Medical Errors Report #6

A Four-Year Solution Implementation Study

Communication in Health-care Needs Urgent Improvement

There is an urgent need to correct the bad communication and hostility which presently exists between nurses, medical staff and other health-care workers. There is too much hostility in communication among hospital workers. Based on this study, a lot of second guessing of physician orders, misinterpretation of instructions and miscommunication due to bad handwritings have led to deadly mistakes killing   patients. In an Illinois case which occurred about 15 years ago, a physician called a female X-ray tech a bitch. She slapped him. The physician insisted the tech should be fired. The physician in-charge of the radiology department told the doctor he would fire the girl as long as he (the offended physician) was ready to start shooting X-rays.

 Looking at the effectiveness of communication regarding quality improvement from another perspective, Sharon LaDukes, RN a patient-documentation analyst at Claxton-Hepburn Medical Center in Ogdensburg, NY says in her article, “Nurses May Be Your Best Tool for Improving Quality of Care,” (August 2002) that many hospitals are not honoring the system of reporting concerns. Her article discusses the failure of the reporting system to improve patient care. She says that many hospitals have policies in place to report concerns and even have special procedures to file complaints, but many of the nurses believe their concerns are either not reaching the hospital administration or are falling on deaf ears. She indicates that many hospital policies are made involving nurses without nurses’ input making it very difficult for some of the nurses to work with the policies. She cites the reporting system that the nurses refused to use, fooling the administration into believing that lack of report meant there are no problems. Sharon indicated that busy nurses were unable to read and study the utilization of a three-page policy about reporting concerns when they have a large number of patients to take care of. She also hints that in many of situations, most of the nurses were unaware of the policy because the policy was never fully disseminated to the nursing staff. She explains that just because a policy looks good on paper does not mean that policy is effective for better patient care. This article outlines more effective ways information is being collected and disseminated in other institutions. One hospital is using a team of quality improvement specialists from the risk management department to go from nursing station to nursing station, asking nursing staff about their concerns about patient safety. The team collects information, analyzes it and designs solutions. She also warns that nurses want to see results from their reports; otherwise they may stop reporting incidents leading to errors.

 Communication Breakdown Leads to Medical Errors

Lack of health-care workers’ effective communication regarding warnings of potentially dangerous processes has contributed to ongoing errors and patient death. For example the systemic failure that killed Jesica Santillian was already identified, by our project and publicized to the medical community all the way to JCAHO – a regulatory organization over most of the health-care institutions.  But, the lack of dissemination of that information to the medical community all over the nation led to her death. The Sentinel report has been inadequate in addressing the issue because, the report as designed by JCAHO goes into action after the incident has already occurred. Our project proactively identified the systemic failure, but no body listened. This is where the media could have been potentially useful in dissemination of such information. To avoid litigation many of the health-care institutions are not reporting dangerous situations leading to patients harm. There has to be an online national data pool which medical professionals can use when evaluating process-lines for potential errors.

 Patrice Spath’s article of March 2003, “Prevent Communication Breakdown – Errors can Occur During Information Transfer,” discusses another angle to the issue. She indicates that transfer of information, whether oral, written or electronic, is critical. The information has to be correctly transferred, read, understood and utilized. Ineffective transfer of information during patient care creates a dangerous situation that increases harm to the patient. She also cites other studies about communication failure indicating as a contributor to adverse events.