A 61 y/o male was admitted with acute onset of stroke. Neuroradiologic imaging confirmed a thrombotic etiology, and alteplase was administered. The patient was emergently brought to an interventional suite for definitive treatment. He was intubated by the anesthesia team consisting of an attending anesthesiologist and a CRNA. The interventionalist attempted arterial access in the right groin but encountered difficulty. Contrast medium extravasation was observed emanating from the right iliac artery. This observation was not conveyed to the anesthesia team. The interventionalist instructed a radiology fellow to hold pressure on the right iliac artery while he then proceeded to obtain vascular access via the left femoral artery instead. During the three-hour case, the CRNA struggled to maintain hemodynamic stability of the patient. Throughout the procedure, she also neglected to communicate to either the attending anesthesiologist or the interventionalist the significant amount of vasopressor and fluid support required to maintain the hemodynamics. At the end of the procedure, when the attending anesthesiologist was made aware of the hemodynamic instability, an arterial blood gas sample was obtained. The ABG revealed profound anemia and acidosis. A massive transfusion protocol was initiated and a tear in the right iliac artery was identified and repaired. Unfortunately, the patient expired the following day from hemorrhagic shock leading to multisystem organ failure.

Communication during a procedure is an essential component of safety culture. This concept applies to communication between the members of the anesthesia team, the proceduralist, and anesthesiology clinicians. In this case, the interventionalist instructed the CRNA to keep the blood pressure in the range of MAP=80. She failed, however, to mention that there was a potential ongoing bleeding from the right iliac artery.

Likewise, the CRNA failed to communicate to the attending anesthesiologist that over 3,000 ml of crystalloid fluids and several infusions of vasopressors were being administered to comply with the request of the radiologist. The knowledge of a potential ongoing blood loss would have prompted earlier resuscitation with blood products and likely would have affected the patient’s outcome. This is a classic example of intraoperative “failure to rescue.”

Over several decades, multiple studies have shown how inadequate communication inside the OR is associated with adverse events. In 2003, communication failures were cited in 60% of sentinel events reported to The Joint Commission (asamonitor.pub/4c6RsR3). Multidisciplinary teamwork and the relationship between effective communication and safety have been described in detail (Qual Health Care 2001;10:65-6; Saf Sci 2003;41:409-25).

Specific types of communication failures have also been well described. In the case presented, both “content failure” (i.e., insufficient information was transferred) and “purpose failure” (i.e., communication purpose was unclear and not achieved) are described (Qual Saf Health Care 2004;13:330-4).

Additional factors, seen in this case, can contribute to communication failures:

  • Attempt to communicate is too late to be effective (e.g., radiologist waited until the end of the procedure to disclose the presence of a vascular injury).
  • Content is incomplete or inaccurate (e.g., interventionalist asked to keep the blood pressure up, but failed to express the concern for bleeding).
  • Key individuals are not included in a conversation (e.g., CRNA did not communicate blood pressure concerns to the attending anesthesiologist).
  • Issues are left unresolved until the point of extreme urgency (e.g., severe anemia was discovered three hours later; intervention was ineffective at that point).

Further retrospective evidence for the negative impact of poor communication comes from the Closed Claims Project. For example, communication among providers was identified as contributing to patient injury in 13% of all claims originating in ambulatory centers (J Patient Saf 2021;17:513-21). A 2022 study reviewed anesthesia closed claims since 2004 and identified at least one communication failure contributing to patient injury in 43% of claims (Br J Anaesth 2021;127:470-8). The most common contributory factor identified was insufficient or inaccurate information exchange between an anesthesia team member and a surgeon.

However, real-world evidence linked to outcomes, by its nature, will be retrospective and thus potentially tainted by hindsight and outcome bias. The best evidence linking communication deficiencies with decreased clinical performance can be seen in simulation studies. In a prospective study conducted by the Simulation Assessment Research Group, 263 consenting board-certified anesthesiologists doing Maintenance of Certification in Anesthesiology simulation courses each participated in two standardized high-fidelity simulated crisis management scenarios in which communication and teamwork were important elements of successful performance. Trained, independent blinded anesthesiologists scored the video-recorded encounters using standardized competency-based rating tools. Overall, participants successfully completed over 80% of pre-established clinical performance elements. However, in a quarter of the encounters, the anesthesiologist’s behavioral (i.e., teamwork and communication) scores were in the lowest tertile (≤3 out of maximum score of 9). In a scenario involving hemorrhagic shock during laparoscopy, less than half of the participants communicated with the surgeon the need to open the abdomen to obtain definitive surgical hemostasis. During a LAST scenario, nearly one-third of participants failed to ask the surgical gynecologist to clarify what drugs/dose/route was used to perform the field block. Later in that scenario, 31% of participants failed to tell the team that the patient was having intermittent ventricular tachycardia.

The presented case highlights another caveat — cognitive errors often serve as a root cause of an adverse event. Specifically, so-called “anchoring” led the CRNA to focus on maintaining a blood pressure within a required range without questioning the means (i.e., the need for 3,000 ml of crystalloid fluids plus vasopressors) and the reason behind extreme hemodynamic instability. Additionally, it is possible that “overconfidence bias” played a role and prevented the CRNA from seeking advice from his attending anesthesiologist.

Alternatively, performance in a high-stress/high-stakes environment such as the OR can be negatively impacted by fear of speaking up due to intimidation or feelings of insecurity. This especially applies to trainees in a hierarchical academic practice (Saf Sci 2020;125:104648).

This case underscores the importance of creating a safe environment where all perioperative team members feel comfortable communicating their concerns regarding patient management. In a simulated hemorrhage scenario, anesthesia residents exposed to an “impatient” surgeon scored significantly lower on four performance metrics and reported that the environment had a negative impact on team performance, as compared to a control group (BMJ Qual Saf 2019 28:750-7).

Finally, the attending anesthesiologist in this case had not checked on the patient and CRNA throughout the three-hour duration of the case in this off-site location. As the attending of record, not only does this physician have a duty to both the patient and the CRNA, but the Centers for Medicare & Medicaid Services standard for medical direction requires that the physician “monitors the course of anesthesia administration at frequent intervals” (asamonitor.pub/3TpCj6k). While the precise time definition of this requirement is not specified, it is generally advised that such a physical check on the patient should occur every 60-90 minutes.

In conclusion, this case discussion highlights the importance of timely and proper communication within and between the teams, situational awareness, and avoidance of cognitive errors in the perioperative workplace.