Case reports: invaluable learning from mistakes

Learn from the mistakes of others. You won’t live long enough to make them all yourself – Eleanor Roosevelt

The busy and distraction‐rich environment in which anaesthetic practice occurs is fertile ground for error. Frequently, ad hoc teams with variable experience assemble to deliver high‐stakes care. During this time, multiple medications are prepared and administered, patient physiology is altered by pharmacology and surgical insult, and an increasing number of monitors and other technological devices compete for clinicians’ attention. It should be unsurprising, therefore, that errors do occur. Numerous groups have recognised the value of error reporting and have implemented mechanisms to capture and analyse data. Incident reporting systems are now routine at an institutional level and larger patient safety databases exist to cover specific circumstances across multiple institutions. Published case reports allow colleagues from across the world to learn from the experiences of others by providing nuanced and varied accounts of error or failure which clinicians deem impactful enough to share in a public forum. They also provide an opportunity for the clinicians involved to share and reflect on the learning points from the case and a basis for debate and discussion among peers. The impact of reporting an error on the clinicians involved may, however, influence whether something is reported in a public forum. The second victim effect, whereby healthcare providers involved in an unanticipated adverse patient event, medical error or patient‐related injury experience event‐related trauma, may also discourage the reporting of at least some cases. Conversely, other errors may not be reported because they are deemed to be ‘low level’ or of a lesser importance or significance; however, the educational value of these lower‐level errors should not be underestimated. The invisibility of these near misses or ‘low level’ errors may not reflect the potential impact they have on patient care and safety.

Learning from errors

Case reports allow the reporting of errors to benefit the education of one’s peers, and can serve to highlight individual, system or human factor failures [1]. Often, case reports are the initial public recognition of a potential systemic problem or error [2]. Safe medical practices can be more easily achieved if all parties involved recognise the benefits of reporting and learning from errors; we need to know about as many as possible so that proactive (rather than reactive) and generalisable action can be taken. This may require a cultural change within a specialty or an organisation as well as a sensitive handling of the report [3]. In healthcare systems such as the UK National Health Service (NHS), root cause analysis is used as a tool to retrospectively study events where patient harm or undesired outcomes occur. The precise methodology of how this is carried out varies between institutions, however the fundamental principles remain the same: define the event; identify the causes; identify the root cause; find solutions; and take action. Case reports describing error‐related events follow a similar pattern whereby the event is defined, causes are identified and discussed, and potential solutions or recommendations are proposed. This structure allows for a methodical analysis of the event, allowing the reader to follow a clear and concise overview of the error.

Although there are multiple sources of potential error, the complex environment of anaesthetic practice is particularly prone to cognitive errors – errors in thought processes which are made despite a clinician 'knowing better' [4]. Deviations from standard practice, although occasionally necessary to provide optimal care, can exacerbate the risk for errors, whereas effective decision‐making and risk management tools can reduce the risk of adverse events in the operating room. Reviewing and reflecting on other’s cases allows us to broaden our understanding of potential pitfalls.

The second victim effect

Despite major advancements in safety within the specialty of anaesthesia, the specialty involves an inherent vulnerability to adverse events as anaesthetised patients are both unable to participate actively in error prevention, and subject to sudden and significant influences on their physiology. Even in the absence of error, the physiological extremes that may arise can generate emotional extremes in the healthcare professionals that care for them.

When a patient experiences an adverse event leading to harm, they become the ‘first victim’, and patient harms should be recognised and investigated. Though they may be devastating for patients and families, adverse events are often difficult for the health professionals involved, who may question whether and how their actions contributed to the end result. In the case of medical error, this may indeed be the case. Knowing that one’s actions played a role in patient harm can be burdensome, even when care is delivered with the best of intent and to the best of one’s abilities. The clinicians involved can thus become ‘second victims’ [5, 6].

Each second victim passes through a series of uniquely personal emotional states. This is subject to many influences, such as their prior experiences, magnitude of the error and the attitude and support of others [7]. For some, there may be initial fear of consequence (for both clinician and patient), panic or denial. Later emotions can include anger, guilt, loneliness and despair. Perhaps the end goal is that of acceptance – of responsibility, of consequence and comfort derived from good intent despite a potentially bad outcome. However, like patients and their families, not all second victims achieve closure.

In contrast to other publications such as reports of research studies, case reports relate to a particular patient and team of health professionals. They offer scenario‐specific information that relays a level of detail and nuance that is frequently lost to the constraints of standard‐format databases and aggregate analyses. They can ignite the reader’s senses of what was heard, said, seen and done. The clinicians involved are likely identifiable by the author list and institutional affiliations, even if not referred to by name within the text of the report.

Being a second victim requires a period of recovery; constructing a case report may impact upon that recovery. The act of writing a case report may prompt later discussion among authors about a case that otherwise would not have arisen. It promotes an exchange of perspectives on a shared event, and an opportunity for authors, as well as readers, to learn. Individual authors can vary in their emotional responses, not least because they made individual contributions to an event; sometimes, healing wounds can be reopened.

A problem shared is a problem halved

The reporting of an adverse event, even if duty bound, and even if internal and confidential, often requires courage; disclosure can be stressful. The submission of an adverse event report for publication in a journal such as Anaesthesia Reports may be an extension of that difficult process for some authors. A state of acceptance is therefore likely reached before the experience is volunteered to the broader community for learning. These clinicians are voluntarily re‐exposing themselves, and re‐advertising their error to their peers. The greater the threat of patient harm from the error, the more vulnerable the clinician may feel in telling others about it. However, it is these stories that have arguably the greatest need to be told.

Case reports can prompt external judgement on the quality of care that has been delivered by the authors and their institutions. These judgements may be based only on partial insight into a case, not least because many more individuals with varying vantage points will have been involved in the case than have contributed to its reporting. The actions of the involved clinicians, particularly in scenarios of error, may have fallen short of their own expectations, or those of their peers.

In Table 1, we present a selection of error‐related cases published in Anaesthesia Reports grouped by taxonomy of error [8], and highlight the key learning points identified by the authors. Although some reports describe catastrophic events, most reports describe temporary or no patient harm using this taxonomy. Events such as these do not tend to be prioritised for entry into databases or national audits, and even if entered, are less likely to be the subject of system‐based improvement projects when compared with more ‘serious’ events. For this reason, it is conceivable that a clinician who has not experienced a similar event may not be aware of its potential impacts.

Table 1.

Error‐related cases recently published in Anaesthesia Reports, grouped by taxonomy of error.

Title	Description of Error/Incident	Degree of Patient Harm	Category	Individual Error Mode	System Failure Mode	Human Factors	Outcome	Learning Point
Tracheal tube obstruction as a complication of transoesophageal echocardiography [9].	“It was suspected that the tracheal tube had been deformed by the [transoesophageal echocardiography] probe in the operating theatre”	Minimal temporary harm. Precursor safety event.	Equipment	None	None	Equipment failure recognised through appropriate corrective actions to unexpected patient condition	‘… patient’s condition improved quickly’	Tracheal tubes may be deformed by a [transoesophageal echocardiography] probe. ‘This case demonstrates a potentially serious cause of airway obstruction in the ICU’.
Accidental systemic administration of 1 litre of cardioplegia solution during paediatric cardiac surgery [10].	“a 9‐year‐old boy who mistakenly received 1 l of high strength St Thomas’ Harefield cardioplegia solution delivered into the systemic circulation during cardiac surgery”	Severe temporary harm. Serious safety event.	Equipment, human error	Consciousness: distraction	Technology and environment: input/output, Human capability Communication: information overload	Equipment failure leading to distraction, allowing for overdose of cardioplegia	‘The patient made a full recovery, unhindered by this intra‐operative misadventure’.	‘We have implemented two systems changes in response to this case… Firstly, we no longer recirculate any cardioplegia solutions into the bypass reservoir… Secondly… Although we have routinely used in‐line blood parameter monitoring at our institution for some time, we now calibrate it early with both the manufacturer’s gaseous calibration solutions and with a blood gas drawn as soon as possible after commencing cardiopulmonary bypass’.
A hidden gas sampling line fault [11].	“we found the male‐to‐male Luer lock connector at both ends to be defective. The inner small tubular prolongation was missing at both ends”	No harm. Precursor safety event.	Equipment	Consciousness: lapse	Technology and environment: input/output Process: inadequate checks	Faulty equipment was not identified during pre‐anaesthetic checks. A systematic approach to the recognised failure led to resolution	‘The capnography … gradually returned to normal’.	‘Highlights the importance of examining equipment thoroughly when monitoring abnormalities and alarms are observed’.
Fatal postoperative intracranial hypotension‐associated venous congestion after elective laminectomy [12].	“A laceration of the dura mater, close to the drain tip was discovered”	Death. Serious safety event.	Human error	Unknown	Unknown	Emergency surgery to correct adverse event (haematoma) resulting from previous surgery may have contributed to emotional and cognitive load.	The patient subsequently died after withdrawal of active treatment	‘The sudden loss of CSF results in obstruction of venous outflow from the brain, with the resultant local ischaemia producing radiological findings suggestive of hypoxic ischaemic encephalopathy without a history of systemic hypoxia or cardiovascular instability during surgery’.
Tracheal deviation with phrenic nerve palsy after brachial plexus block [13].	“A chest x‐ray taken 1 h following tracheal extubation revealed elevation of the left hemidiaphragm and a rightward shift of the trachea and mediastinal structures, with no evidence of pneumothorax. Findings were in‐keeping with phrenic nerve palsy complicating the brachial plexus block performed.”	Minimal temporary harm. Precursor safety event.	Procedural complication	None	None	Unexpected and extreme presentation of an expected side‐effect. Systematic approach to the clinical findings avoided a misdiagnosis of tension pneumothorax	‘The patient was asymptomatic and discharged home the next day following repeat chest x‐rays’.	‘While phrenic nerve palsy resulting in an elevated hemidiaphragm is a common complication in supraclavicular brachial plexus blocks, we report the first case of associated tracheal deviation. However, clinicians must remain mindful of other causes of tracheal deviation once detected’
Subglottic stenosis imitating the carina – a case report of airway mimicry [14].	Awake tracheal intubation with flexible bronchoscopy which resulted in incorrect tracheal tube placement. The presence of a stenotic subglottic lesion with an appearance similar to the carina led to the tube being positioned with only the tip within the trachea whilst the cuff was located between the vocal cords.	No detectable harm. Precursor safety event.	Human error	Consciousness: spatial disorientation Competency: normalised deviance	None identified	Presumed cognitive and emotional load from perceived patient discomfort resulted in clinician spatial disorientation and subsequent premature induction of anaesthesia. Assistance of a more experienced colleague was appropriately obtained and tracheal tube misplacement was corrected.	The patient was allowed to emerge from anaesthesia and tracheal re‐intubation was performed with a smaller tube before continuing with planned procedure.	Emphasises the importance of performing the ‘two‐point check’ every time awake tracheal intubation is undertaken: to confirm correct tube placement, both a capnography trace and view of the tracheal lumen including the carina and main bronchi is required.
Spinal subarachnoid haematoma after neuraxial anaesthesia in a patient with polycythaemia vera [15].	“a spinal subarachnoid haematoma after uneventful neuraxial anaesthesia in a patient with optimised polycythaemia vera”	Severe permanent harm. Serious safety event.	Procedural complication	Communication and information processing: incorrect assumption	None identified	Reassuring laboratory and patient history may have led to risk/benefit ratio miscalculation	‘Despite an emergent laminectomy, the patient developed permanent motor deficits’.	Clinicians proceeding with surgery under neuraxial anaesthesia should appreciate these risks even in patients with normal or apparently elevated thrombotic states. This case also demonstrates that traditional coagulation tests may need to be complemented by pre‐operative platelet function tests and screening for von Willebrand disease.
Pneumothorax following serratus anterior plane block [16].	“Intra‐operatively the patient developed a significant episode of oxygen desaturation associated with high airway pressures. A subsequent chest radiograph in recovery demonstrated a large right‐sided pneumothorax which was treated with immediate needle decompression and chest drain insertion”	Moderate temporary harm. Serious safety event.	Procedural complication	Communication and information processing: incorrect assumption	None identified	Earlier recognition of the complication may have been possible if intra‐operative physiological parameters had been considered in context of the regional anaesthesia technique performed	‘The patient made a full recovery and a follow‐up chest radiograph demonstrated complete lung re‐expansion’.	‘This case demonstrates that despite purported advantages of local anaesthetic deposition deep to the serratus anterior muscle there is also the potential for…harm’.

Case reports rarely illustrate perfect care, but they do illustrate human care. Additionally, the subsequent efforts of clinicians in taking corrective actions following an error are often laudable. A case report can thus inform the reader of both how the error came to pass and how it can be mitigated. The incorporation of the authors’ lived experiences into the reader’s own practice may reduce the likelihood of the error happening again and could improve the chances of a good outcome if it does. It is conceivable, even, that a critical mass of high‐quality error‐themed reports could help inform how error reporting databases are constructed and analysed, helping drive forward objective system‐level improvement. In that spirit, we encourage submission to Anaesthesia Reports of novel or educational reports of errors and other adverse events. Future patients are arguably the greatest beneficiaries.