Miscommunication in the OR Leads to Anticoagulation Mishap
Prior to performing a bilateral femoral artery embolectomy on a man with coronary artery disease and diabetes, the team used a surgical safety checklist for a preoperative briefing. Although the surgeon told the anesthesiologist the patient would benefit from epidural analgesia continued into the perioperative period, he failed to mention the patient would be therapeutically anticoagulated for several days postoperatively. No postoperative debriefing was conducted. The anesthesiologist continued orders for epidural analgesia and the epidural catheter remained in place, putting the patient at risk of bleeding. Ian Solsky, MD, and Alex B. Haynes, MD, MPH, both of Brigham and Women's Hospital, discuss communication failures in the operative environment and suggest that interventions to enhance communication should address both individual and systems-level factors.