Communication to cure cath chaos

Abstract

Key Points• Communication errors in the cath lab may lead to incorrect medication administration or dosing, or incorrect sizes of devices deployed in patients, with catastrophic results. Use of closed-loop communication minimizes these errors.• In this study, two rounds of quality improvement projects improved, but did not completely close the communication gap.• Standard setting by professional societies and individual cath lab leaders may be necessary to improve the use of closed-loop communication in cath labsalthough a completely successful strategy remains to be identified. Imagine this scenario: You predilate a 90% stenosis in a calcified 2.4-mm right coronary artery with a 2.5-mm noncompliant balloon.Then you ask for a 2.5-mm drug-eluting stent, but after deployment realize that the stented segment is expanded to 3.5 mm and a class III perforation has occurred. It is successfully treated with a covered stent, but the patient has a complicated course. Several months later you are explaining to the plaintiff's attorney that you asked for a 2.5-mm stent and have no idea how a 3.5-mm stent was mistakenly deployed. You do admit that you are aware that oversizing of balloons and stents is a predictor of perforation. 1 A few years ago, such a mistake was made in our laboratory twice within several months. Fortunately, the arteries were elastic and no adverse events occurred, but the sight of a grossly oversized stent in a small artery was frightening. As a result, we adopted a policy of visually confirming that the balloon or stent is the size requested, before accepting it from the circulating nurse (Figure 1).It is not uncommon that when we think we ask for a 2.5-mm stent, a 3.5-mm stent is pulled from the rack. The doctor may have misspoken or mumbled, or the circulating nurse might have misheard it, but the result is a miscommunication that could have serious consequences for the patient. Perhaps a similar experience prompted Doorey et al to study communication in the catheterization laboratory. 2 Using closed-loop communication as the gold standard, they found that only 38% of orders for medications and 58% of orders for equipment were adequately acknowledged. After two rounds of quality improvement projects, each lasting for months, medication order communication improved to 70% (p < .001), but equipment order communication did not improve (59%, p = .44). Readers of this journal should be familiar with closed-loop communication because it is a fundamental aspect of team dynamics as taught in American Heart Association Advanced Cardiac Life Support courses. It requires the person receiving the order to repeat back the exact specifications of the order, including medication name and dose and stents/balloon diameter and length. Ideally, this repetition of the order by the order recipient is acknowledged by the order giver although that was not required in the current study. Closed-loop communication is important enough that it is designated a key element of communication in cardiac operating rooms by the Ameri...