Patient Safety--Communications

“Jaded Julie, I had a dream.”

“And I suppose, Curmudge, that you want me to put on my amazing technicolor dreamcoat (1) and interpret what you dreamed?”

“No need, Julie. I remember. I was admitted to a hospital, put in a room, and my records were misplaced. My desiccated remains were found months later when a housekeeper opened the door.”

“How horrible! That wasn’t here was it?”

“Who knows? My dreams aren’t site-specific.”

“I presume, Curmudge, that buried somewhere in your adventure in dreamland is a lesson about patient safety. It better be good, because we’ve already blown a third of a page.”

“You know me, Julie. There’s always a lesson, and here it is: Errors in communication can jeopardize patient safety. In fact, communication failure was a primary contributing factor in almost 80% of about 6000 root cause analyses of adverse events and close calls (2). In my dream I ceased to exist when my paperwork was lost. Here are a few other examples that are much more realistic:
Failure to communicate within a surgical team. This would include an incomplete ‘time out’ prior to surgery and reluctance to ‘sound the alarm’ when an error appears imminent (3).
Incomplete information provided during a ‘handoff,’ i.e., when the responsibility for a patient is transferred from one caregiver to another (4).
Inadequate information exchange among physicians caring for the same patient in the community (5).
Illegible handwritten prescriptions and misinterpreted telephoned orders.
Dysfunctional relationships between hospitals and physicians (6).
Failure to reconcile medications across the continuum of care (7).”

“I’m sure your list could go on and on, Curmudge. Most of these issues are well known within the health care community, and many are the subject of efforts to improve. Of course, some of these problems are going to be easier to fix than others.”

“Correct. The ‘time out before surgery’ issue is corrected by just doing it. Medication order read-back should resolve the problem of phoned orders. Staff training is used to improve patient handoffs; this would include teaching SBAR (situation, background, assessment, recommendation) and other, more complete models (4). A technology fix should improve information exchange among physicians. This is a critical need in a city that has more than one principal health care organization.”

“Isn’t the toughest nut to crack the ‘them and us’ relationship between the docs and the hospitals? That problem must vary in acuity from hospital to hospital; I hope it’s not a big issue here.”

“Julie, where it exists, McGinn and Chabon say that, ‘…solutions must be behavioral, cultural and legal.’ (6) You and I will talk more about physicians in a future series of postings.”

“I have read where one benefit of a new system for patient care, called Collaborative Care (8), is improved communication.”

“I read that too. When doctors make their rounds with a pharmacist, a nurse, and sometimes a care manager, everyone is on the same page.”

“Curmudge, I suspect that hospitals of the future will require better communication and improved teamwork. One way to achieve that is use of a government program, TeamSTEPPS (2).”

“Right, Julie. The program’s goal is to produce highly effective medical teams that optimize the use of information, people, and resources to achieve the best clinical outcomes.”

“Golly, Curmudge. That sounds a lot like Lean.”

Affinity’s Kaizen Curmudgeon

(1) Genesis 37; Joseph and the Amazing Technicolor Dreamcoat by Andrew Lloyd Webber and Tim Rice.
(2) http://teamstepps.ahrq.gov/abouttoolsmaterials.htm Leadership Briefing Slides, slides 3 and 18.
(3) Karl, R.C., Staying Safe: Simple tools for safe surgery. Bulletin of the American College of Surgeons 92 (4):16-22 (April, 2007).
(4) http://www.hhnmag.com/hhnmag_app/gateFold/pages/MAY08.jsp
(5) http://www.ncbi.nlm.nih.gov/pubmed/18981442
(6)http://www.hhnmag.com/hhnmag_app/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/11NOV2008/081125HHN_Online_McGinn&domain=HHNMAG
(7) Affinity Health System Policy 03514
(8) http://www.jsonline.com/story/index.aspx?id=735770