Patient Care

Written by Judith Riess, MTM editor-in-chief

Healthcare is complex and has manysilos and many different approaches but the greatest problem is the inabilityto communicate effectively and efficiently with all members of a healthcareteam which is also diverse and siloed. In a recent family experience the lack of communication and inefficiencyof the system complicated a family member’s recovery, all due to five of theeight common root causes of medical errors which in a recent Johns Hopkinsstudy noted the Agency forHealthcare Research and Quality’s (AHRQ) eight common root causes of medicalerrors which include: Communications Breakdowns,Inadequate Information Flow, Human Problems, Patient Related Issues,Organizational Transfer of Knowledge, Staffing Patterns and Workflow, TechnicalFailures and Inadequate Policies as the most common causes of medical errors.

During my family member’s experience five of the eight causesgiven by AHRQ hampered recovery.  As Ihave stated many times in MTM editorials providers never intend to harmpatients but the system they live under is fraught with errors.  These issues can arise in a medical practiceor a healthcare system and can occur between a physician, nurse, healthcareteam member, or patient. Poor communication often results in medical errors orlack of care.

The five issues in my familymember’s case began with a breakdown in communication. The patient wasseverely ill with pneumonia and a kidney infection and spent four days in ICUand four days in hospital. After being released from the hospital the familymember was having difficulty breathing and contacted the infectious diseasedoctor’s office and explained the problem. A member of the doctor’s staff had the patient go in for a chest X-Rayand recommended the patient see a pulmonologist since the patient hadpneumonia, then the trouble continued. The patient, being a well-educated healthcare provider, had asked for acopy of the X-Ray.  Upon seeing, thepatient immediately called the doctor’s office and needed to speak with thedoctor or NP about the x-ray.  Repeatedcalls to the infectious disease doctor’s office and to pulmonologist officeshad no results.

A patient’s family member wasdescribing the patient’s condition to a friend and described the family’sinability to have phone calls returned or reach a pulmonologist.  The family member’s friend was friends with apulmonologist and sent x-ray to him; at which time he contacted the infectiousdisease doctor and told him his patient was in distress and needed to go toemergency room immediately. The patient was re-admitted to the hospital, had achest tube inserted, fluid withdrawn from the lung, spent six additional daysin the hospital with day after day of chest x-rays, CT’s and intravenous antibiotics.

The infectious disease doctordid not deliberately ignore the patient’s calls.  The patient was unable to reach the NP whoordered the chest x ray as she was off for two days and the doctor was inclinic.  The medical assistant to whomthe patient repeatedly spoke said she would relay the message to the doctor butdid not have the skills or knowledge necessary to understand the urgency of therequest even though the patient told the assistant that the patient was NP.

So there was definitely Inadequate Information Flow which we all know is critical. Unfortunately, the critical information was not reaching the doctor or nurse practitioner.

There was also an issue of training orinadequate education on the part of the medical assistant to understand theseriousness and urgency of the situation and therefore highlights the lack of Organizational Transfer of Knowledge within the doctor’s office.

Staffing Patterns and Workflow played a key role in the patient’s inability to reach thenecessary providers.  Since the NP wasoff and the doctor in clinic, someone with the expertise to understand thesituation should have responded to the patient and made sure the doctor had theinformation about the x-ray which leads to the problem of when the x-ray wasread.

In this case, the x-ray is read by a radiologist at the hospital and then sent to the doctor’s office which can cause up to a 24-hour delay which leads to Inadequate Policies between the hospital and the doctor’s office.  As a thought, what would have happened if the patient had a broken leg? Is there a policy for immediate transfer of knowledge of x-ray?  A bit facetious but in this patient’s case far more sever complications than a broken leg! In this case inadequate procedures played a role.

Having highlighted failures, would be remiss if I did not state that the hospital provided excellent care and in two incidents saved the patient’s life.

The JohnsHopkins study further stated, “Studying these mistakes, learning how toprevent, monitor, and respond to them is key to changing the standards of care.By working to eliminate common medical errors, healthcare systems and providerscan protect patients, protect themselves, improve standards of care, and lowercosts.”