Operating Room Miscommunication

Ken Margolin

Contributor

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I handled a tragic case a few years back, in which a healthy 41 year wife, and mother of 5 children, died during routine surgery due to operating room miscommunication. The woman, Marie, (not her real name) went to her community hospital complaining of stomach pain and inability to keep food down. She was diagnosed with an obstructed bowel due to non-malignant, non-life threatening causes. The surgeon had determined that general anesthesia was called for and verbally communicated that decision to a nurse anesthetist, who failed to communicate clearly to the anesthesiologist. The anesthesiologist administered spinal anesthesia.

When the surgeon realized spinal had been given instead of general, he decided to operate despite being unsure whether the spinal would last until the operation was complete. It did not. When the patient began to feel pain in mid-operation, the surgeon told the anesthesiologist to administer general anesthesia by mask. The anesthesiologist did so, but was unaware the operation was for an obstructed bowel, and failed to empty the patient's stomach or protect the patient's airway. Marie vomited large quantities of feculent matter into her lungs and subsequently died, despite transfer to a teaching hospital and all-out efforts to save her. The surgeon testified at deposition that he thought the anesthesiologist was required to read the chart and know the purpose of the operation; the anesthesiologist, who was a temporary employee, who had worked at 11 hospitals in 10 years, testified that she had relied on the surgeon to tell her what the operation was about. The case settled for the full policy limits of the surgeon and anesthesiologist, as well as contributions from the nurse anesthetist, the temporary chair of the anesthesiology department, and the president of the hospital, who was in the midst of a cost-cutting campaign.

Surgical malpractice with catastrophic results are often caused by miscommunication amongst members of the operating team. The very term operating "team" connotes the idea of communication that is fundamental to any team. Some years ago, the notion existed in the medical profession that the surgeon was "captain of the ship" and presumptively responsible for the actions and omissions of all members of the team. That notion, while still held to, ironically, by some surgeons, does not reflect current thinking. Today, every member of the operating team is responsible for the patient's welfare. Moreover, each member, even a scrub nurse, has the obligation to speak up if they notice something occurring that they believe may harm the patient. To use an extreme example - if non-medical members of an operating team see a surgeon about to amputate the wrong limb, they cannot remain silent on the theory that it was the surgeon's responsibility. In that situation, every member of the operating team who knew or should have known that the wrong limb was about to be amputated, had the obligation to speak up.

The dangers of miscommunication amongst members of the operating team has been recognized by the medical profession. What remains is a persistent and effective campaign to reduce surgical death and surgical injury, due to failure of communication.