[ILLUSTRATION OMITTED]

Nurse #1: "Here's the report. She's got a subdural." (My kid is failing algebra and I've got to get out of here on time tonight.) Pre-occupied.

Significant personal problems adversely affect our functioning.

Johnson: "Which side?"

Nurse #1: "I don't have the report."

Nurse #2: "The patient you left in room 6 is in V-tach. We need you immediately."

Nurse #1: "I think the radiologist said right."

Johnson, pre-occupied with the patient in room 6, processes left instead of right.

Don't snicker. After a week of Hurricane Isabel news. veteran Jim Cantore of The Weather Channel called it "Isadore" and didn't catch himself. Trot Nixon, right fielder for the Boston Red Sox. tossed a fly ball he caught to a fan, mistakenly thinking it was the third out. Why would any of us think we couldn't do what Johnson just did?

Nurse #3: "Doctor Johnson, Dr. Calkins is on the phone, and the 5 year-old in room 7--or was it the 7-year-old in room 5?--is ready for suturing."

We now have two major interruptions, several numbers thrown into the mix, and a busy physician juggling several bits of information, depending upon his memory. Johnson has information overload. He assumes he knows the side of the subdural, and if he doesn't, so what? Somebody will straighten it out--unless, of course, the system doesn't have the ability to correct. The consequences follow.

Johnson: "OK, call the OR and let the neurosurgeon know she's on her way with a left-sided subdural."

Johnson, as many of us, had difficulty with left-right distinction. So did Nurse #1, so she didn't correct him.

In the OR....

OR Nurse: "Let's get her prepped for a left-sided crani."

Dr. Smith (Anesthesiologist): "We certain of that?"

OR Nurse: "That's what the ED said."

The neurosurgeon arrives. He saw the films, but left-sided subdurals are on the right side of the image on CT scans. While be knows that, he has been in a hurry all day. didn't get much sleep the night before and has heard two ED personnel and an OR nurse say the subdural is on the left side. Films were not routinely sent to the OR. In addition, his daughter dented his brand new BMW and he's waiting for the shop to call about the estimate.

How many feel they can function normally when in a hurry? Fatigued? Pre-occupied? All three?

Neurosurgeon: "We're opening the left side."

A few minutes later ...

Neurosurgeon (shocked): "This is normal brain. What's happening? Quick, get the films and turn her over--quickly! Get the betadine and shave her!"

The other side is quickly opened and the subdural evacuated.

The patient ultimately died.

Your thoughts?

1. The patient probably would have died anyway. Perhaps, but does that excuse the mistake? Anesthetic gas was mixed up in a hospital a couple of years ago, and two patients died. (1) No investigation occurred after the first death, since the patient was expected to die anyway. Only after the second death (unexpected), was it discovered that safety pins were broken on the oxygen flowmeter, allowing it to be plugged into the wrong receptacle.

2. This would never happen at my facility. Really? Maybe if you had a confidential, protected reporting system you might discover a lot of things happen that would surprise you.

3. The neurosurgeon was careless. But he was also fatigued, hurried, pre-occupied, and three other people told him the subdural was on the left.

4. The ED should discipline their staff. Why, for hiring people who mix up left and right and have difficulty juggling six critically ill patients?

5. A better system is needed to prevent wrong-side surgery, recognizing human failings such as left-right confusion, hurry, pre-occupation and interruptions. Such a system needs safeguards to deal with symmetry issues, ensure films go to the OR, and remove human memory as the sole source of reliability. Saying the same thing in two different ways (the upper outer quadrant of the right breast, at 11 o'clock; the right or ascending colon, for example) would additionally help.

What really happened?

Nothing changed.

When the medical director suggested something needed to be done, he was told he was not welcome at future department of surgery meetings.

[ILLUSTRATION OMITTED]

Fatigue

"I fell asleep during a conference. When I awoke, I couldn't understand why there was this squirrel in the room.... Gradually, I realized that rather than a squirrel, the guy sitting in front of me had very curly hair and was moving his head." (2)

"I am unable to concentrate, to repeat clearances back.... These effects seem to be cumulative and intensifying." (3)

The first comment comes from a resident, the second from a commuter airline pilot. How would you like having your life depend upon them?

How many of us have been disoriented when awakened on call? How many errors, close calls, personality aberrations or automobile accidents among physicians are due to fatigue?

Being awake for 24 hours is comparable to a blood alcohol level of 0.1 percent. (4,5) Working when fatigued is akin to working while drunk. While we consider it inexcusable and indefensible to work when drunk, working when fatigued is considered expected behavior.

After missing a night of sleep, cognitive performance declines 25 percent by the next afternoon. Initiative, ability to make decisions, integrate information, plan and execute all deteriorate, and we're not aware of it. One night of recovery sleep is insufficient to restore normal functioning. (6)

If we can't get uninterrupted sleep, we should consider naps, especially in the afternoon or between midnight at 6 a.m. (6,7)

Interruption

You see a new patient with congestive heart failure, diabetes and peripheral neuropathy taking eight medications. Three times during the evaluation, there is a knock on the door telling you there is a call from the hospital. You take each call then return to the patient's room. Now, where were you?

Interruptions and distractions are a major source of error, especially medication errors, causing us to omit steps in a process. Think bar codes will solve the problem? A quarter of price scanners in Arizona are inaccurate. But that is only money, not somebody's Coumadin.

Conversations are a powerful way to distract people. We are able to perform two tasks concurrently (talking on the phone and writing a prescription) under limited circumstances, even if we are skilled at performing each task separately. (8,9)

The more expert we are, the greater the likelihood interruptions will cause us to skip steps.

Interruptions are red flags! When interrupted:

1. Consciously identify that you are being interrupted.

2. After the interruption, ask yourself "What was I doing before I was interrupted?"

3. Decide what action you need to get back on track.

Designating specific times or people to handle interruptions might be useful.

Hurry-up syndrome and non-linear tasks (10)

A radiologist accepted an addon patient when he was far behind schedule, going out of town and had staffing shortages. He missed a cervical spine fracture.

We don't want to turn away business or anger referring physicians, so we take the extra case and may hurry through it. Because most of the time nothing bad happens, we are reinforced and feel the behavior appropriate in all circumstances.

Linear tasks, where one required task follows another, may often be done automatically, with error unlikely (unless interrupted). Non-linear tasks, having a non-logical sequence, are prone to error. When hurried, we may take shortcuts, turning linear tasks into non-linear ones.

1. Slow down and perform tasks in as orderly, or linear fashion as possible.

2. Maintain awareness of potential for error.

3. If hurry occurs because of an interruption, remember how to deal with interruptions.

Information overload

Talking does not mean information transfer. Too much information, too many numbers or words that sound alike cannot be easily remembered, especially with interruptions, distractions or preoccupations. (11,12)

* Find a good time to deliver messages. If the receiver appears preoccupied, consider writing it down so it may be reviewed later.

* Two disparate messages are remembered better than two similar ones. Frequently used words are better than uncommonly used words. (13)

* Too many numbers are poorly remembered. (12)

* It is difficult to do two tasks simultaneously even if both are automatic.

* Require information to be read back to you. While not perfect, it ensures both people are saying the same thing, it enhances the attention span, decreasing the chance of error and it shows that you were actually listening! (14)

References:

1. http://groups.yahoo.com/group/iatrogenic/message/212

2. Resident Life, TV series on TLC network. September 2003.

3. Matchette R. "One More Leg." ASRS Directline. Issue 5, March 1993.

4. http://cf.alpa.org/internet/projects/ftdt/backgr/fatigue_performance_impairment_1997.html

5. Weinger MB and Aricoli-Israel. "Sleep Deprivation and Clinical Performance." JAMA. 2002. 287 (8).

6. Merry A. and Smith AM. Errors, Medicine, and the Law. Cambridge: Cambridge University Press, 2001.

7. Bogner MS. Human Error in Medicine. Hillsdale, N.J.: Lawrence Erlbaum Associates, 1994.

8. www.psych.org/pnews/00-09-01/napping.html

9. Dismukes K. Young G, Sumwalt R. "Effective Management Requires a Careful Balancing Act." ASRS Directline. Issue 10, December 1998.

10. McElhatton J. Crew C. "Hurry-up Syndrome." ASRS Directline Issue 5. March 1991

11. Norman DJ and Shallice T. "Attention to action: willed and automatic control of behavior." In Deardin, RJ, Schwartz GE, and Shapiro D (eds.) Consciousness and Self-Regulation, Advances in Research and Theory, New York: Plenum, 1986.

12. Wright B and Patten M. "Callsign Confusion." ASRS Directline. Issue 8. June 1996.

13. George D. "One Zero Ways to Bust an Altitude." ASRS Directline. Issue 2. October 1991.

14. Monan B. "Readback/Hearback" ASRS Directline. Issue 1. March 1991.

By Michael S. Smith, MD, MS

Michael S. Smith, MD, MS, a statistician, wants to help people in the medical community use statistics to make better, faster and easier decisions. He is self-employed and may be reached at 520-410-7917 or [e-mail].