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Patient Safety World
September
2021
Ambiguous Language in the OR
Our January 5, 2016 Patient Safety Tip of the
Week “Lessons from AirAsia Flight QZ8501 Crash” discussed the crash of AirAsia Flight
QZ8501 into the Java Sea on December 28, 2014, killing all 162 people aboard.
Though there were multiple contributory factors, there were several ambiguous
communications that were significant factors in failure to avert the crash.
A series of serious miscommunications
occurred once the stall alarm triggered. The pilot in command shouted
“level…level…level” (repeated 4 times). But it was not clear whether he meant
to level the wings or level the “attitude” or orientation of the plane to the
ground. Then he followed with the command to “pull down…pull down” (repeated 4
times). As above, this order is ambiguous because if you pull the level/stick
down, the plane goes up and accentuates a stall.
It should come as
no surprise that use of ambiguous language in the OR can be dangerous and
contribute to adverse events and poor patient outcomes. Liu et al. (Liu
2021) reviewed video
recordings of six surgical procedures performed by residents under the
supervision of specialist physicians. In all, there were 319 minutes of surgery recorded and reviewed.
Overall, they found 3912 examples of potentially ambiguous language, a
rate of 12.3 per minute. Of these, they identified 131 near misses associated
with potentially ambiguous language.
It does have a table that provides examples of how the various types of ambiguous language led to near misses and what alternative language might have been used.
Of interest to us
is lack of comment on other forms of communication that should have taken
place. Of course, we are talking about “hearback”.
The Liu article does note that airline pilots must repeat safety messages back
to the controller but does not go into detail about use of hearback
in the OR.
Back in that January 5, 2016 Patient Safety
Tip of the Week “Lessons from AirAsia Flight QZ8501 Crash” we noted another miscommunication that was
one that did not take place but should have. When the pilot in control began to
manipulate his stick/lever, standard operating procedure would have been to
call out “I HAVE CONTROL” and responded by the other pilot transferring the
control by call out “YOU HAVE CONTROL”. Had that happened, perhaps the
cancelling action of operating to sticks/levers simultaneously would not have
occurred. Perhaps the analogy in the OR would be communication between the
surgeon and anesthesiologist regarding when it is safe to use electrocautery
once oxygen flow has been stopped. It might go something like this: surgeon
“READY TO USE ELECTROCAUTERY”, anesthesiologist “YOU MAY USE ELECTROCAUTERY”.
Hierarchy in the OR may also affect
communication. Liu et al. acknowledge that ambiguous language use between
teaching and training surgeons has the potential to lead to catastrophic
surgical outcomes, “especially when the training surgeon is junior”.
There is much more to language than the
actual words. The way the words are spoken is critical. Tone and inflection
count as well. We always tell the story about the copilot saying softly in a
monotone voice “We are running out of gas” several times before a plane crashed
because it ran out of gas. He obviously should have been shouting it out
loudly. The hierarchical nature of that cockpit probably prevented the copilot
from speaking up. How many times has that happened in the OR? Lots.
And you’ve heard us often remind everyone
that 90% of communication is nonverbal. While body language may be somewhat
obscured in the OR due to masks and gowns, it still occurs. People can convey
an awful lot of information with their eyes.
Though the Liu article has the problems we
noted above, it does have some thoughtful and useful recommendations for
improving communication in the OR and avoiding ambiguity. Some are very
practical. For example, defining a directional frame of reference at the start
of a procedure may be very useful (eg. left-right
from the patient’s perspective or the surgeon’s prospective, use “toward the
head” rather than “up/down”, etc.). It’s worth having not only your surgeons,
but your whole OR team, look at these recommendations.
References:
Liu C, McKenzie A, Sutkin G. Semantically Ambiguous Language in the Teaching Operating Room. Journal of Surgical Education 2021; Article in press 23 April 2021
https://www.sciencedirect.com/science/article/abs/pii/S1931720421000738?via%3Dihub
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