Spotlight Case November 2003

1. Spotlight Case November 2003 The Missing Suction Tip

2. Source and Credits • This presentation is based on the Nov. 2003 AHRQ WebM&M Spotlight Case in Surgery • See the full article at http://webmm.ahrq.gov • CME credit is available through the Web site • Commentary by: Eric J. Thomas, MD, MPH; Frederick A. Moore, MD; The University of Texas, Houston Medical School • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Tracy Minichiello, MD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Identify the risk factors for retained foreign bodies. • Understand methods used to prevent and identify retained foreign bodies. • Appreciate the roles of teamwork and communication in errors of this type. • List the specific system failures that can lead to communication breakdown.

4. Case: Missing Suction Tip A 65-year-old obese man with aortic stenosis and coronary artery disease underwent a combined aortic valve repair and coronary artery bypass grafting. The patient’s surgery, scheduled as the second case of the day, began in mid-afternoon. The surgery was complicated by a prolonged time on bypass, totaling 7 hours after incision.

5. Case (cont.): Missing Suction Tip During the post-bypass period, the scrub nurse noticed that the removable, small (1 cm) round metal tip of the surgical suction catheter was missing. He notified the surgeon. The surgeon replied, “You’ll find it on your table somewhere,” and continued to attain hemostasis and close. The nurse searched the table without success.

6. Case (cont.): Missing Suction Tip The nurse recalled that the tip had been clotting earlier and preventing adequate suction. He thought it must have been removed at that time and theorized that the tip had found its way into a basin of saline later used to irrigate the open wound. The nurse notified the surgeon that he believed the suction tip catheter was inside the patient.

7. Retained Foreign Bodies • True incidence not known • Risk Factors • Emergency surgery, unexpected change in surgical procedure, higher body mass index • Complications • Death, bowel perforation, sepsis, repeat surgery, and malpractice litigation . Gawande AA, et al. NEJM. 2003;348:229-35.AORN J. 1999;70:1083-9.

8. Case (cont.): Missing Suction Tip While preparing to close, the surgeon made an effort to search the chest cavity but did not find the suction tip. The anesthesiologist suggested an x-ray be obtained before closing the chest. However, the surgeon felt that the risk of the tip being in the chest was low and decided to defer the x-ray until after the chest was closed.

9. Steps to Take if Missing Instrument Suspected • Recheck sponge and instrument counts • Manually search the surgical site • Order an intraoperative radiograph • Some suggest routine intraoperative radiographs after all high-risk procedures Pierson MA. In: Alexander’s care of the patient in surgery. 1995:19-34.Gibbs VC, Auerbach AD. In: Making health care safer. 2001: 255-257.

10. Case (cont.): Missing Suction Tip A post-operative x-ray confirmed the tip was somewhere inside the patient’s chest. The patient was taken back to the operating room for removal of the tip. The re-exploration required that the patient go back on cardiopulmonary bypass, receive several additional units of blood products, and remain in the operating room for at least 6 additional hours. However, there were no long-term adverse sequelae.

11. Missing Tip: Contributing Factors • Obesity • Patient weighed 124 kg • Fatigue • Afternoon case lasting 7 hours • Concern over possible delay in obtaining portable x-ray • Time waiting for x-ray may have clinical consequences to the patient • Poor communication among team members

12. Possible Factors Leading to Poor Communication • Surgeon doubted RN assessment • Did not believe tip was in the body cavity • Surgeon not listening • Preoccupied, fatigued • Surgeon perturbed that his judgment was questioned • RN ambiguous with concern

13. Communication Across an Authority Gradient • A survey of surgical team members’ attitudes about communication • 40% of surgeons believed that junior team members should not question decisions of senior team members • 40% of surgical nurses rated the quality of teamwork and collaboration with surgeons as low Sexton JB, et al. BMJ. 2000;320:745-9.

14. Believe that junior staff should not question senior staff decisions Sexton JB, et al. BMJ. 2000;320:745-9.

15. Teamwork level rated “high” Sexton JB, et al. BMJ. 2000;320:745-9.

16. System Failures Leading to Communication Breakdown • Differences between team members’ goals • Differences between team members’ interpretation of events • Knowledge that did not make it into the team consciousness • Due to fear of speaking up or assumption that others already know • Environmental features • Noise, lighting, new equipment or technology Dekker S. The field guide to human error investigations. 2002.

17. How to Improve Teamwork? • CRM training programs for health care providers • Focusing on information sharing, inquiry, and assertion • Outline of daily goals • All providers on the team agree on the goals for the patient each day • Collaborative rounds Pronovost P, et al. J Crit Care. 2003;18:71-5.Uhlig PN, et al. Jt Comm J Qual Improv. 2002;28:666-72.

18. Take-Home Points • Surgery involving retained foreign bodies can result in serious morbidity or even death • Risk increased in obese patients, emergency surgery, and prolonged operations • Poor communication also may increase the risk of this and other medical errors in the operating room • Sponge and instrument counts alone are not sufficient to prevent such errors

19. Take-Home Points • Appropriate use of intraoperative radiographs may decrease the risk of retained foreign bodies • Efforts to improve teamwork and communication may translate into fewer errors in the operating room