How Communication Causes Patient Safety Problems: How Basic Patient Safety Errors Cause Medical Malpractice
Healthcare Global, a magazine dedicated to providing healthcare information to industry leaders, recently published an article discussing nine ways that basic communication errors can lead to patient safety problems. Importantly, though, the article also provides how to solve these basic issues, thus preventing bad outcomes, including hospital negligence.
1. Patient test results can be delayed getting to the right doctor
According to the article, the Joint Commission has identified “delays in the communication of critical test results as a major problem for patient safety.” These problems also lead to longer hospital stays, higher hospital bills, and lawsuits. The solution to this problem, according to the article, is to enable text alerts or to have critical results flagged in to the electronic medical record system. While these may seem like obvious options that should already exist in most hospitals (especially the flagging), they unfortunately do not.
2. Doctors having difficulty reaching other doctors to discuss patient treatment plans
In the age of cell phones, email, and pagers, doctors still complain about an inability to reach their colleagues regarding treatment plans for patients. We expect constant and immediate communication regarding our care, but that does not often happen. The solution? “Online staff directories or on-call scheduling calendars.” Most, if not all, hospitals already have this “solution.” It seems as though the best answer is to have a system that knows when a doctor has been contacted/responded, and when there has been no communication. In cases of the latter, an alarm will go off to notify the nurses and attending physician.
3. CODEs can take a long time and be disorganized
A CODE is an emergency alert sent throughout the hospital. There are several types, but they all require immediate response. If the team delays getting to the scene, or if they are not organized, the results can be catastrophic for patient safety. Again, the article’s solution is based on common sense and should already be implemented in every hospital: Emergency notifications to help transit information quickly and reliably. It is highly likely that not having this type of system in place is below the standard of care, or negligent.
4. HIPAA violations occur if patient details are transferred without encryption
Again, in the modern age of technology, this seems like a no-brainer issue that should already be solved. Unfortunately, it is not. All devices (phones, computers, tablets, etc.) should be encrypted and secure. Protecting patient information should be of the utmost importance.
5. Not having a paging system for backup can make an emergency situation even more complicated
For decades, hospitals have used paging systems to alert doctors and nurses of CODEs and other critical information. The problem does not seem to be how to implement a paging system; the problem is that doctors and nurses are not using it properly, thus negatively affecting patient safety.
6. Incoming calls may get misdirected when being processed
Another example of how a simple error can have devastating consequences. Staff need to be properly trained on how to route incoming calls, and how to notify the doctor or nurse that the call is urgent.
7. Patients can lose sleep that is necessary for recovery because of loud activity noise
The noises in hospitals are never-ending. Nurses, doctors, patient care techs, machines, alarms, cleaning crew . . . the list goes on and on. Rather than simply turning down the volume on critical alarms, nurses need to respond more quickly when an alarm goes off.
8. Nursing staff might walk an unnecessarily long distance during the course of their shift
Yet another red herring patient safety concern. If hospitals are truly worried about the distance their nurses are walking, there are 2 easy solutions: (1) Streamline where medical tools and charts are located; and (2) Hire more nurses. Unfortunately, these two easy solutions also require the hospital to spend money. More and more often, hospitals are becoming profit centers instead of patient safety centers, so spending money on “unimportant” issues like this get bypassed.
9. Contacting a doctor when he is not on-call can inhibit his personal time
Everyone wants to believe that doctors are there to help and protect us. Most of the time, they are. But patient safety is not at the top of every doctor’s list. Oftentimes, doctors are unwilling to respond to patient needs if they are not “on the clock.” Instead, they leave it to the on-call physician who does not have as much information regarding the patient’s course of treatment and his/her needs. When this happens, patient safety is severely compromised.
In all, the magazines article offers very little in terms of how to actually improve patient safety. What the article does highlight, however, is that many hospitals lack the very basic programs and guidelines that should be implemented in every single hospital in the country. When these basic guidelines are not enacted, patient safety suffers, and victims are injured or killed for no reason.
Date: October 27, 2014