Patient Safety Lessons Learned:

The Case of the Serious Medication Overdose

It was another typical day in the inpatient unit, with multiple patients having challenges and needing constant interactions with the treatment team. One patient in particular was having difficulty maintaining blood pressure and a physician barked out a verbal order at the bedside for a medication dose ten times the normal amount. The RN repeated back the verbal order, but did not challenge the dose. The medication was given and the patient's blood pressure shot up over the desired range.

Fortunately, there was no adverse outcome to this patient, but the situation created extra work and stress for the team. This case has lessons to learn regarding team culture and communication. The physician, new to working in this area, thought the correct dose was ordered and assumed the nurses would make the necessary adjustment. The communication was not crystal clear. Because the situation was urgent, the doctor did not feel that there was enough time to enter an order into the computer. The nurse thought the dose was high, but didn't want to challenge the physician publicly at the bedside. The team had not worked together enough to know how to communicate well between members. The Pyxis was overridden, which circumvented one of the medication safety protective features.

Communication is a two way street. The sender of the information must have a partner/receiver who needs to clearly understand the information sent. Many of us played the telephone game as kids where you sit in a circle and whisper a message to the person next to you. The outcome of this game is usually nonsensical or hilarious. But you probably don't want the same botched communication for your patients.

In a crisis situation, there are all kinds of barriers, including sending an unintended message, not being clear on the content of the message received, ambient noises, distractions and activities. Communication is 60 percent based on physical transmission of the message. Yet, in health care, assumptions are often made, unknown or unexpected variables exist, and information seems to is sometimes be transmitted telepathically between team members. All of these scenarios can create misinformation that leads to patient harm.

Ways to prevent miscommunication

1. Make eye contact with the receiver of the information, when possible.
2. If you are a sender, ask for confirmation of the information sent, if you are not confident that the message was received.
3. If you are a receiver, read back the information, or repeat it back in an emergency. This is the same technique used by air traffic controllers.
4. Use technology (enter orders in EPIC), if possible.
5. Nursing should use SBAR communication with the medical staff, if possible.

References

Link to the following articles for more information on physician communication:

• Physician Communication in the 21st CenturyTo Talk or to Text?

By Leora I. Horwitz, MD; Allan S. Detsky, MD, PhD 

• Effective Physician-to-Physician Communication: An Essential Ingredient for Care Coordination

By Diane Shannon, MD, MPH

• Communication among health care professionals: An essential component of quality care

By Scott G. Kirby, MD

If you have questions or comments about this article or SHC's Patient Safety program, contact Steve Chinn, DPM at sdchinn@stanfordmed.org or 650-723-6395.

By Steve Chinn, DPM, MS, MBA, Director, Accreditation and Regulatory Affairs