Last week, in our Patient Safety Tip of the Week “Psst! Pass it on…How a kid’s game can mold good handoffs” we focused on communications issues related to handoffs, which are primarily done nurse-to-nurse, physician-to-physician, etc.
Well, communication across professional roles is even more important. Root cause analyses (RCA’s) of serious incidents and sentinel events find communications problems in 70-80% or more of cases reviewed. And an equally high number of malpractice claims include examples of breakdowns in communication.
Several excellent recent papers highlight the role that physician-nurse communication, in particular, plays in some high-risk settings. First was a white paper “Optimizing Physician-Nurse Communication in the Emergency Department” from CRICO/RMF which, by the way, has a wealth of very useful patient safety educational and implementation materials. CRICO/RMF is the medical malpractice company and risk management foundation for the Harvard community. They have a large database of information from malpractice claims and regularly convene collaboratives to develop lessons learned and best practices to share in attempt to promote patient safety. From their claims database they determined that missed or delayed diagnoses in the ED are the leading cause of malpractice liability in emergency medicine. They convened their Emergency Medicine Leadership Council to look at the issues. But that group found that, rather than being caused primarily by cognitive errors, communication breakdowns were a major contributing factor.
Yes, they did identify the usual suspects such as delayed lab and radiology reports, lack of information from patients’ past medical history, problems with consultants, fumbled handoffs, etc. But they also identified barriers to effective communication between physicians and nurses taking care of the same patient and came up with good recommendations on strategies to improve such communication.
Failure to address abnormal vitals signs was a root cause found in many of their malpractice claims. That might be discharging a patient who still had abnormal vital signs or failure to promptly attend to a patient having deterioration of vitals signs while still in the ED. The example they provide for the former might be a patient who has a persistent tachycardia even after IV fluids. They recommend that all abnormal vital signs be reconciled prior to discharge, perhaps in a structured communication between physician and nurse. Similarly, setting up a system where abnormal vital signs trigger a change in triage can be important. They cite one hospital that set up such a trigger system and significantly cut the time to initial physician visit, time to first intervention, and LOS in the ED.
Structured communication events and physician/nurse huddles were also identified as important. During such events a nurse might convey important information about the ED as a whole (eg. capacity, bed availability, patient flow, etc.) but huddles specific to each patient are also important. Bedside rounding, which allows the patient and/or family to also be kept in the loop (and perhaps chime in with relevant information like “no, he does not use insulin!”), is also a good practice. One hospital developed the “STOP” format:
S significant issues
O oxygen and last vital signs
P pending issues
A discharge “timeout” where the physician and nurse get together and go over all the issues relevant to discharge was noted to have identified many near misses that got fixed prior to actual discharge.
While many institutions have implemented hi-tech solutions for tracking patients in the ED, all agree that such need to be complemented by face-to-face communications.
They also discuss quality improvement activities, use of LEAN techniques, education and training, simulation and teamwork training, leadership skills, and clear delineation of roles and responsibilities as important in improving overall communication within the ED.
Two papers (Lyndon 2011a, Lyndon 2011b) from UCSF describe physician-nurse communications in labor and delivery. In the first paper, Lyndon and colleagues present a case scenario of a patient at 39 weeks of gestation in whom the physician wants to induce labor. The indication for induction is that the patient had an elevated blood pressure for 3 days (see our February 8, 2011 Patient Safety Tip of the Week “Inducing Too Early” for a good discussion on the issues surrounding labor induction) but the nurse has concerns about inducing. They present a dialogue that might have taken place between the physician and nurse and how communications breakdowns lead to unpleasant and escalating situations. They point out that such differences of opinion and communication breakdowns are actually quite common on labor & delivery units. Often it is differing “world views”, particularly on the topic of labor induction, at the root of communication breakdowns. They do a good discussion on the role that differing “mental models” and failure to make intentions and rationales clear up front. Just as important, they stress “listening” skills as critical to fostering a constructive dialogue in which opinions of all parties are both heard and appreciated and considered. Being respectful in these dialogues is critical. And, of course, they talk about some of the reasons that people are reluctant to speak up when they disagree with a course of action or see something potentially harmful. They then recreate the dialogue to show how more effective communication might have gone in the same scenario.
In their second paper (Lyndon 2011b) they embedded some questions about perception of potential harm and likelihood of speaking up about such potential harm into an assessment tool being used to assess overall safety climate on two labor and delivery units. It turns out that physicians typically had lower perceptions of potential harm than nurses did. About 12% of respondents indicated they were unlikely to speak up even when they perceived a high potential for harm (no surprise – see our March 29, 2011 Patient Safety Tip of the Week “The Silent Treatment: A Dose of Reality”). This disparity in the perceptions of potential harm are obvious targets to work on in teamwork training and simulation exercises. The authors also speculate that this may be one of the reasons for consistent disparities in ratings of teamwork on formal “culture of safety” surveys (physicians always rate teamwork as having been much better than how nurses rate it). By the way, also see our September 7, 2010 Patient Safety Tip of the Week “” and our April 2011 What’s New in the Patient Safety World column “ ” for descriptions of some comprehensive programs to improve patient safety in Ob/Gyn settings that also included interventions like teamwork training and simulation.
Breakdowns in communication on surgical services also may be problematic. One study observed communication failures in operating rooms () and found that communication errors related to equipment (36%) and related to keeping team members informed of the progress of the operation (24%) were the most common failures. After implementation of a teamwork training program, they noted a significant reduction in such communication failures.
And, while policy changes are usually considered relatively weak patient safety interventions, surgical services at four Harvard hospitals (working in conjunction with CRICO/RMF) saw improved resident/attending communications after implementation of several policy changes (). Their policy changes included requirements for residents to notify attendings of significant changes in patient status, daily attending-patient communication, and increased frequency of attending visits on weekends. They saw improvement in all 3 areas after implementation across the multiple hospital system. Though they did not measure actual impact on patient outcomes, they did note that the improved communication resulted in changes in patient care plans about a third of the time.
Lastly, one of the few studies tying actual “hard” outcomes to an intervention aimed at improving communication was just published (O’Leary 2011). In this study, implementation of structured inter-disciplinary rounds (SIDR) was shown to result in a significant reduction in preventable adverse events on a medical floor compared to historical and concurrent controls. The rounds were held daily at 11 AM, led by the nurse manager and unit medical director, and attended by all nurses, resident physicians, and a pharmacist, social worker and case manager. The structured tool was modeled after the well-known Daily Goals tool and was formally used for discussing all new admissions. Daily plans of care on all other patients were also discussed, though the structured tool was only used on the new admissions. Preventable adverse events dropped from 2.1 per 100 patient days before the implementation down to 0.9 per 100 patient days (and the rate on a similar medical unit was 2.8 per 100 patient days). Moreover, they noted SIDR was well received by all professionals and nurses’ ratings of collaboration and teamwork improved significantly.
Sometimes the simplest elements are left out of critical communications. We can’t tell you how many times we’ve encountered instances where nursing staff or the emergency department have said “I really wanted the attending to see this patient” and the attending said “They never asked me to see the patient”. Including that simple request in the communication is, thus, critical. If you’re using SBAR format for your communications, it’s easy to add under the R (recommendation) “I think you should come see the patient”.
The value of good communication among all healthcare workers cannot be overestimated. Every organization needs to invest resources (time, personnel, money) into improving communication at every level. We’ve noted before that unit-based quality improvement interventions have the highest likelihood of success. All the above examples really focused on unit-based interventions. So while some of the skills, training and techniques used are applicable to any area of your organization (hey, the same communication breakdowns probably happen daily in your finance, environmental services, HIT, etc. departments, too!) the best place to start working on improving communications is at the unit level. So focus first on your ED, or OR, or ICU or a specific unit. Build on your successes there. Identify your barriers (which probably are also often unit-specific). Then take your lessons learned to other parts of your organization. Of course, we don’t like any organization working “in silos” and obviously communication across departments is also important. But if you start addressing better ways to communicate at the unit level, you will see better teamwork and safer patient care.
CRICO/RMF. Optimizing Physician-Nurse Communication in the Emergency Department: Strategies for Minimizing Diagnosis-related Errors. Proceedings from the CRICO/RMF Strategies Emergency Medicine Leadership Council 2010; White paper February 14, 2011
Lyndon A, Zlatnik MG, Wachter RM. Effective physician-nurse communication: a patient safety essential for labor and delivery. Am J Obstet & Gynecol 2011; 205: xx-xx
published online 18 April 2011
Lyndon A, Sexton JB, Simpson KR, et al. Predictors of likelihood of speaking up about safety concerns in labour and delivery. BMJ Qual Saf 2011; published online July 1, 2011 doi:10.1136/bmjqs.2010.050211
Halverson AL, Casey JT, Andersson J, et al. Communication failure in the operating room. Surgery. 2011; 49(3): 305-310
Arriaga AF, Elbardissi AW, Regenbogen SE, et al. A policy-based intervention for the reduction of communication breakdowns in inpatient surgical care: results from a Harvard surgical safety collaborative. Ann Surg. 2011; 253(5): 849-854
O’Leary KJ, Buck R, Fligiel HM, et al. Structured Interdisciplinary Rounds in a Medical Teaching Unit: Improving Patient Safety. Arch Intern Med. 2011; 171(7): 678-684