Case Scenarios: Handling Challenging Communications

You have been asked to head a small working group within your organization. When your group was assembled, you were pleased to see that a colleague named Ron had been assigned to your group. Ron is reputed to be a very bright and creative fellow who was part of another highly successful group in the organization. However, Ron has been arriving late to group meetings and recently showed up halfway through the meeting and was clearly unprepared.

You overheard two members of the group discussing Ron's behavior. One group member, Marsha, was wondering why Ron had not been removed from the group yet; the other team member, Bill, speculated that Ron has been having some problems at home and suggested that everyone should cut him some slack.

Next week your group is expected to complete an important project so that the results can be passed along to other members of the organization. Each team member is responsible for a different part of the project, and Ron is responsible for the two most important parts. Your group is scheduled to meet tomorrow to do any last minute coordination that may be required. Based on that timetable, you gave the head of your Association your personal guarantee that the project would be done by Monday.

Ron calls you today and says he doesn't have his sections finished and probably won't be able to finish them before the meeting. He says he just needs more time.

What would you say to Ron? In the space below, write in your own words exactly how you would respond to Ron to address this situation.

Mary is a 39-year-old mother of two small children who presented to the hospital's GI suite to undergo a procedure under moderate [procedural] sedation. Her parents, Bill and Beth, accompany her. Toward the end of the procedure, the nurse notices that Mary has turned blue and stops the procedure. The nurse also notices that Mary is not breathing, and her EKG shows a heart rate of less than 30. The nurse calls for a code blue response while the team involved in the procedure begins to administer CPR. When the code team arrives, there are some delays in providing appropriate care while different physicians argue about the proper course of treatment. Eventually the team is able to re-establish Mary's normal heart rate, blood pressure, and adequate blood oxygen level.

During the resuscitation efforts, information obtained from the devices monitoring Mary's EKG, blood pressure, and blood oxygen levels reveals a period of approximately 7 minutes during which she may not have been breathing adequately, possible from too much sedation medication during the procedure. The nurse involved in monitoring Mary appears visibly shaken and states that she was distracted during the procedure because she was trying to obtain different pieces of equipment for the procedure.

Bill and Beth are in the waiting room. They have heard the overhead call of code blue and have seen many people running to the procedure area.

You have been asked to go to the waiting room and speak with Mary's parents. You approach Bill and Beth in the waiting room.

In the space below, write in your own words exactly what you would say to Mary's parents.

Adam, a 55 year-old male is admitted to your hospital for an elective removal of his spleen. The nurses, operating surgeon and anesthesiologist are all employed by the hospital, which is self-insured for professional liability. The procedure is technically challenging due to the patient's obesity but appears to go smoothly.

Adam is discharged after 3 days and has mild, persistent abdominal pain.  The medical team attributes the pain to the surgical incision. When Adam returns for his 2-week post-operative check at the surgeon's office, he reports increasing abdominal pain and a 3-day history of a low-grade fever.

An X-ray of the abdomen reveals a surgical sponge. Adam undergoes another surgery to remove the sponge, at which time an abdominal infection is discovered. The surgery is performed by a different surgical team at the same hospital. Treatment of the abdominal infection requires a 4-day stay in the hospital followed by a 3-week course of intravenous antibiotics at home. Adam, who is employed as an architect, misses a total of 8 weeks of work.

The root cause analysis reveals that the sponge counts took place before and after the surgical procedure, and correct counts were documented. The patient's physical make-up was considered to be a causative factor.

In the space below, write in your own words exactly what you would say to Adam and his family.

Alphonse, a 50 year-old CEO of a large aerospace company with a family history of high cholesterol has come to your hospital for cardiac bypass surgery. He has been married to Sonia for 25 years, and they have three college-aged children.  The operating surgeon and anesthesiologist are both members of different multi-specialty physician groups that purchase their professional liability insurance from physician mutual insurance companies, and the hospital is self-insured.

The hospital has recently purchased a new piece of equipment for blood administration during a surgical procedure. The anesthesiologist received training on the equipment and has used it in six surgical cases to date. The equipment is being used in this surgical case. Two units of blood have been administered during the case using the equipment. As the anesthesiologist administers the last unit of blood, the patient suddenly experiences cardiopulmonary arrest.

The anesthesiologist suspects that Alphonse has an air embolus, and appropriate resuscitative measures are undertaken. He is successfully resuscitated but experienced a prolonged period of limited oxygen to the brain. Over the next few days, it is clear that he has suffered a significant brain injury due to the lack of oxygen. He is discharged to a skilled nursing facility with little prospects of ever returning to work.

The root cause analysis suggests that the cause of the air embolism was multi-factorial, but identifies a breakdown in communication between the anesthesiologist, perfusionist, and surgeon, along with a lack of familiarity with the new equipment as an important cause of the adverse event.

In the space below, write in your own words exactly what you would say to Alphonse's family.