I came across an interesting study while preparing this issue and thought it worth discussing. The article entitled "A String of Mistakes: The Importance of Cascade Analysis in Describing, Counting, and Preventing Medical Errors" by Woolf et al1 was published in Annals of Family Medicine in August 2004. The thing about this article that caught my attention was the finding that although 83% of errors in patient care were mistakes in treatment or diagnosis, 2 of 3 of these errors were set in motion by errors in communication.
Communicating is something healthcare providers do on a daily basis, and given our busy work lives, we probably give little thought to it. After all, we have been doing it since we were born, right? For those of us in the health care field, it is becoming clear that communication is a crucial issue in how we do our jobs and a crucial factor in the quality of the care we give. Part of the purpose of the Woolf et al study was to determine whether cascade analysis is of value in clarifying the epidemiology and causes of errors. For the study, 18 family physicians in the United States who were participating in a 6-country international study filed 75 anonymous error reports. The researchers determined that 80% of the errors that initiated cascades involved informational or personal miscommunication such as communication breakdowns among colleagues and with patients (44%), misinformation in the medical record (21%), mishandling of patients' requests and messages (18%), inaccessible medical records (12%), and inadequate reminder systems (5%). The researchers concluded that miscommunication appears to play an important role in propagating diagnostic and treatment mistakes. Although this study has several limitations, which are addressed by the authors, it raises the issue of how health care providers communicate in today's workplace and how that communication affects the care we give our patients. The authors suggest that safety initiatives should focus less on professional interventions to improve clinical judgment and more on management systems to improve the quality of information transfer between providers.
Shortly after I read this study, I came across the Joint Commission on Accreditation of Healthcare Organizations' Sentinel Event Alert Issue 30 (July 21, 2004; available online at http://www.jcaho.org) regarding perinatal death or permanent disability. Interestingly, this sentinel event alert indicates that of the 47 cases of perinatal death or permanent disability reported to Joint Commission on Accreditation of Healthcare Organizations since 1996, communications issues topped the list of identified root causes (72%). In addition, 55% of the reporting organizations indicated that organizational culture was a barrier to effective communication and teamwork in their facility. Examples of barriers in the organizational culture included hierarchy and intimidation, failure to function as a team, and failure to follow the chain of communication. The Alert provides several recommendations, 2 of which can be applied to all areas of the hospital:
1. Conduct team training to teach staff to work together and communicate more effectively.
2. Conduct clinical drills for high-risk events to help staff prepare for when such events actually occur, and conduct debriefings to evaluate team performance and identify areas for improvement.
As nurse executives, we need to think about how the nurses in our facilities are communicating with each other and with other members of the healthcare team. Are nurses intimidated and afraid to speak up? Are they rushed and therefore prone to give incomplete information? Are they overwhelmed and unable to do complete and accurate charting? Consider the knowledge you might glean about these issues from shadowing nurses on your busiest unit. This knowledge will provide you with insight as to why mistakes are being made and what you can do about them.
One of the articles in this issue focuses on another aspect of dealing with mistakes. It discusses the Practitioner Remediation and Enhancement Partnership Program piloted by the North Carolina Board of Nursing and how that program encouraged nonpunitive reporting of mistakes made by nurses in that state. The program could certainly be adapted for internal use by a facility and might be one way to address communications issues leading to errors in your facility. We are interested in hearing other solutions that nurse executives have found to deal with communications issues in their facilities and are working on a feature issue dealing exclusively with nursing errors and real-life solutions to communications problems. To submit an article or just share an anecdote, e-mail me at [email protected]. Author guidelines can be found further on in this issue.
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