Close call in the OR: Speaking up prevents patient harm

Lily Maguire, M.D., and Joseph Brooks

Caring, teamwork and integrity. These three Michigan Medicine values were exemplified during an incident in the operating room late last year that could have resulted in severe patient harm but, thanks to a team member’s sharp eye and courage to speak up, didn’t.

It was a cold day in December and research clinical subjects coordinator Joseph Brooks remembers it was dark in the OR. The type of surgery being performed, a laparoscopic total colectomy, typically occurs in a darkened room to enable the surgeon and other team members to better view the monitors they rely on during the procedure.

Brooks was in the room that day as part of an anesthesia research project headed by Phillip Vlisides, M.D., to study the effects of caffeine on pain, brain function and mood following surgery. Brooks had placed an EEG cap on the patient, who was participating in the study, and was periodically checking the cap when he noticed something was wrong.

“It happened in a split second,” said Brooks. “I turned to check on the patient and noticed something didn’t look right. He was literally slipping, head first, off the table.”

Sounding the alarm

During the procedure being performed, the patient is moved into many different positions by the operating table.

“My resident and I have our eyes focused on the TV screens that are allowing us to see the laparoscopic view of the operation in progress,” said Lily Maguire, M.D., the colorectal surgeon performing the procedure that day. “While our eyes were fixed on the screen and our patient was positioned in a steep head-down position, we were not noticing that he was gradually slipping off the table.”

Other members of the OR team that day were focused on the tasks they were there to perform and had not noticed the patient slipping either.

“I immediately shoved my arm in to get beside the patient and prevent him from falling,” Brooks said. “I told the team what was happening. Everyone responded very quickly to get the table flat again and keep the patient safe. It took the whole team working together to move him.”

The patient and the team were fortunate that the patient was participating in the study and that an extra set of eyes were in the room that day. They were also fortunate Brooks had the courage to say something.

Everyone has a voice

Maguire and Brooks both acknowledge that the traditional hierarchy in an operating room can sometimes make it scary to speak up. In fact, Maguire remembers a few situations where people were afraid to voice concerns in the OR during her years in training at another institution.

“The OR is a really complicated place,” she said. “It’s incumbent upon all of us, especially surgeons and anesthesiologists, to be open and approachable so we’re not making people scared to voice their concerns. When people are fearful or upset about the way they’re being treated, it’s hard for them to perform at their best.”

Maguire’s sentiments are directly in line with one of the key characteristics of a highly reliable organization (HRO): encouraging employees to work as a team and support one another, creating a culture of respect and accountability.

Maguire learned years ago to put her own fears aside and speak up, recognizing that you can’t let anyone else’s words or actions keep you from taking good care of a patient.

“If you are afraid to speak up,” she said, “that can lead to serious mistakes.”

Part of the new safety statement created through Michigan Medicine’s work to become an HRO is as follows: “We are open and transparent about errors, and will stand up for those who speak up.”

Maguire’s understanding of the importance of every voice, and her desire to empower her team, have guided her in creating a safe setting in the OR where people feel comfortable providing input and sharing concerns.

“It’s so important, in my mind, that the operating room feel like a team environment and that everyone is empowered and confident to speak up for patient safety,” said Maguire.

Brooks has strong feelings on the subject of speaking up, as well, and has even led workshops on the topic.

“If there’s ever any risk of danger to a patient, you have to respond,” said Brooks. “One way to look at it is this: If it were your mother, child, family member or close friend, would you say something or would you let something happen because you’re afraid of hurting someone’s feelings or getting in trouble?”

Preventing future incidents

After completing the patient’s procedure, Maguire shared the incident with the patient’s family and immediately filed a safety report detailing what had happened.

“The incident of the patient slipping was due to a malfunction in the operating table itself,” said Maguire. “I wanted to be sure this would not happen again.”

Maguire said the rapid and robust safety response system already in place at Michigan Medicine was extremely helpful. She remembers an entire team of people coming in over the holiday weekend to inspect every OR bed. As a result, problems with other beds were identified and corrected.

Also a result of Brooks’ intervention that day, Maguire is now much more vigilant when repositioning patients.

“We couldn’t do what we do without the technology we have,” said Maguire, “but, at the same time, we need to make sure we are keeping our eyes on the patient and not getting distracted by that technology.”

Working together to keep patients safe

Brooks encourages everyone to speak up for patient safety.

“If something doesn’t look right, say something,” he said. “In chaos, or even a calm surgical setting, not everyone sees everything. Everybody has their own job to do.”

Maguire couldn’t agree more.

“Lots of things were going on in the OR that day,” she said. “We were very fortunate Joe was paying attention to the case and that he spoke up when he noticed something was wrong.

“There is nothing about me that caused this to be a near miss or great save,” she continued, wanting to be sure credit is given where it is due. “Major kudos to Joe, and to the rest of the team, for their quick response to a situation that could have had a poor outcome.”

Kudos to Brooks, for sure, and to Maguire for creating an environment in which every team member has a voice and is comfortable using it.