The patient was being prepared for a surgical procedure, and everything seemed in order. Before the patient was wheeled into the OR, an anesthesia resident and pharmacist discussed this case and discovered that an important medication had not been ordered for the procedure.
The patient had hemophilia, the inability of blood to coagulate properly, which raises the risk of bleeding complications in surgical cases. These patients require medication to supplement their clotting factors.
“Factor medication is like their natural clotting factors,” explained Kenneth Leonard, Pharm.D., a UF Health Shands Clinical Pharmacy Services OR pharmacist. “In this case especially, going into surgery and having tissues cut, it’s really important to ensure the blood is coagulating properly so there is minimal blood loss.”
Concerned about the patient’s factor medication being ordered, both the anesthesia and pharmacy teams worked together to contact the patient’s vascular surgery and hematology team to discuss what steps needed to be taken. After a correct dosage was placed, the OR pharmacy members contacted their team to coordinate the patient’s medication.
“This is a case where the anesthesiology resident’s attention to detail and the great relationship with the pharmacy team really made a huge difference in the care of the patient,” said Lawrence Caruso, M.D., an associate professor in the UF College of Medicine anesthesiology and physician director of quality.
“Once I developed a plan, I called my own team and stated this medication had a high level of urgency, the patient is waiting to go into surgery,” Leonard said. This led to more teamwork and urgent follow-through.
With the patient’s factor ordered, the Nursing and Perioperative teams administered the medication. In the end, six different care teams coordinated in a very narrow window of time to get the patient ready for surgery.
The experience was an example of the importance of seamless teamwork between multiple teams.
“I think when you look at this specific case and this great catch that happened, it occurred because of the relationship that anesthesia, pharmacy and the OR staff have,” said Leonard.
“A misconception that people might have is that there was an unsafe situation that happened. But it’s quite the opposite. It’s because we think and breathe medication safety that we caught this situation. When you have an organization that has medication safety as a top goal, you remain a safer organization for the patients we treat,” Leonard said.
Caruso echoed that view.
“Because we’ve built in these systems and fostered the relationships,’’ he said, “safety doesn’t happen by accident.”