I sincerely appreciate all the conversations we had during John Nance’s presentation. I am so proud of every comment that was made and am proud to be a part of this group. However large or small, I feel that each and every one of us will make a difference towards a common goal.
Perception, assumption, and communication. These are all so powerful in terms of areas in which medical errors may occur. Just focusing on communication alone, we were all unable to recall when a sentinel event occurred in the absence of a communication issue. I strongly believe that at least 12.5% of the communication that goes through between person to person is misunderstood. Just from the domino game we had from day 1, such a simple task was actually not so simple. There were so many ways in which an error was made through misinterpretation. During the last exercise when both the provider and nurse were allowed to speak, we still ended up misinterpreting towards the end.
This further makes me reflect on the innumerable times during a patient’s care in which an error may be made due to communication. Let’s take verbal orders alone as an example. Despite, read backs, there may still be misinterpretations as demonstrated in the domino game.
We also assume that EHR will help us better communicate with one another across various interdisciplinary teams, but sometimes EHR may also be the root cause for our communication problem. How often do we thoroughly read everybody’s notes regarding the patient’s care? It is very easy to miss an intended plan of care across the team members. For example, a physician I’ve worked with had completed discharge notes and communicated in the EHR for conditions in which the patient is discharged. The physician did not personally communicate with the nurse. The night nurse and the day nurse did not see the message in the EHR. The physician assumed the patient had already been discharged since the day before and did not see the patient. The patient ended up being discharged later than had been intended as a result of the communication problem between the physician and nurses and a missed note on the EHR.
There are always areas for improvement in communication, whether it be between the provider and the patient or any occurrences in our lives.