A 56-year-old man was undergoing a laminectomy. The procedure got off to a good start, with the surgeon sticking to the surgical plan that was defined in advance. However, in the middle of the operation, the anaesthetist noticed that the patient’s blood pressure was falling. After being alerted to the issue several times, the surgeon decided to stop the procedure and analysed potential sources of bleeding with the anaesthetist. He quickly concluded that the blade of the tool used during the operation was damaged and had severed patient’s iliac artery, causing haemorrhaging in the pelvis. In this case, clear communication between team members narrowly prevented a serious adverse event. Teamwork and communication between team members can be improved through strategies such as CRM training and tools like CUS and the Two-Challenge Rule.
Date de parution : 09/2019
Thème : Communication
Mots clés : CRM, teamwork, TeamSTEPPS
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