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In the healthcare profession, communication is key to an efficient and productive work environment. Unlike other industries, poor communication between healthcare workers can lead to harmful consequences for patients who depend on these professionals for their aid. One area where poor communication is common in a hospital setting is between the non-nursing and nursing staffs. In order to increase patient safety, interdisciplinary communication needs to be addressed to eliminate issues that could arise. This paper depicts how interdisciplinary communication and various factors can result in patient safety events.
Patient Safety Event
Lack of proper communication in a neurosurgical intensive care unit (neuro ICU) resulted in the incorrect handling of a patient with an external ventricular drain (EVD) and potentially could have caused adverse health effects. Unless specified by a neurosurgeon, an EVD typically remains at the level of the auditory meatus and is left open to drain. On the day of the incident, not only was the neuro ICU short of the recommended number of nurses on duty, but the hospital had recently cut the number of technicians in various radiology departments.
An echocardiogram was ordered for the patient as part of the stroke workup. When the ultrasound technician arrived at the patient’s room to begin the exam, the primary nurse was administering care to another patient in a different room. The technician proceeded to prepare the patient for the echocardiogram without speaking to any nurse on the unit. In order to perform the exam, the patient’s entire bed was raised and the angle of the head of the bed was increased. Both of these adjustments were higher than the level desired for the EVD to function properly.
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Without knowledge of the EVD, the ultrasound technician continued the exam for approximately ten minutes before the primary nurse arrived at the patient’s room. Realizing that the drain was no longer level, the nurse immediately clamped the EVD, to stop the draining of cerebral spinal fluid (CSF).
From the time when the technician elevated the bed to when the nurse clamped the drain, over 60cc of CSF drained from the patient, when the previous rate was roughly 8cc/hour. Fortunately, the patient did not experience any of the potential major negative side effects that can occur from large amounts of CSF draining in a short time span.
Internal Factors
Upon analysis of the incident, many factors were identified that contributed to the adverse event. Internal factors, such as written warning, staff resources, and education played key roles in how the accident transpired.
Personalized Written Cautions
It is common practice at this facility for the nurses to post written warnings or cautions, concerning the patient’s care, throughout the patient’s room. These primarily act as a reminder for the family visiting, but can also come in handy for a team member tending to an unfamiliar patient.
The primary nurse tended to this patient in previous shifts and thoroughly educated the patient’s family on the importance of not repositioning the bed without a staff member present. Knowing this, the nurse decided not to post a written sign, as the family had been compliant with the regulations on previous shifts. The family was not present during the time of the echocardiogram to act as another error prevention barrier.
Staff Resources
The most crucial internal factor which played a role in the incident was the technician neglecting to obtain acknowledgment from the nurse prior to performing the exam. When the technician is unable to find the primary nurse, it is appropriate to ask the charge nurse about initiating any tasks with the patient. The charge nurse is responsible for having basic knowledge of all patients on the unit and would have been able to answer simple questions.
Had the technician consulted with the charge nurse, the nurse could have clamped or leveled the drain properly. Conversely, charge nurses at this facility regularly are assigned their own patients during the shift. It is possible that the technician did not see an available nurse, and decided to proceed with the exam.
Education
Another factor to consider in this situation is the lack of educational training for non-nursing staff on medical devices. It is the responsibility of the organization to educate its staff on safe practices involving patients and employees. This is not to say that technicians are to be experts in regards to the products, but at a minimum should be able to recognize and acknowledge the need of a nurse when a patient has a specific device in their room. If any of these factors had been mitigated, then the patient’s safety would not have been compromised during this event.
External Factors
External factors consequently are much more difficult to manage on a day to day basis. The chief external factor that contributed to the safety event was a change in ownership over the organization. In prior months, the hospital endured a change in ownership which ultimately lead to a redistribution of budgetary funds. This new disbursement led to reduction of staff to balance with the new budget.
Among the departments that were affected, the diagnostic technicians had the most difficulty keeping up with the increased demand caused by the higher technician to patient ratios. The number of examinations ordered had not changed, but there were roughly half as many technicians to perform them. When an exam is ordered statim (STAT) or as soon as possible (ASAP), the technicians are to complete these exams within a designated time frame. Since the budgetary cuts, fewer staff members were available to do these tests and technicians often were rushed to complete the exams.
According to Hughes, staffing shortages increase a nurse’s stress level, their workload, and can adversely impact patient outcomes (2008). This idea is universal among all hospital employees and is not reserved to nurses alone. When a clinician feels rushed to complete a task and does not have the proper support available, they are prone to more errors. Performance is improved when the right resources are available and adequate time is provided. The lack of appropriate resources in this example points to an organizational error rather than an individual error.
Donaldson, Corrigan and Kohan state, “designing safe systems means taking into account people’s psychological limits and either seeking ways to eliminate any preconditions or intervening to minimize their consequences” (2000, p.61). These include work schedules, high workload, unnecessary time pressure and many others. The hospital neglected to take these factors into account when the number of diagnostic employees were reduced and ultimately caused the patients to be at further risk for safety errors.
Interprofessional Communication
In this situation, interprofessional communication is one of the main cornerstones involved. The lack of communication led to the EVD drain not being adjusted or clamped and ultimately caused the patient to drain excessive amounts of CSF which perpetuated the risk for harm. Brindley and Reynolds assert that medicine is rarely a solo pursuit, it is a team effort that requires communication. Yet according to The Joint Commission, “communication failures are found to be the primary root cause of more than 60 percent of sentinel events reported” (Hughes, 2008, p.34).
If communication had transpired between the two disciplines, it is more likely that this error would not have occurred. The duty falls on both departments to instill proper collaboration, as they are one team focusing on the health of the patients. Team work is the responsibility of the organization as a whole and needs to be fostered and encouraged.
Prevention of Future Events
Fortunately, by developing an action plan these types of errors can be prevented in the future. One solution is to have a hospital wide standard location in the patient’s room for pertinent information to be displayed. “Standardization reduces reliance on memory and allows newcomers who are unfamiliar with a given process or device to do the process or use a device safely”(Hughes, 2008, p.60). Since every patient has a unique care plan, the hospital should compose an organizational wide system to notify interdisciplinary staff of any precautions that will require a nurse’s acknowledgement before working with the patient.
This location would be most beneficial in the chart where all healthcare providers have access, as well as displayed in the patient’s room. Hospital wide training needs to be implemented to ensure that all staff members are aware of this safety initiative. An alternative solution is geared towards proper staffing ratios. Although this may seem simple, this institution experienced financial issues which led to the budgetary cut in staff members. This reduction in staff members caused a ripple effect of additional staff members resigning their positions.
The additional wave of employees leaving amplified these unsafe ratios. While the institution needed to balance their budget, they also should have taken the patients’ safety into account. For this specific organization they cannot make money without spending money. Insurance companies determine their payment of claims based on quality of care and adverse events. If a patient falls or acquires a pressure ulcer during their hospitalization, these entities typically will not pay the claim submitted. Essentially, the quality of the service provided has a direct correlation to the payment for that service.
As previously stated, the increase in stress has a parallel association to patient errors. So, in order to prevent errors, adequate staffing needs to be provided. Ultimately, a financial shift towards additional employees will improve the hospitals standing with patients, therefore increasing revenue. Lastly, and essentially the simplest solution, any staff member that is unfamiliar with the patient must talk to the nurse prior to entering the patient’s room. This may lead to time ‘wasted’ waiting on the nurse, but the patient’s safety should be the primary concern.
Conclusion
Overall, lack of communication ultimately led to a potentially sentinel event and could have been avoided. Hughes said, “interdisciplinary collaboration has the potential to increase the system resilience to error” (2008, p.34). In the described event, both internal and external factors led to a decline in patient safety. Lack of education and staffing are large problems that need to be corrected and as a whole, healthcare is moving towards minimizing these error producing factors. It is only through combined efforts that healthcare professionals can improve the quality and safety of care to all patients.
References
- Brindley, P.G., Reynolds, S.F. (2011). Improving verbal commutation in critical care medicine. Journal of Critical Care, 26 (2), 155-159. Retrieved from THSLC Library Catalog
- Donaldson, M. S., Corrigan, J. M., & Kohn, L. T. (2000). To err is human: Building a safer health system. Washington, D.C.: National Academies Press. Retrieved from THSLC Library Catalog
- Hughes, R. G. (Ed.). (2008). Patient safety and quality: An evidence‐based handbook for nurses. Washington, D.C.: Agency for Healthcare Research and Quality. Retrieved from THSLC Library Catalog
- Taylor, B. (2013). CHI to acquire st. luke’s episcopal health system in houston region. Retrieved September 17th, 2018, from https://www.chausa.org/publications/catholic-health-world/article/may-15-2013/chi-to-acquire-st.-luke%27s-episcopal-health-system-in-houston-region
