LAUSR

The practice of medicine long ago stopped being just about one patient and their doctor. Medicine is now a team sport. Nowhere is this more true than in the cardiac catheterization laboratory, where an interdisciplinary team of nurses, technicians, and physicians performs increasingly complex coronary, electrophysiologic and structural heart procedures on patients. Effective teamwork is critical to a safe cath lab environment that can avoid the medical errors that are responsible for 44,000–98,000 deaths annually in the United States. While many factors contribute toward ineffective teams including strict hierarchies, understaffing, stress, and personality conflicts, the most common and proximate cause of errors is poor communication. Miscommunication is to blame for up to 43% of errors in the operating room. Malpractice cases triggered by communication failures are both more likely to result in a payment and a larger‐ than‐average payment according to the Control Risk Insurance Company. Standardized communication procedures originally derived from military and aviation radio transmission protocols have been shown to reduce the risk of miscommunication in health care. Closed‐loop communication (CLC) is one such technique which is highly applicable to the busy, noisy, and verbally driven cath lab. In CLC, the physician vocalizes an order to a specific recipient, who must then verbally acknowledge receipt of the message and read it back to the physician for confirmation and acknowledgment. Ideally, when the requested supply item has been retrieved, requested drug delivered, or requested action performed another round of CLC occurs to inform the recorder and physician that the order has been carried out. Doorey in this issue of Catheterization and Cardiovascular Interventions applied his personal background in aviation safety to this 5‐year quality improvement project on cath lab communication. Observations of cath lab staff at baseline (with the staff having no knowledge of being observed) demonstrated only 38% complete compliance with CLC principles for medication readbacks and 58% for equipment readbacks. After educational efforts on CLC by the study personnel and cath lab leadership on the importance of CLC in communications, the CLC complete readback rate improved to 62% and 58%, but further improvement with Six Sigma training from the facility's quality committee was minimal (rates of 69% and 59%). Some examples of CLC failure from the study are shocking and of clear risk to patient care: