The volumes and complexities of patients under discussion daily, both substantially impede communication accuracy despite efforts to standardize procedures, as Dan Cohen describes.
The analysis of patient safety incidents has consistently demonstrated that challenges in communication are frequently contributing or causal factors when it comes to adverse events. These events often result in harm, disability and even death. When one considers that there are now estimated to be more than 200,000 deaths related to healthcare in the US every year, and many more injuries, it becomes obvious that standardizing processes and procedures for communication should be a high priority for healthcare systems.
Communication between clinicians and patients, and between clinicians and other clinicians, represent two separate domains with distinct challenges.
The communication calculus of independent and dependent variables that exist when talking with patients presents real impairments to safe and effective healthcare. Communication with patients is first about setting the agenda or purpose for each conversation, listening to patients and family members, explaining appropriate details of diagnosis and therapeutic options, and finally about asking questions regarding understanding.
Variability in intellectual abilities, cognitive skills and comprehension capabilities, language and fluency issues, education and knowledge factors, beliefs and innumerable social and economic factors all combine to alter the clinician-to-patient communication terrain. Given that patients are generally responsible for implementing care plans outside of hospital or residential settings, highest quality and safest outcomes require increased attention to these details, human and social factors and the utility of “speak-back” or “read-back” methodologies.
"The implementation of standardized checklists for surgery, universal protocols, medication reconciliation efforts, etc., are excellent examples where improvements have been noted."
All communication between clinicians and patients should conclude with clinicians listening to and probing the answers provided by patients and family members to the following questions:
“Do you really understand everything?”
“Is there anything else you would like to ask before we finish our discussion?”
“Can you please explain to me what we have just discussed?”
For clinician-to-clinician communication, the issues are arguably more clear-cut and should be amenable to uniformities of processes and procedures. The use of standardized checklists to assure accurate, complete communication and comprehension of messaging is the norm in the aviation industry, and anyone who has briefly listened to the radio communication between aircrew and air traffic controllers is aware of the constant use of “speak-back”, to confirm receipt and accuracy of transmitted instructions:
Tower: “UA 122 descend to flight level 150, turn right to vector 275o.”
Co-pilot: “UA 122 descending to flight level 150, turning right to vector 275o.”
The aircraft has been instructed to descend to 15,000 ft. (barometric) at a direction just north of due west on the compass. Message transmitted, received, confirmed. The instructions are also scrutinized for correct execution as the air traffic controller’s computers monitor the changes in altitude and direction and alert the controller regarding any deviations from instructions. Good thing!
If only healthcare were so simple. Unfortunately, the frequency of human-to-human, and now, human-to-digital platform communication in healthcare is enormous compared to what happens in a cockpit or between the flight deck of an airplane and air traffic control towers on the ground. In addition, the volumes of patients under discussion daily and the increasing complexities of human illnesses, both severely encumber communication accuracy despite efforts to standardize processes and procedures. Of course there have been notable success stories, and the implementation of standardized checklists for surgery, universal protocols, medication reconciliation efforts, etc., are excellent examples where improvements have been noted.
All in the details
Have you ever been in a situation where you tell someone something and then later that day that person denies or can’t recall that you had mentioned one particularly important item? I find that happens pretty consistently, not because people have bad memories, but rather because communication is tricky. The more details we need to convey and the greater the environmental distractions and human factors liabilities may be, the greater the risk for errors.
The more patients to be discussed and the increasing complexity of such patients, both contribute to risks in transitions. Today, many institutions have established checklist-monitored protocols that govern the transitions between shift changes and between units. Institutions that have adopted such strategies have seen reductions in errors related to transitions. Unfortunately that is not always the case when moving patients between institutions, especially if these institutions are not affiliated.
Transitions in care represent dangerous weak links that couple together the complex array of care options that patients may encounter as they traverse modern healthcare systems. Errors in communication can occur at shift changes for nurses and physicians, especially house officers, between units within hospitals (in some systems multiple transfers between wards is the norm) and between separate healthcare, or healthcare and residential care facilities.
Each of these transitions requires the transmission of precise, relevant information that enables the transition to go smoothly so that errors are anticipated and eliminated, or at least reduced to the bare minimum of risk. Failure to do so can have catastrophic consequences.
Case study
A 70-year-old retired university professor, resident in a care facility because of chronic incapacitating rheumatoid arthritis, psoriasis and lack of locally available family members to provide care, was transferred to an acute care hospital because of persistent hematochezia, bright red blood in his stools, for diagnostic testing. He had had a previous myocardial infarction but had been stable on low dose aspirin and an ACE inhibitor for two years. He also suffered from mild depression and functioned at a high intellectual level with broad interests in politics and history.
He was due to undergo a colonoscopy and possibly other studies depending on what was found. His records referred to his regimen for rheumatoid arthritis that included etanercept (Enbrel) and methotrexate in addition to a statin for hypercholesterolemia, his cardiac medications and an antidepressant.
After an assessment by anesthesia, and a standard bowel prep for 24 hours, the patient was taken to the procedure room where he underwent a colonoscopy that revealed a fungating, infiltrative carcinoma, 2.5 cm in diameter, in the ascending colon, 25 cm distal to the ileo-cecal valve. The patient was scheduled for surgery 72 hours later after obtaining consultations from nutrition support services, rheumatology, cardiology, dermatology, cardiac anesthesia and psychiatry.
It was envisioned that a right hemi-colectomy would be performed with resultant colostomy, so the stoma team was also engaged preoperatively.
For two days prior to surgery the patient complained of increasing arthritic pain and substantial weakness, and the nurses noted a decreased attention span, one commenting in a nursing note that he seemed overly somnolent. On the day of surgery the patient appeared confused in the morning, but this concern was not communicated to the surgical team, and as no-one on the anesthesia team really knew the patient, no-one paid much attention to this.
Postoperatively, the patient failed to recover as expected. He remained somnolent and incoherent and was found to be in profound electrolyte imbalance with severe hyponatremia and hypoglycemia. He suffered a cardiac arrest on the third postoperative day and could not be resuscitated.
A review of this unexpected death revealed that, in addition to the medications listed above, the patient had been taking prednisolone daily for two years for his severe rheumatoid arthritis. This information was missing from the transfer note from the residential care facility to the acute care hospital. The patient’s symptoms preoperatively were consistent with acute adrenal insufficiency, most likely due to chronic prednisolone therapy and associated adrenal suppression that made him extremely vulnerable to major surgery. The failure to provide steroid support during and after surgery was directly linked to his death.
Communication shortcomings between institutions and between clinicians within the acute care hospital setting, were contributing factors in this man’s death. If the doctors providing care had listened more closely to what the nurses were telling them, to what was written in the nursing notes, and if a nurse had verbally alerted the surgeon or anesthesiologist on the day of surgery, the secondary adrenal insufficiency caused by exogenous administration of prednisolone could have been identified by simply measuring serum electrolytes. As the patient’s original baseline studies had been normal, repeat studies were not obtained preoperatively though his symptoms suggested that they should have been rechecked.
A preventable death was caused by a failure to include one medication in the clinical summary note provided during a transition in care between institutions and because of failed communication between clinicians on one ward. Another grandfather bites the dust due to a communication confusion with catastrophic consequences.
Dan Cohen, Datix, US
