International Journal for Quality in Health Care 15:441 (2003)
© 2003 International Society for Quality in Health Care
Every defect is a treasure |
Lack of clear channels of communication in patient transfer between care facilities leads to fragmentation in care
A potential health problem in a 1-day-old infant transferred for further evaluation from a community hospital to an acute care setting is exacerbated as a result of poor communication between providers at the two facilities.A 1-day-old infant is transferred from a community hospital to an acute care hospital to rule out a gastrointestinal bleed. An intravenous line (IV) containing calcium gluconate is infusing in his right foot. At the acute care hospital, the notes written over a 2-day period—one from each nursing shift—indicate that the IV is running well. On the third day, however, a nurse notes a darkened area of necrosed tissue at the IV site and makes a notation in the patient’s chart, tracing the original IV insertion to the transferring hospital. A plastic surgery consult is made.
Later that day, the patient is transferred to the intensive care unit (ICU). A transfer note specifies the time the infiltrate was discovered and records the fact that the IV site was checked prior to the transfer to the ICU; however, for unclear reasons the notes from this transfer do not appear in the patient’s chart. In addition, nursing flow sheets from the shift when the infiltration was discovered and from the one preceding it contain scratch-outs and re-writing over the original entries.
When the parents visit the next morning, they discover their son’s injury and become upset. When they question the staff, the injury is characterized as a blister that has ‘popped’. In addition, one physician tells them that the IV medication is very caustic and is usually reserved for babies with a heart problem. The parents were not told that their son had a heart problem and, indeed, he did not. A second physician suggests that the problem originated in the community hospital. A third physician informs them that the infiltrate should not have occurred and that he would not discourage them from taking their son out of the hospital. Two days later, when the infant is discharged, his parents are surprised by the extent of his injury and need for follow-up care.
Enhancing systems for communicating between hospitals can make the health care system safer. In particular, having a transfer checklist in place when a patient is transferred from one facility to another can improve information exchange and ‘handing off’ care. Further, it can serve as a reminder to members of health care teams about aspects of patient care that need to be addressed at the time of discharge and subsequent admission (e.g. to check IV sites).
Flow sheets may lack adequate space to document pertinent findings and may be difficult to read, even for the most conscientious staff. This, combined in this case with a lax policy on checking IV sites for skin integrity, especially in the newborn population, increased the likelihood of injury. In reality, policies often do not work in all aspects, especially for those in the frontline delivery of care. Input from practicing clinicians is often overlooked. Having frontline staff provide a ‘reality check’ and exploring better methods and systems for caregivers to communicate and provide documentation in transfer cases may decrease the potential for patient harm.
When things go wrong there is an ethical obligation on the part of health care providers to maintain open and honest communication with the patient and family. Having a multidisciplinary approach in place to establish the basic clinical facts is essential. In these kinds of cases, most patients want to know three things: (1) how it happened; (2) that their caregivers care about them sincerely and will not abandon them in their time of need; and (3) what steps will be taken so that it doesn’t happen again. In this case, the parents felt that they were not being told the truth as nurses and physicians blamed one another for the injury. The injury, which was described as a blister ‘popping’ (implying a minor injury), proved to be a third degree burn with significant scarring; conflicting accounts on the source of the problem caused the parents considerable distress and aroused distrust in the system.
As this case illustrates, ongoing improvement in communication skills among practitioners is an essential component of a safety culture. Developing systems that minimize the chance of error by improving communication and learning from mistakes, instead of placing blame, is critical. At the end of the day, restoring public trust in medicine is essential. To succeed, clinicians need to feel supported by individuals at all levels of the organization. Leadership should encourage staff to report adverse events to create a more accurate picture of recurring problems.
Footnotes
Adapted with premission by Kathleen Dwyer, MS, from Forum, May 2003. Forum is a publication of the Risk Management Foundation of the Havard Medical Institution, Cambridge, MA, USA.
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