Learning Objectives

At the conclusion of this educational activity, participants should be able to:

• Identify principles of effective communication between health care providers
• Explain some of the reasons that cognitive errors occur even among informed, well-intentioned, and conscientious clinicians
• Describe some of the considerations for and against administering prophylactic anticoagulation to patients with acute traumatic injuries

The Case

A 38-year-old non-English speaking man with a body mass index of 45 crashed while riding a motorcycle and was brought to a trauma center with altered mental status (Glasgow Coma Score, GCS 6) and respiratory distress. Attempts at endotracheal intubation were unsuccessful, so an emergency cricothyroidotomy was performed. Subsequent computed tomography (CT) imaging revealed trace left occipital subarachnoid hemorrhage, right occipital condyle fracture, C6-C7 traumatic disc rupture, bilateral pulmonary contusions, right hemopneumothorax with 6th through 9th rib fractures, left hemothorax with 3rd through 7th rib fractures, T6 spinous process fracture, and a proximal left humerus fracture. The patient remained mechanically ventilated for altered mentation and presumed aspiration pneumonitis. On hospital day 2, the primary trauma surgery team ordered magnetic resonance imaging (MRI) of the brain, due to concern regarding possible hypoxic-ischemic encephalopathy, and spine consultants requested concomitant MRI of the spine to determine whether operative stabilization of the C6-7 injury might be necessary. These studies, completed on hospital day 6, showed no evidence of traumatic or hypoxic brain injury and no ligamentous injury; the radiologist noted “minimal cervical spine epidural blood or fluid with no compromise of the spinal cord.” This incidental finding was not documented in progress notes by either the trauma team or the spine surgery team.

In the meantime, on hospital day 4, the patient had been started on 7500 units of unfractionated heparin every 8 hours due to his risk of venous thromboembolism. He slowly regained consciousness and the ability to intermittently follow commands in his primary language, but he remained mechanically ventilated for respiratory failure and aspiration pneumonia, immobile most of the time. On hospital day 7, the patient’s nurse documented that the patient withdrew his lower extremities (LE) to stimuli, but then documented no LE response the following day. On hospital day 9, the nurse documented “unable to move BLE, sensation intact, team aware.” However, the trauma surgery team’s progress notes described the neurological exam as “moves all extremities” during hospital days 5-10. By hospital day 13, the patient’s inability to move his legs was recognized by all care providers and a repeat MRI study showed a large C3-C7 epidural hematoma with cord compression. The patient underwent emergency laminectomy and decompression but had persistent virtually complete paralysis below the C7 level upon hospital discharge and at follow-up six months later.

The Commentary

by Garth Utter, MD

Modern inpatient care is highly capable—but also highly complex—and thus prone to errors involving information management and communication. Among the numerous individuals involved in the care of a multiply injured patient, no single physician or nurse is likely to have access in real time to the full complement of dynamic clinical information about a patient, including historical details, serial physical exam findings, laboratory and imaging results, and recommendations and thought processes of other physicians, nurses, and therapists. Furthermore, team members with less experience typically serve as the real-time “eyes and ears” of the enterprise, but they may lack a thorough understanding of how critical changes can quickly result in otherwise preventable death or severe morbidity. We are not computers: Our fundamental cognitive processes, along with time constraints, limit us to recognizing patterns quickly, or — when we actively decide to override this efficient but potentially error-prone form of thinking — expending greater time and energy to focus attention on more complex problem-solving.¹

Communication Issues

Most notably, this patient’s team experienced a breakdown in communication regarding the predisposition to and development of spinal cord compression. This breakdown occurred on several levels. The primary problem was insufficient communication between the ICU nurse(s) and the primary team. The nurses’ notes indicate that the “team” (presumably at least a junior resident at this trauma center) was aware of the change in motor function, but at least 1 day after a nurse first documented abnormal lower extremity motor function. This is an inexcusably long period for a finding that could represent any of several neurologic emergencies, including ischemic or hemorrhagic stroke, progression of an occult traumatic brain injury, spine instability causing spinal cord compression, or in this instance, a spinal epidural hematoma causing such compression—all problems that potentially require immediate intervention. A secondary problem seems to have been poor communication among the physicians taking care of this patient, as 4 days passed between documentation of the “team” being “aware” and this awareness extending to the whole team, prompting action. Communication was also suboptimal between the radiologist and the primary team, as well as between the spine consultants and the primary team. If one or more of these communication links had been stronger, key information might have been comprehended better and a poor outcome potentially averted.

Effective communication requires that one party impart information and another party receive it, and miscommunication can result from deficiencies with either step. In today’s hospital culture, no patient should suffer as a result of reluctance of nurses, physicians, and other health care personnel to communicate with each other. Principles of “crew resource management,” borrowed many years ago from the commercial aviation industry, dictate that all individuals, no matter their level of experience or stature, feel empowered to advocate for the benefit of the patient, without fear of disrespect or retribution.² Such collaboration should now be ingrained into hospital processes, including such practical considerations as having nurses participate in physician rounds, encouraging nurses to contact their nursing leadership or senior physicians if they feel that management by junior physicians is inadequate, and augmenting bidirectional nurse-physician teaching. However, communication errors can occur even in an environment of mutual respect and cooperation, so active engagement by minimizing distractions, repeating critical information, confirming receipt of the information, and following through on the planned management of such findings are all good routine communication practices.³

Adjuncts to promoting communication, such as checklists, formal sign-out practices with changes of shift,⁴ and structured progress notes, are useful but might not have helped address this error because the critical information (i.e., the presence of a subtle spinal epidural hematoma and the change in the lower extremity motor exam), was apparently unrecognized, or at least its significance was underappreciated. Similarly, mandatory notification criteria (i.e., requiring junior team members to elevate certain types of new findings to senior team members) may have helped, but the key deficiency seems to have been awareness of the critical finding in the first place, and not a failure to communicate a recognized critical finding. One cannot warn others about what one fails to perceive.

Electronic Health Records and Cognitive Processes 

Lack of communication was probably compounded by a cognitive failure to recognize the importance of the exam finding. Our understanding of the influence of electronic health records (EHRs) on clinicians’ processes is still in its infancy, but such realities as “copying-and-pasting” (perhaps contributing to the series of progress notes in this case documenting “moves all extremities”),⁵ “note bloat,” and alarm fatigue suggest that we are far from ideal practices in efficiently capitalizing on EHRs to optimize our cognitive processes. EHRs with poor user interfaces lead to provider fatigue⁶ and probably detract from available time to examine patients.⁷ EHRs allow rapid access to large amounts of information critical for patient care, but EHR user interfaces do not always organize and present this information in a way that facilitates our perception and use of it.^8,9 For example, physicians in this case may have been unaware for a few days that the nursing notes documented deteriorating motor function because they perceived reviewing nursing notes as an inefficient means to gather pertinent information from the EHR. Furthermore, EHRs may propagate erroneous information. For example, some of the treating physicians might have been falsely reassured by the progress notes of others documenting “moves all extremities.” Issues related to the impact of EHR usability, copy-and-paste notes, and autopopulated text are discussed in a previous WebM&M on this case.

An additional underlying factor that may have contributed to the team’s failure to contextualize the significance of the lower extremity exam changes is that the initial MRI spine study was requested by a separate team and ordered primarily to evaluate whether a ligamentous injury was present; the small epidural hematoma was an incidental finding. This classic cognitive pitfall of failing to recognize what one is not looking for, a form of “anchoring,” can be remedied only by thorough, systematic review of study results, including: (1) reading the narrative text of radiologic reports and not simply the summary findings; (2) interval re-evaluation of any such reports that are labeled as preliminary in case readings change upon final interpretation; and (3) documentation of such review in progress notes. Additionally, to facilitate communication, radiologists should highlight key findings of studies, especially drawing attention to important but unanticipated findings, and adhering to best practices in direct communication of critically important and time-sensitive findings.¹⁰

Expecting the Unexpected: When the Physical Exam Changes 

Several patient factors may have contributed to the delayed recognition of this patient’s lower extremity exam changes: he was morbidly obese and mechanically ventilated for a prolonged period; had mental status changes, limited mobility, and concomitant injuries; and communicated in a different language.¹¹ Unlike exam findings such as respiratory distress or abdominal distension which are readily apparent and visually observed, providers would have had to actively elicit the key finding, loss of motor function, in this obtunded, non-verbal patient. However, the clinical team must anticipate and counter these challenges by adhering to frequent and targeted but complete neurologic exams, using interpreting services or other bilingual personnel when possible, and focusing on all possibly important clinical signs of deterioration—even if they don’t match the most prominent perceived risk, such as anoxic brain injury for this patient who was initially difficult to intubate. In the context of many confounding factors, the patient pays for the collective failure of all providers, at all levels of experience, to maintain constant vigilance.

Prophylactic Anticoagulation in the Multiple Injured Patient 

In the best of circumstances, and even with perfectly communicated information, ordering clinicians must still manage competing risks with their treatment decisions. The patient in the case was clearly at risk for venous thromboembolism as a complication. He had multiple orthopedic injuries and was relatively immobile for several days.¹² Anticoagulation with low molecular weight heparin is typically preferred after traumatic injury, but in the context of a small intracranial subarachnoid hemorrhage, unfractionated heparin was a reasonable option.¹³ Notably, it had already been started before the first MRI study that detected the small spinal epidural hematoma, raising the question whether earlier recognition of the hematoma would have prompted stopping the heparin. As for many rare but serious risks associated with anticoagulation, studies of patients at risk for venous thromboembolism do not provide clear answers regarding the optimal use of prophylactic anticoagulation, and one could reasonably argue for either stopping or continuing the heparin.^14,15 Additionally, patients with traumatic injuries have variability in their response to unfractionated heparin—with some patients requiring large doses to achieve adequate prophylaxis and others needing smaller amounts, presumably due to variable levels of antithrombin during the post-injury systemic inflammatory response.¹⁶ Adjunctive testing, such as monitoring of the partial thromboplastin time (PTT) or activated factor X levels, has been proposed as a means to monitor the effectiveness of heparin prophylaxis;^17,18 it is unclear if such monitoring was used in this case to detect potential heparin overdosing. However, recognition of the epidural hematoma might have at least increased the attentiveness of clinicians to any changes in motor function of the lower extremities. It is at least theoretically possible that an EHR-based alert, such as new documentation of weakness by a nurse in a structured field, could have prompted faster recognition of a possible neurologic complication in a patient on anticoagulation.

Take Home Points

• Despite (and perhaps sometimes because of) advances in electronic health records, clinicians must be both vigilant regarding managing large volumes of clinical information and aware of cognitive pitfalls in processing this information.
• Good communication involves all team members at all levels and requires active engagement by both the giver and receiver of information.
• In acutely injured patients, ordering clinicians must carefully weigh the risks and benefits of pharmacologic prophylaxis against venous thromboembolism.

Garth Utter, MD MSc
Consulting Editor, AHRQ’s Patient Safety Network (PSNet) 
Professor
Department of Surgery, Division of Trauma, Acute Care Surgery, and Surgical Critical Care 
UC Davis Health 
ghutter@ucdavis.edu

References 

1. Kahneman D. Thinking, fast and slow. 1st pbk. ed. New York: Farrar, Straus and Giroux; 2013.
2. Kim S, Appelbaum NP, Baker N, et al. Patient safety over power hierarchy: a scoping review of healthcare professionals' speaking-up skills training. J Healthc Qual. 2020;42(5):249-263. [Available at]
3. Diaz MCG, Dawson K. Impact of simulation-based closed-loop communication training on medical errors in a pediatric emergency department. Am J Med Qual. 2020;35(6):474-478. [Available at]
4. O'Toole JK, Starmer AJ, Calaman S, et al. I-PASS Mentored Implementation Handoff Curriculum: Implementation Guide and Resources. MedEdPORTAL. 2018;14:10736. [Free full text]
5. MacDonald S. "'Copy and Paste' Notes and Autopopulated Text in the Electronic Health Records." AHRQ Patient Safety Network (PSNet). October 31, 2023. Accessed July 15, 2024. [Free full text]
6. Khairat S, Coleman C, Ottmar P, et al. Association of electronic health record use with physician fatigue and efficiency. JAMA Netw Open. 2020;3(6):e207385. [Free full text]
7. Arndt BG, Beasley JW, Watkinson MD, et al. Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations. Ann Fam Med. 2017;15(5):419-426. [Free full text]
8. Ahmed A, Chandra S, Herasevich V, et al. The effect of two different electronic health record user interfaces on intensive care provider task load, errors of cognition, and performance. Crit Care Med. 2011;39(7):1626-1634. [Available at]
9. Nijor S, Rallis G, Lad N, et al. Patient safety issues from information overload in electronic medical records. J Patient Saf. 2022;18(6):e999-e1003. [Free full text]
10. Advancing safety with closed-loop communication of test results. Quick Safety. December 17, 2019;(52):1-3. [Free full text]
11. Divi C, Koss RG, Schmaltz SP, et al. Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health Care. 2007;19(2):60-67. [Free full text]
12. Knudson MM, Ikossi DG, Khaw L, et al. Thromboembolism after trauma: an analysis of 1602 episodes from the American College of Surgeons National Trauma Data Bank. Ann Surg. 2004;240(3):490-496; discussion 496-498. [Free full text]
13. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 Suppl):381S-453S. [Available at]
14. Chang R, Scerbo MH, Schmitt KM, et al. Early chemoprophylaxis is associated with decreased venous thromboembolism risk without concomitant increase in intraspinal hematoma expansion after traumatic spinal cord injury. J Trauma Acute Care Surg. 2017;83(6):1088-1094. [Free full text]
15. Kim DY, Kobayashi L, Chang D, et al. Early pharmacological venous thromboembolism prophylaxis is safe after operative fixation of traumatic spine fractures. Spine (Phila Pa 1976). 2015;40(5):299-304. [Available at]
16. Owings JT, Bagley M, Gosselin R, et al. Effect of critical injury on plasma antithrombin activity: low antithrombin levels are associated with thromboembolic complications. J Trauma. 1996;41(3):396-405; discussion 405-396. [Available at]
17. Ko A, Harada MY, Barmparas G, et al. Association between enoxaparin dosage adjusted by anti-factor Xa trough level and clinically evident venous thromboembolism after trauma. JAMA Surg. 2016;151(11):1006-1013. [Free full text]
18. Kopelman TR, O'Neill PJ, Pieri PG, et al. Alternative dosing of prophylactic enoxaparin in the trauma patient: is more the answer? Am J Surg. 2013;206(6):911-915; discussion 915-916. [Available at]