Table 2.

Communication failure examples by type of failure.

Communication failure examples
Content failures
Medication management: a 70–80-yr-old ASA 3 man with multiple comorbidities, including hypertension, congestive heart failure, atrial fibrillation, and a prior stroke, was scheduled for elective orthopaedic surgery. The patient stopped warfarin 7 days before surgery, as instructed by the surgeon. The anaesthetist cancelled the case for further cardiac evaluation. Neither the anaesthetist nor the surgeon instructed the patient to restart warfarin. The patient was off warfarin for 17 days before the rescheduled surgery. He sustained an intraoperative stroke and died a few days later.
On-patient fire: a 55–65-yr-old ASA 2 woman presented for blepharoplasty under monitored anaesthesia care. There was no preoperative discussion between the anaesthetist, surgeon, scrub technician, and circulating nurse regarding fire prevention; 3 L min−1 of oxygen via nasal cannula was administered and propofol infusion started by the anaesthetist. The patient was prepped and draped. The surgeon applied the cautery to the patient's face and a spark occurred, igniting the drapes and melting the nasal prongs. The fire was extinguished. The patient sustained third-degree burns to her face, requiring skin grafting, but was left with visible scars.
Audience failures
Wrong site surgery: a 20–30-yr-old man presented for a right Achilles tendon repair under general anaesthesia. The correct surgical site was recorded in the pre-anaesthesia evaluation, the procedure schedule, and on the surgical consent form. The surgeon was talking on the phone during the preoperative ‘time out’ and not paying attention. The procedure was performed on the left ankle.
Purpose failures
Disagreement on treatment of intraoperative complication: a 50–60-yr-old ASA 4E man underwent emergency laparotomy for bowel perforation with ischaemic bowel. During the abdominal wall closure, the oxygen saturations dropped and high ventilation peak pressures occurred during attempted closure. The anaesthetist asked the surgeon to stop closing the abdomen because of concern of abdominal compartment syndrome. The surgeon closed anyway. Oxygen saturations remained very low through the end of the procedure and during the first hour in the ICU, when the patient had a cardiac arrest, was resuscitated, and then returned to the operating theatre. Oxygen saturations improved dramatically with surgical reopening of the abdomen. The patient sustained hypoxic brain damage.
Production pressure during line placement: difficult i.v. catheter placement in preoperative holding resulted in case delay. The surgeon arrived and threatened to cancel the case if not ready in 10 min. The anaesthetist took the surgeon aside to continue the discussion away from patient bedside. Later, central venous catheter placement in the operating theatre was rushed, resulting in a pneumothorax. The patient testified to conflict between surgeon and anaesthetist.
Timing/occasion failures
Delayed test results: a 25–35-yr-old ASA 2 woman presented for spine fusion. The hospital required preoperative pregnancy testing. The patient denied possibility of pregnancy during the pre-anaesthesia evaluation. The test results were not in the electronic hospital record before induction. After incision, the anaesthetist found the positive results. The procedure was aborted. The patient elected for termination and sued for emotional distress.