A 17-month-old female infant in the pediatric
intensive care unit (PICU) developed acute respiratory
While setting up the laryngoscope and
endotracheal tube, the PICU physician gave a verbal order for
atropine, etomidate, and rocuronium. Shortly thereafter, but prior
to intubation, the infant acutely desaturated. The team realized
the patient received the paralytic agent prematurely. She was
immediately intubated without difficulty and her respiratory status
Upon review of the event, the team discovered
that the nurse, who was new to the PICU, had not realized the
medication was a paralytic agent and thus administered it before
the intubation tray was ready, resulting in the infant’s
desaturation. The physician who ordered the medication had not
indicated the timing of administration or that the medication was
to be drawn up but not given until later.
In this case, a child suffered a hypoxic episode
because she was paralyzed prematurely during an urgent, but not
emergent, intubation procedure. We will review this case using a
human factors approach (1,2), the
overall goal of which is to identify threats to patient safety and
then devise strategies to minimize the risk to future patients. The
steps in the process are listed in Table 1,
and a checklist for contributory factor analysis is detailed in
Table 2. (Please
refer to Figure for
explanation of risk priority assigned in Table
Teamwork and Communication
This case illustrates an unfortunately common occurrence in health
care: flawed teamwork related to deficiencies of interpersonal
communication. Based on work in the business arena (3), Weinger has
proposed that effective teamwork in the health care setting
requires the presence of the "5 C’s" outlined in Table 3. In the
present case, one might be tempted to give the team a failing grade
on three of the five C’s: Competence, Communication, and
Coordination. Coordination is dependent on effective
The Evidence for Communication
Failures.—In one ICU study, failures of communication
between team members accounted for 37% of all errors reported
during a 4-month period, yet represented only 2% of task activities
documented during a 24-hour direct observation period.(5) In ongoing
anesthesia patient safety research in San Diego, CA, communication
failures contributed to 16% (20 of 98) of operating room events
reported by the primary clinicians when directly queried by a
researcher (nearly 90% were reported within 2-4 hours of the end of
the case). In a separate study (Weinger, et al., unpublished work),
communication or coordination issues played a role in about 11% of
118 actual operating room events captured during more than 700
hours of direct observation and videotaping. At Dartmouth-Hitchcock
Medical Center, failures of team communication were identified in
61% of the 42 events that have been reviewed by the Sentinel Event
Committee over the last 4 years. Differences in incidence across
studies and settings reflect different methods, definitions, and
review criteria, and may reflect different interpretations by nurse
and physician participants.(6)
Failures of Interpersonal Communication in
Health Care.—Although physicians and other health care
professionals spend many years learning an impressive array of
scientific information and skills, health care curricula largely
omit topics such as interpersonal influence and group dynamics,
organizational behavior, negotiation, or conflict resolution. The
increasing use of standardized patients is a welcome addition to
health care professional education but does not address issues of
deficient provider–provider communication and
The increasing complexity of modern medicine
means that care is now being provided by teams of individuals. The
diversity of modern teams adds to the challenge: individual team
members will differ, not only in their training and degrees, but
also in their values, needs, and cultural or other expectations.
Working effectively as a team member requires training and
practice. Perhaps recent changes in expectations of the
Accreditation Council for Graduate Medical Education (ACGME) and
other health care regulatory bodies about clinician competency in
interpersonal skills will begin to address this serious issue.
It´s Not Just What You
Say.—How you say something will affect whether the
intended recipient understands and acts appropriately on the
message. In both realistic simulations and actual patient care, it
is common to see clinicians bark out instructions (eg, "Get an IV
in this guy") without any direction as to who should do it.
Extensive research in social psychology shows that words, as well
as their order and timing, will all affect how other people
respond.(7) Vocal cues
(rate, tone, pitch, volume, emphasis of speech) typically contain
20%-40% of the overall message. Tannen has documented clear gender
differences in both communication style and understanding of what
others mean by what they say.(8)
Communication is not just verbal—perhaps up to 50% of the
"message" is conveyed in nonverbal behavior (facial expression,
body posture and movement, eye contact, etc.).(9,10) Effective
team communication involves unspoken expectations, traditions,
assumptions about task distribution, command hierarchies, as well
as individual emotional and behavioral components. Xiao and
colleagues recently showed that highly skilled trauma teams
communicated in a variety of ways, many of which were nonverbal and
nonverbal cues are even more susceptible to misinterpretation, due
to changing context or differences in gender and culture.
Taxonomy of Communication
Failures.—There are many types of communication failures
and many ways to classify them. Fundamentally, they can be broken
down into failures of message transmission and reception. Table 4 provides
a comprehensive taxonomy. Work in Crew Resource Management (CRM)
has revealed that team communication markedly improves with the use
or other techniques to acknowledge that a message has been received
Clinical competence involves more than knowledge and technical
skills. In the complex care environment, one also needs to know
when and how to apply knowledge, solve problems, make good
decisions, communicate effectively, and work as part of a team.
Clinical experience does not always equate with clinical expertise:
with improper training, one can learn very well how to do something
incorrectly. Additionally, expertise is not an unchanging personal
property but a dynamically varying relationship between
environmental demands and that person’s resources to cope
with those demands at that particular time.(13)
For example, an anesthesiologist, who is an accomplished
laryngoscopist in the operating room, may find her skills lacking
when trying to manage a difficult airway in a remote location with
poor lighting, awkward patient positioning, or without the usual
equipment and support.
The Importance of Situation
Awareness.—In this case, the PICU physician was
apparently not aware of the competence of the assisting nurse, nor
was he aware of the status of the drugs that had been "ordered"
until after the infant desaturated. The accepted term for a
comprehensive and coherent cognitive representation of the current
clinical situation, continuously updated based on repetitive
assessment, is situation awareness (14,15), which
appears to be an essential prerequisite for safe operation of any
complex, dynamic system. In anesthesia, surgery, or critical care,
adequate "mental models" of
the patient and the associated care environment (clinical
facilities, equipment, personnel, etc.) are essential to effective
situational awareness. Acute care clinicians must be able to
recognize clinical cues quickly and completely, detect patterns of
cues, and set aside cues that are distracting or less relevant.
Even in less acute settings, situation awareness about the actions,
thoughts, and intentions of other team members is critical to
The Importance of Preparation.—In
this case, the induction drugs were administered before the
intubation equipment was ready. The patient suffered no harm, but
this near miss
points to the importance of being prepared for unexpected events.
Clinicians need to anticipate the risks of each situation and
strive to structure the care environment preemptively to reduce
their occurrence and impact. Preparedness is paramount in high
tempo, high risk domains like anesthesiology and critical care.
Optimal response in crisis situations requires not only
availability of the necessary equipment and drugs, but also mental
and physical readiness. Excellent clinicians prepare themselves for
all possible scenarios and their risks by mentally simulating what
both patients and team members might do (or not do) in different
Designing Effective Interventions to Address
Deficiencies of Teamwork and Communication
The goal of a formal case review should be to identify threats and
facilitate the design of countermeasures, creating enhanced safety
for the next patient. Crew Resource Management training, used in
the aviation industry to train members of the flight deck, has
become a model for team training in some sectors of medicine. David
Gaba and colleagues have been instrumental in adopting CRM to the
anesthesia domain, termed Anesthesia Crisis Resource Management
Training (ACRM).(12,16) High
fidelity patient simulation typically plays a key role in
CRM-oriented team training because realistically recreating the
complexity of the clinical environment helps assure that the
behaviors and lessons learned are transferred to real patient care.
Such simulators can be calibrated to the needs of the team; some
can recreate incidents that provoke performance failures among even
the best of clinicians.(17-19) Such
simulations give groups a safe setting in which to practice the
full range of effective teamwork behaviors such as task allocation,
read-backs, closed-loop communication, and clarifying roles and
responsibilities for each team member. Simulated exercises are
usually videotaped to facilitate the critical structured debriefing
sessions in which performance failures are reviewed and lessons
One of the limitations of using simulation more
broadly in health care has been the expense of setting up a
facility (eg, in addition to a dedicated and usable facility, the
cost of a patient simulator will be $30,000 to $200,000, and
clinical and video equipment might be $10,000 to $100,000), the
cost of conducting simulation courses (including the cost of
relieving instructors and trainees from regular clinical duties),
and the small number of learners that can have a truly hands-on
experience at any one time (typically less than 8 in a group).
Nonetheless, many academic medical centers, including ours, have
created Simulation Centers to enhance clinical training. Both of
our groups have been conducting simulator-based "mock codes." At
Dartmouth, simulated pediatric sedation events are conducted to
"stress test" various clinical settings where sedation care is
provided. Although more than 300 individuals provide this care at
Dartmouth-Hitchcock Medical Center, no more than 20 clinicians
participate in each mock code. Thus, to broaden the learning from
each simulated sedation exercise, videos demonstrating code
reenactments are sent to all 300 providers over the hospital
internet—essentially an internet debriefing for a large
audience. If efficacy can be established, dissemination models like
these should prove useful for hospitals and providers unable to
afford simulation centers or to support their complex
Using simulation in the PICU at the
Children’s Hospital at Dartmouth, we closely emulated this
case in two videos. [Limited by the constraints of the plastic
mannequin simulator, the case involves a 6-year-old instead of a
neonate. In addition, we took the creative license to include an
additional putative contributory factor (that may or may not have
been present in the original case) of parental presence and
involvement because this is increasingly common in PICUs and has
been suggested to play a role in some accidents.] The first
video is titled "Poor Communication" (Video 1) and might be what
happened in this case, with the caveats described above. The second
video is titled "Good Communication" (Video 2) and is meant to show
how communication might have been different if the clinicians had
all participated in a team-based CRM course. Take particular notice
of how the ICU physician and nurse communication differs (both in
terms of confirming that the order was understood and seeking
clarification of intent) as you watch the two 3-minute videos.
This case nicely illustrates the fact that errors
are increasingly due to failures in communication and teamwork.
Traditional training models, such as lectures and readings, can
play only a limited role in preventing these errors. Moreover,
isolated training silos (training doctors and nurses about teamwork
in separate rooms) will not help diverse professionals learn to
work together as a team during crisis situations. The use of CRM,
video simulations, role-plays, and other innovative training models
will be needed to tackle communication and teamwork errors.
B. Weinger, MD
Director, Center for Healthcare Simulation of the San Diego Center
for Patient Safety
Professor of Anesthesiology, University of California, San Diego
School of Medicine
Staff Physician, VA San Diego Healthcare System
San Diego, CA
George T. Blike,
Director, Dartmouth Medical Interface Laboratory
Associate Professor of Anesthesiology and OB/GYN, Dartmouth College
Staff Anesthesiologist, Children’s Hospital at Dartmouth and
Dartmouth-Hitchcock Medical Center
Faculty Disclosure: Dr. Weinger and Dr.
Blike have declared that neither they, nor any immediate members of
their families, have a financial arrangement or other relationship
with the manufacturers of any commercial products discussed in this
continuing medical education activity. In addition, their
commentary does not include information regarding investigational
or off-label use of pharmaceutical products or medical
Acknowledgements: We would like to
thank Jens Jensen, Joseph Cravero, and Dartmouth’s Pediatric
ICU nursing and respiratory therapy staff that supported the
creation of the videos used to supplement this article.
Funding/Support: Dr. Weinger was
supported by grants from the Agency for Healthcare Research and
Quality (AHRQ P20-HS11521 and R01-HS11375) and the Department of
Veterans Affairs (HSRD IIR 20-066). Dr. Blike was supported by a
grant from the National Institute for Child Health and Human
Development (NICHD RO3-HD041229).
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