Patient Safety: Lessons Learned
“Can You Hear Me Now?”
By: Steve Chinn, DPM, MS, Administrative Director, Accreditation and Regulatory Affairs, Interim Patient Safety Officer, Stanford Health Care
Communication is key to reducing medical errors and improving patient safety.
This phrase from a cellular carrier commercial is a bit overdone, but it highlights an issue that we have in health care: communication is key to patient safety. Have you ever had a misunderstanding with your significant other about what you were planning to do for a weekend? You were 100 percent sure you were clear about needing time to finish writing up that case study for publication and preparing for a presentation, but somehow it got scrambled where the plan was going with friends to the mountains. You’re wondering how things got so mixed up.
Communication is a two-way street. There is a sender and receiver of the message. Any time that message gets jumbled or is missing key parts, it’s a setup for errors. Take health care, for example. I was told repeatedly in my training that successful medical practice is highly dependent on my communication skills. This concept has not changed for centuries. However, when health care communication is incomplete or inaccurate, bad things can happen to patients. Consider the following scenario:
A physician gives a nurse a verbal order for a medication. The nurse thought the medication was unusual for the patient’s condition. But because it was extremely busy, the nurse took the order anyway, not 100 percent sure. Unfortunately, it was the wrong medication and ended up seriously injuring the patient.
What were the breakdowns in this situation?
- All verbal orders must have a “read back” to the prescriber to confirm the verbal order. Anecdotal reports from other staff receiving verbal orders have stated that prescribers do not stay on the phone long enough to confirm the order. This is a crucial safety step.
- The nurse was unsure about the medication order. With the tools in EPIC and the Internet, plus the opportunity for a pharmacy consultation, double-checking to make sure the medication was correct may have prevented this event from occurring.
- Another phenomenon is “production pressure,” trying to do more with less time, or multi-tasking. It turns out that both the physician and the nurse involved had been trying to do multiple things at the same time just to keep up with the workload.
- Teamwork and culture play a part in this situation. The nurse might have been too intimidated by the physician to confirm or challenge the order. This is a very difficult situation, because none of us wants to look bad or do the wrong thing.
Stanford Health Care is looking to roll out a team communication concept this coming year. Known as TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety), this program was developed by the Department of Defense’s Patient Safety Program and the Agency for Healthcare Quality and Research (AHRQ) to improve teamwork, communication and culture. Scientifically rooted in more than 20 years of research, this evidence-based teamwork system has been applied by hundreds of organizations throughout the world.
TeamSTEPPS provides higher quality, safer patient care by:
- Producing highly effective medical teams that optimize the use of information, people and resources to achieve the best clinical outcomes for patients.
- Increasing team awareness and clarifying team roles and responsibilities.
- Resolving conflicts and improving information sharing.
- Eliminating barriers to quality and safety.
Stay tuned for more information on this and other initiatives to improve quality and patient safety.
For more information about Stanford Health Care’s Patient Safety program, please contact Lisa Schilling, Vice President, Quality Patient Safety and Effectiveness at SAFE@stanfordhealthcare.org