A recent PA-PSRS report concerned a patient admitted with head trauma who was evaluated with a CT scan, then monitored. He showed signs of worsening, prompting a repeat CT. The radiologist noted a change warranting treatment and called the ICU to inform the surgeon who was responsible for the patient. The ICU nurse transcribed the reading and called the surgeon in the OR, reaching the anesthetist. The anesthetist conveyed the reading to the surgeon, who was doing an emergency operation. The surgeon found the message confusing.
He explained to the circulating nurse how to retrieve the CT on the PACS system in the OR. The nurse displayed the first early morning film instead of the second late morning film. The surgeon, thinking he was viewing the second film, read it as unchanged, requiring no further treatment. After leaving the OR hours later, the surgeon discovered the error and instituted the indicated treatment, but belatedly. The family was notified of the problem. The hospital’s assessment found the root cause to be ineffective communication. Policies were changed to ensure direct physician-to-physician conversation.
The hospital is to be commended for a thorough investigation and identification of the importance of effective communication. Two components of communication are salient to this report. One is that the fewer intermediaries, the less the chance for misunderstanding. The second, less obvious point, is that the less the intermediary understands about the content, context, and implications of the message, the greater the chance of misrepresentation.
The clinical staff involved in this occurrence already understood the importance of transmitting changes noted in obviously urgent studies, of writing down what is said, of shortening the information chain, of making the information accessible, and of being transparent to the family.
In commentary, we also note that this report indicates the hazards of multi-tasking. The surgeon attempted to process critical information while doing another important task. Under these conditions, the probability of error is known to increase.1 Multi-tasking cognitive tasks is not an indicator of efficiency. In this case, individuals were being called upon to do too much at once. Safety experts warn against trying to solve safety problems solely by being more careful, or working harder, or being more efficient. Experts who have studied highly reliable systems mention reserves and reorganization: the ability to bring more resources to the problem.2 Others describe this as capacity. If the system has adequate capacity, it is not necessary for a nurse assisting a surgeon to become a radiology file clerk or for the surgeon in the middle of an operation to make a decision about another patient.
Notes
- Schacter DL. The seven sins of memory: how the mind forgets and remembers. Houghton Mifflin (NY); 2001.
- Roberts KH, Yu K, Van Stralen D. Patient safety as an organizational systems issue: lessons from a variety of industries. In Youngberg BJ, Hatlie MJ, eds. The patient safety handbook. Sudbury MA: Jones & Bartlett; 2004:169-86.