New Horizons in Patient Safety: Understanding Communication: Case Studies for Physicians 9783110455014, 9783110453003

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Annegret F. Hannawa, Albert W. Wu, Robert S. Juhasz New Horizons in Patient Safety: Understanding Communication

New Horizons in Patient Safety: Understanding Communication | Case Studies for Physicians Annegret F. Hannawa Contributing authors: Albert W. Wu Robert S. Juhasz

Author Annegret F. Hannawa, Ph.D. (ISCOME™ Vice President) Associate Professor and Director, Center for the Advancement of Healthcare Quality and Patient Safety (CAHQS), www.patientsafetycenter.org Faculty of Communication Sciences, Università della Svizzera italiana (USI), Switzerland Contributing authors Albert W. Wu, M.D., M.P.H. Center for Health Services and Outcomes Research, Johns Hopkins Bloomberg School of Public Health, USA Robert S. Juhasz, D.O. President, Cleveland Clinic South Pointe Hospital Associate Clinic Professor of Medicine, Ohio University Heritage College of Osteopathic Medicine, USA Case authors Annegret F. Hannawa, Ph.D. (Switzerland) Thomas Hannemann, M.D. (Germany) Wolfram Heipertz, M.D. (Germany) Sandra W. Hwang, M.S.P.H. (USA) Robert S. Juhasz, D.O., F.A.C.O.I., F.A.C.P. (USA) Wolfgang A. Krüger, M.D. (Germany) Citations for AHRQ WebM&M reprinted cases are acknowledged in the respective chapters.

Case coordinator Sandra W. Hwang, M.S.P.H. Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA Case editors Sandra W. Hwang, M.S.P.H. Johns Hopkins Bloomberg School of Public Health, USA Eric Kang, B.A. Johns Hopkins University, USA Kara Guisinger, B.S. Ohio University-Heritage College of Osteopathic Medicine, USA Nicole Rothfusz, B.S. Ohio University-Heritage College of Osteopathic Medicine, USA WebM&M case editors Erin E. Hartman, M.S.; Robert M. Wachter, M.D. University of California, San Francisco, USA Book reviewers Brian H. Spitzberg, Ph.D. School of Communication, San Diego State University, USA Richard L. Street, Jr., Ph.D. Department of Communication, Texas A&M University, USA J. Michael Wieting, D.O., M.Ed., FAOCPMR-D, FAAOE, FAAPMR (ISCOME™ Vice President) Lincoln Memorial University-DeBusk College of Osteopathic Medicine, USA Lorri Zipperer, M.A. Zipperer Project Management, USA

ISBN 978-3-11-045300-3 e-ISBN (PDF) 978-3-11-045501-4 e-ISBN (EPUB) 978-3-11-045410-9 Library of Congress Cataloging-in-Publication Data A CIP catalog record for this book has been applied for at the Library of Congress. Bibliographic information published by the Deutsche Nationalbibliothek The Deutsche Nationalbibliothek lists this publication in the Deutsche Nationalbibliografie; detailed bibliographic data are available on the Internet at http://dnb.dnb.de. © 2017 Walter de Gruyter GmbH, Berlin/Boston Cover image: Mario Castello/Corbis Typesetting: le-tex publishing services GmbH, Leipzig Printing and binding: CPI books GmbH, Leck ♾ Printed on acid-free paper Printed in Germany www.degruyter.com

Foreword When things go wrong in life, poor communication is invariably involved. We are all familiar with its role in creating a misunderstanding between friends, in an inadvertent act of humiliation, or in unknowingly misleading someone who then makes a bad decision. Even when it does not cause physical harm, its impact can be long lasting: two friends who never speak again; a person’s loss of confidence in the workplace; or a situation that triggers severe depression. And those examples only illustrate poor communication involving words. A person’s body language, for example, can disrupt a group’s dynamics, sour the atmosphere at the top table of a wedding, or shut down a discussion. Poor communication may be part of the warp and weft of the human condition, but that does not make it trivial. When it comes to the major events in life, the quality of communication becomes even more important. Decades of research in many different academic disciplines have illuminated the nature of communication when someone becomes ill and encounters a healthcare system and its practitioners. There are multiple strands to this area of communication, often described in unsatisfactory topic descriptions: “breaking bad news,” “the sick role,” “the consultation,” and “shared decision making.” This vast field of study has enriched understanding of the nature and role of communication in health, illness, cure, and care. Some of the resulting knowledge has been translated into improvements in communication; most commonly, the practical actions have been in the area of medical and nursing education and training. The academic discipline of communication science has been growing in importance to take its place alongside psychology, the social sciences, and evaluative methods in helping to understand and explain the role of communications in a wide range of fields, including medicine and healthcare. In healthcare, though, much of the focus has been on the process of patient care and not on wider themes. Important amongst them is patient safety, a particular priority for all health systems around the world. Unsafe care is a major problem for modern healthcare, whether it is being delivered in high-, middle-, or low-income countries. It arises from: simple mix-ups (e.g. an inadvertent overdose of a medicine being given), persistent errors (e.g. wrong site surgery), chronic failures to reduce risks (e.g. pressure sores), dysfunctional care (e.g. bad clinical management of the acutely-ill, deteriorating patient), and sudden catastrophic events (e.g. failure to act on signs of fetal distress leading to a baby’s death). These and many other situations can, and do, cause injury, disability, and death. Professional, academic, and policy interest in patient safety began in the early 2000s and, at the outset, the term most often used was “medical error.” While error is indeed a core element, the experience of safety work in other high-risk industries is that weak and poorly designed systems make error more likely and amplify its impact when it does occur. This systems thinking, helped by the insight created by James Reason’s metaphor of the Swiss Cheese, is now deeply embedded in healthcare. The

VI | Foreword

systems perspective is recognized as the paradigm shift that led to sustained improvement of aviation safety. While healthcare worldwide has embraced systems thinking in patient safety, hopes that it would be equally transformative have proved to be misplaced. The level of understanding on why similar adverse events repeatedly occur is poor. In other sectors, accident investigation yields actionable findings that have reduced future risk. Healthcare cannot claim much success in understanding nor in effective action. When accidents or poor safety performance occur, investigations almost always reveal more than one failure in communication. In non-health sectors, such communication failures have been codified and led to successful change. Patient safety is in desperate need of rigor and clarity in assessing the role of communication in causing harm. Annegret Hannawa, the leading figure in advancing the role of communication science in patient safety, has done a great service by turning her attention to producing a proper framework for analysis and explanation of unsafe healthcare. She and her contributing chapter authors, Albert Wu and Robert Juhasz, have used a series of clinical vignettes to draw out main communication contributions to critical incidents. This bottom-up approach is immensely revealing. It should not be a surprise to see how central communication was to what went wrong. But it is surprising to see the scale and complexity of it. The resulting framework set out in the seminal chapter by Hannawa is a groundbreaking conceptualization of the role of communication in the causation of unsafe care. The ideas and constructs in the book not only will be of great value to scholars but also to patient safety practitioners and policy makers. In healthcare, the use of the term “communication failure” is too often taken as an acceptable causal explanation in its own right. No longer will this be credible. In future, for those who claim that communication played a part in the causation of harm, the challenge will be: “That is too vague to be of any value. Explain how it fits into the Hannawa Framework.” Sir Liam Donaldson, M.D. Former Chief Medical Officer for England Founder of the World Alliance for Patient Safety

List of Abbreviations ACE ACL AHRQ AIDS Beta-hCG BIPAP BP C. difficile CBC CD CHF COPD CPR CT CVA d DNI DNR ED EHR GERD GI H1–H2 ICHOM ICU INR IOM ISMP IUP LMP MRSA NP NSTEMI OBGYN OR ORIF PACS PACU PCI PCP PEA PO POLST PSA PSNet SACCIA

angiotensin-converting enzyme anterior cruciate ligament Agency for Healthcare Research and Quality acquired immunodeficiency syndrome human chorionic gonadotropin beta noninvasive bi-level positive airway pressure blood pressure Clostridium difficile complete blood count compact disk congestive heart failure chronic obstructive pulmonary disease cardiopulmonary resuscitation computed tomography cerebrovascular accident day do not intubate do not resuscitate emergency department electronic health record gastroesophageal reflux disease gastroenterology blockade for histamine receptors 1 and 2 International Consortium for Health Outcomes Measurement intensive care unit international normalized ratio Institute of Medicine Institute for Safe Medication Practices intrauterine pregnancy last menstrual period methicillin-resistant Staphylococcus aureus nurse practitioner non-ST segment elevation myocardial infarction obstetrics and gynecology operating room operative reduction-internal fixation picture archiving and communication system post-anesthesia care unit percutaneous cardiac intervention primary care provider pulseless electrical activity per os (taken orally/by mouth) physician orders for life-sustaining therapy prostate-specific antigen Patient Safety Network Sufficiency, Accuracy, Clarity, Contextualization, Interpersonal Adaptation

VIII | List of Abbreviations

SNF STAT TBI TTP UTI VTE WebM&M WHO

skilled nursing facility signal transducer and activator of transcription traumatic brain injury thrombocytopenic purpura urinary tract infection venous thromboembolism Morbidity and Mortality Rounds on the Web World Health Organization

Contents Foreword | V List of Abbreviations | VII Preface | XIII

Part I: Principles and challenges of healthcare quality, patient safety, and interpersonal communication 1

1.1 1.2 1.3 1.4 1.5 1.6 1.7 2

2.1 2.2 2.3 3

3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8

Principles of healthcare quality and patient safety | 3 Albert W. Wu, M.D. and Robert S. Juhasz, D.O. A global quest for improved healthcare quality and safety | 3 Common misconceptions about healthcare quality and safety | 4 What constitutes “healthcare quality” and “patient safety”? | 5 Principles of healthcare quality | 7 Principles in conflict | 9 Principles of patient safety | 9 Conclusion | 10 Myths and truths of human communication | 11 Annegret F. Hannawa, Ph.D. Common myths about communication | 11 Principles of human communication | 14 Principles in sequence and combination | 20 Communication topics in healthcare quality and patient safety | 24 Annegret F. Hannawa, Ph.D. Topic 1: “Time” | 24 Topic 2: “Patient-centered care” | 25 Topic 3: “Sound-alikes” | 26 Topic 4: “Safety culture” | 27 Topic 5: “Digitization of care” | 28 Topic 6: “Patient/Family engagement” | 29 Topic 7: “Handoffs” | 30 Summary | 30

X | Contents

4

4.1 4.2 4.3 4.4 5

5.1 5.2 5.3 6

6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8

Interpersonal communication: Challenges, processes, and issues | 31 Annegret F. Hannawa, Ph.D. Two core challenges of interpersonal communication | 32 The processes of interpersonal communication | 34 Error-prone aspects of human communication | 37 Summary | 43 The Hannawa SACCIA Typology of Communication Errors in Healthcare | 45 Annegret F. Hannawa, Ph.D. Communication errors across the cases | 47 Errors within principles of human communication | 50 Summary | 50 Lessons from communication science | 55 Annegret F. Hannawa, Ph.D. On the challenge of being communicative | 55 On the challenge of initiating communication | 55 On the challenge of achieving a shared understanding | 55 On the challenge of being accurate | 56 On the challenge of being digital | 56 On the challenge of being contextual | 56 On the challenge of being patient-centered | 57 On the challenge of being efficient | 57

Part II: Case studies across six stages of care Stage 1: Medical history taking | 61 Case 1: Penicillin allergy | 62 Provider-patient interaction Case 2: Reconciling records | 66 Provider-family interaction Case 3: Not a miscarriage | 70 Team interaction Case 4: Sick and pregnant | 74 Inter-professional interaction Case 5: Medication reconciliation pitfalls | 78 Cross-professional interaction Case 6: Omitted history of cerebral edema | 83 Inter-institutional interaction

Contents | XI

Stage 2: Diagnosis | 89 Case 7: Delayed treatment of rectal cancer | 90 Provider-patient interaction Case 8: The “customer” is always right | 94 Provider-family interaction Case 9: A seasonal care transition failure | 99 Team interaction Case 10: Lost in transition | 103 Inter-professional interaction Case 11: Communication with consultants | 107 Cross-professional interaction Case 12: Techno trip | 112 Inter-institutional interaction Stage 3: Treatment planning | 117 Case 13: Code status confusion | 118 Provider-patient interaction Case 14: Poorly advanced directives | 123 Provider-family interaction Case 15: Discharge against medical advice | 127 Team interaction Case 16: Eptifibatide epilogue | 131 Inter-professional interaction Case 17: Code blue – Where to? | 135 Cross-professional interaction Case 18: Right? Left? Neither! | 139 Inter-institutional interaction Stage 4: Storage | 143 Case 19: Bad writing, wrong medication | 144 Provider-patient interaction Case 20: Nothing-per-oral (NPO) for possible fracture | 148 Provider-family interaction Case 21: A room without orders | 153 Team interaction Case 22: Tacit handover, overt mishap | 157 Team interaction Case 23: Empty handoff | 161 Inter-professional interaction Case 24: A triple handoff | 165 Cross-professional interaction Case 25: Transfer troubles | 170 Inter-institutional interaction

XII | Contents

Stage 5: Treatment execution | 175 Case 26: Totally wrong knee replacement | 176 Provider-patient interaction Case 27: Mismanagement of delirium | 180 Provider-family interaction Case 28: Raise the bar | 186 Team interaction Case 29: Acute care admission of the behavioral health patient | 190 Inter-professional interaction Case 30: The results stopped here | 194 Inter-professional interaction Case 31: Medication overdose | 198 Cross-professional interaction Case 32: The case of mistaken intubation | 202 Inter-institutional interaction Stage 6: Post-treatment care | 207 Case 33: Discharging our responsibility | 208 Provider-patient interaction Case 34: Discharged blindly | 212 Provider-patient interaction Case 35: Discharge instructions in the post-anesthesia care unit (PACU): Who remembers? | 216 Provider-family interaction Case 36: Communication failure – Who’s in charge? | 222 Team interaction Case 37: Treatment challenges after discharge | 227 Inter-professional interaction Case 38: July syndrome | 231 Cross-professional interaction Case 39: Discontinued medications: Are they really discontinued? | 236 Inter-institutional interaction Concluding thoughts | 241 Bibliography | 247 Answer Key | 252 Index | 253

Preface Significance of the problem Health expenditures in industrialized countries have doubled in the last 30 years (Leatherman and Sutherland 2004). However, the quality of healthcare in these countries has remained uneven and is often inadequate (Chassin 2013; Classen et al. 2011; Landrigan et al. 2010; McGlynn et al. 2003; World Health Organization 2000). Healthcare systems around the world produce substantial unnecessary costs through the underuse, overuse, and misuse of resources, services, and interventions (McLoughlin and Leatherman 2003). Even in developed countries, only every second patient receives recommended treatments (Harrison et al. 2015; McGlynn et al. 2003; Schuster et al. 2005; Jha et al. 2010, 2013) and many physicians do not follow medical guidelines (Farquhar et al. 2002). These figures call for urgent interventions to improve the quality of care worldwide. Although healthcare provides benefits, it also poses a safety risk to patients. Initial global estimates from the World Health Organization (WHO) show that at least 43 million patients are harmed by medical care each year at a cost of at least 23 million disability-adjusted life years and $132 billion in excess healthcare spending (Jha et al. 2013). More than two-thirds of these incidents result from preventable errors, ranking medical errors among the third most common causes of death (Makary and Daniel 2016) and among the 10 top medical causes of disability in the world (Jha et al. 2013). In colloquial terms, this count exceeds the fatalities that would be incurred by three jumbo jets crashing every 2 days and the combined number of injuries and deaths that result from motor and air crashes, suicides, falls, poisonings, and drownings (Kohn et al. 2000). This makes medical errors a worldwide public health problem ahead of high-profile diseases like acquired immunodeficiency syndrome (AIDS) and breast cancer. Ineffective communication has been identified repeatedly as a major root cause of harmful events in medical care, accounting for between 25% (Wakefield 2007; Australian Institute of Health and Welfare & the Australian Commission on Safety and Quality in Healthcare 2007) and 80% (Joint Commission 2007, 2012) of sentinel event reports. The literature consistently shows that health outcomes are enhanced when clinicians communicate well with colleagues and patients. On the other hand, when communication is poor, health outcomes and patients are placed at significant risk (Kesten et al. 2010; Klipfel et al. 2011; Pfrimmer 2009; Twedell and Pfrimmer 2009). Because healthcare is a particularly unforgiving context for communication deficiencies, competent communication must be considered a fundamental criterion of “good medical practice” (Beyer et al. 2009).

XIV | Preface

Gap in the existing literature To date, research on the role of communication in patient safety and quality of care has generally concentrated on optimizing the quantity and clarity of communication content in medical interactions. However, human interaction encompasses much more than that. Miscommunication entails more than insufficient or unclear message contents. It is a frequent byproduct of the complex process of co-constructed human communication. Thus, beyond optimizing the quantity and clarity of messages to avoid or minimize error, it is important to understand the communication processes that hinder and foster favorable patient outcomes. Health practitioners tend to be overconfident in their own abilities to communicate (Lake Wobegon Effect; see Alicke and Govorun 2005; Sedikides et al. 2003). Thus, one of the bigger hurdles to an individual developing better communication is the awareness that they need to and could benefit from doing so. Communication problems are easy to find in others and hard to see in oneself. This bias is reinforced by the relative lack of catastrophic errors in everyday life (e.g. “no one that I know of has died from my inability to communicate, so I must be a good communicator”) and impedes self-reflection. Just because we communicate every day of our lives, this does not mean we communicate competently all the time. Importantly, the consequences of incompetent communication can be much greater in the context of healthcare than in the everyday conversation. For over 100 years, scholars in communication science have applied scientific methods and systematic observations to describing communication processes across a variety of contexts. Communication science focuses on understanding these processes as a prerequisite for the successful translation of communication-centered issues into safe and high-quality clinical practice. Insights from communication science have the potential to advance healthcare’s pressing agenda to improve communication. However, few investigations to date have attempted to shed light onto the critical interdisciplinary connections that could directly enhance the quality and safety of care (Pannick et al. 2015).

Unique features of this book This book of case studies is unique in its integration of the literature from communication science with key topics in patient safety. It manifests a valuable interdisciplinary collaboration that translates the basic tenets of human communication science for educators, students, and practitioners of medicine and nursing, providing a conceptual, evidence-based foundation for practices that can advance patient safety and quality of care. The models and typologies are based on established theory, knowledge, and published research from communication science. The discussions are based on real cases of medical errors that were reported anonymously by clinicians and subjected

Preface | XV

to expert analysis. The majority of the case descriptions were loaned from the Agency for Healthcare Research and Quality’s (AHRQ) Morbidity and Mortality Rounds on the Web (WebM&M), where they benefited from a rigorous process of review and editing (https://psnet.ahrq.gov/webmm). Through the discussion and analysis of these cases, communication theory is put into practice to facilitate experiential learning, granting insights into diverse aspects of healthcare delivery. Thought-provoking discussion questions, illustrative activities, and references for further reading make this book an indispensable resource for medical and nursing practitioners and students across the world.

Synopsis of contents This book features a collection of 39 critical incident descriptions that exemplify perennial “hot topics” in patient safety, such as handoffs, falls, adverse drug events, wrong-site surgery, and diagnostic errors. The cases were not a random sample of all safety incidents, so they do not provide a representative estimate of the prevalence of problems. However, they indicate the pervasiveness and extent of communication problems in medical care, highlighting positive and negative situations and places when communication failed or succeeded in ensuring high-quality care and preventing patient harm. The book presents interdisciplinary and evidence-based perspectives on communication processes (e.g. conflict, hierarchical communication, whistle-blowing, speaking up) that contributed to close calls and adverse events, applying basic principles from communication science to illuminate the case studies with practical communication insights. In summary, this book is a unique, practical, cutting-edge resource for educators, students, and front-line practitioners of medicine and nursing. It is organized chronologically along the continuum of medical care delivery, providing quick access to solutions in safety and quality-compromised situations and illustrating how skillful communication can be the key to a more effective prevention, intervention, and response to “close calls” and adverse events.

Structure and layout This book is organized into two parts. Part I contains six chapters that focus on core principles and challenges related to healthcare quality, patient safety, and human communication. With consistent cross-referencing to the case studies in Part II of the book, these chapters discuss (1) core principles of healthcare quality and patient safety, (2) myths and truths about human communication, (3) communication topics in healthcare quality and patient safety, (4) key challenges and issues in interpersonal

XVI | Preface

communication, (5) a typology of communication errors in healthcare, and (6) lessons learned from communication science. Part II of the book contains the 39 cases. The cases are arranged along a “goto-timeline” that represents six stages in the continuum of care delivery (see Hannawa and Roter 2013): (1) medical history taking, (2) diagnosis, (3) treatment planning, (4) storage, (5) treatment execution, and (6) post-treatment care. Each stage contains six layers of communication that range from micro-, meso-, to macro-level interactions. Micro-level interactions include provider-patient and provider-family encounters. Meso-level interactions entail medical teams (i.e. clinicians and staff who work within a medical team) and inter-professional encounters (i.e. a few single clinicians from dissimilar medical backgrounds interacting with each other). Macro-level cases include cross-professional (i.e. among many clinicians from diverse medical backgrounds) and inter-institutional (i.e. across at least two healthcare sites) interactions. To promote recognition of these communicative levels across the case chapters, each case is labeled with a representative icon on top of the page (Table 1). The case studies relate to nine common topics of patient safety. For easy reference, these topics are also identified with representative icons. Table 2 shows the nine topics with their corresponding icons and the frequency of occurrence across the 39 cases in Part II of this book. Additional characteristics of the case studies are summarized in Table 3. The frequencies in this table demonstrate that the 39 cases represent a broad variety of patient safety events that cover examples of near misses (cases 2, 4, 13, 17, 18, 34, 38), harmless hits (cases 3, 6, 8, 14, 20, 23, 24, 31), adverse events (cases 1, 5, 9, 12, 15, 16, 19, 21, 22, 27, 28, 30, 32, 33, 35, 37, 39), and sentinel events (cases 7, 10, 11, 25, 26, 29, 36). Most of the cases reflect acute and inpatient settings, but they also cover examples of outpatient care and scenarios that involve both acute-on-chronic and routine/ follow-up care. Each case is followed by a “diagnostic” section that lists and labels communication errors, organized within the core principles of human communication. A brief discussion presents additional comments on each case in reflection of content discussed in Part I of the book. Each case study chapter closes with discussion questions and applied exercises, and with a “lessons” activity that encourages educators, students, and practitioners to identify and apply the respective “Lessons from Communication Science” from Chapter 6 in Part I to each case scenario in Part II. This pedagogical activity facilitates experiential comprehension of the communication principles and their implications for clinical practice.

Macro-level

Meso-level

Micro-level

Case 1

Case 2

Case 3

Case 4

Case 5

Case 6

Provider-family

Medical team

Interprofessional

Crossprofessional

Interinstitutional

Stage 1: Medical history taking

Provider-patient

Level of communication

Tab. 1: Structure of Part II of this book.

Case 12

Case 11

Case 10

Case 9

Case 8

Case 7

Stage 2: Diagnosis

Case 18

Case 17

Case 16

Case 15

Case 14

Case 13

Stage 3: Treatment planning

Case 25

Case 24

Case 32

Case 31

Cases 29 and 30

Case 28

Cases 21 and 22

Case 23

Case 27

Case 26

Stage 5: Treatment execution

Case 20

Case 19

Stage 4: Storage

Case 39

Case 38

Case 37

Case 36

Case 35

Cases 33 and 34

Stage 6: Post-treatment care

Preface | XVII

XVIII | Preface

Tab. 2: Patient safety topics and icons. Icon

Patient safety topic

Incident

Count

Medication

Misuse Overuse Underuse Inadvertent use Omission

8 3 1 1 1

Diagnosis

Inaccurate Missed Delayed

3 1 4

Handoff

Incomplete

3

Timeliness

Delayed treatment Delayed diagnosis

8 4

Post-operative monitoring

Insufficient

1

Resuscitation/intubation

Inadvertent Misunderstanding

3 1

Discharge

Inadvertent Unsuccessful

1 3

Surgery

Inadvertent Unsafe Wrong site

1 2 1

Patient falls

Preventable

1

Tab. 3: Additional (non-iconized) case characteristics. Type of event Near miss Harmless hit Adverse event Sentinel event

Type of care 7 8 17 7

Acute Acute-on-chronic Routine/follow-up

Care setting 30 7 2

Inpatient Outpatient

28 11

Preface | XIX

How to use this book This book is best used as a reference guide. Although some will want to read it from front to back, students and clinicians may find it most useful by skipping to relevant cases, based on their individual needs and interests. Educators teaching about patient safety may recommend some or all of the chapters in Part I of the book, and focus on cases covering different patient safety topics in Part II. Medical educators in general may want to select cases to enhance their presentation of specific phases of clinical care. Patient safety professionals and risk managers investigating patient safety incidents may be able to enhance their analysis by referring to related case studies. Part I of this book contains pedagogical value on its own, whereas Part II presents practical communication insights, discussions, and experiential learning exercises that offer opportunities to apply the insights obtained from Part I of the book to the cases. Pedagogical value can also be gained from the “communication lessons” sections that appear in the form of a color-coded box at the end of each case chapter in Part II. These sections encourage readers to cross-reference applicable “lessons from communication science” from Chapter 6 (Part I) of the book to summarize the problematic interpersonal processes in each case. In addition, advanced insights can be gained from discussions that consider the interplay across the various categorical schemes that are introduced in this book to identify ways in which additional factors can either add to, mitigate, or prevent the communication errors in each case.

Summary The contents and layout of this book facilitate a rich learning experience. The book sharpens the reader’s eye for common communication processes, themes, and errors that are relevant to the quality and safety of care. It promotes deeper comprehension of these issues and trains recognition skills that can trigger diagnostic and corrective mechanisms during the provision of care. It is evident that safe and high-quality care processes require active contributions from all care participants. Thus, on several occasions, this book refers to patients and family members as active partners for safe and high-quality care. In the same vein, this book uses “error” and “failure” as terminologies to connote and promote a culture of learning that should replace preceding cultures of blame.

| Part I: Principles and challenges of healthcare quality, patient safety, and interpersonal communication

1 Principles of healthcare quality and patient safety Albert W. Wu, M.D. and Robert S. Juhasz, D.O.

1.1 A global quest for improved healthcare quality and safety At the beginning of the twenty-first century, two influential reports from the Institute of Medicine (IOM), “To Err is Human” and “Crossing the Quality Chasm,” highlighted serious gaps and concerns regarding healthcare quality and patient safety (Kohn et al. 2000; IOM 2001). These publications triggered a cascade of research and initiatives across the globe to improve the quality and safety of healthcare delivery. In 2000, U.S. President Bill Clinton declared medical errors to be a major public health problem and ordered all hospitals in the United States to take steps to reduce medical errors. In 2002, the WHO Member States agreed on a World Health Assembly resolution on patient safety by an unprecedented nearly unanimous margin, with the resulting launch of the World Alliance for Patient Safety in 2004. This group has initiated campaigns to reduce healthcare acquired infections and improve surgical safety worldwide, and now provides direction and guidance in addressing core problems in patient safety. Patients for Patient Safety (WHO) in over 100 countries aim to incorporate the patient, family, and community voice into all levels of healthcare through engagement and empowerment. Research supported by the U.S. Agency for Healthcare Research and Quality (AHRQ) demonstrated that the previously unconceivable goal of zero healthcare acquired infections can be achieved (Pronovost et al. 2006). The U.S. Joint Commission has taken up patient safety as a pillar of its activities and investigated other high-reliability industries such as aviation to see how similar methodology could be applied to healthcare settings (Chassin and Loeb 2013). There are now influential scientific journals dedicated to patient safety, and the leading website Patient Safety Network has curated a vast number of important publications on the topic. The initial global investigations of healthcare safety (Jha et al. 2010; Jha et al. 2013; Wilson et al. 2012) have provided the basis for patient safety and the reduction of healthcare-induced harm to become a central collaborative goal for providers and patients worldwide. It is recognized that problems with communication are pervasive, both between clinicians and among clinicians with patients and their families at all levels of the healthcare system. The Joint Commission (2016) has found that communication issues are the most common root cause of serious preventable harm to patients. In the operating room (OR), for example, poor communication has been directly linked to surgical complications (Mazzocco et al. 2009). For these reasons, this book focuses on problems with communication, in hopes of creating opportunities to improve the safety and quality of healthcare.

DOI 10.1515/9783110455014-001

4 | 1 Principles of healthcare quality and patient safety

1.2 Common misconceptions about healthcare quality and safety There are a number of misconceptions about healthcare quality and patient safety that are shared by healthcare providers, patients, and the general public. Three common misconceptions are that (1) medical errors and safety problems are rare, (2) most safety problems are caused by individuals, and (3) punishment is an effective deterrent.

Myth 1: Quality and safety problems are rare Most people underestimate the importance of problems related to quality and patient safety, including the prevalence of medical errors and preventable injuries that are induced by healthcare (Brasaite 2015). For example, one survey found that although many patients and physicians report errors in the care of a family member, neither views medical error as a significant problem. Both groups underestimate the number of preventable deaths in hospital care (Blendon 2002). Furthermore, evidence suggests that patients are often inadvertently injured as a result of their healthcare. Worldwide studies suggest that an average of 10% of acute care hospitalizations involves an adverse event, with one-third of these leading to permanent injury or death (Classen 2011; Jha et al. 2010; Landrigan 2010; Vincent et al. 2001; White 2010). At least half of these incidents may be preventable. Although there is some disagreement about absolute numbers, one paper suggested that adverse events might be the third leading cause of death in the United States (Makary and Daniel 2016). These studies make it clear that healthcare quality and patient safety are not a rare problem, but a prevalent challenge across the globe.

Myth 2: Most quality and safety problems are caused by individuals Members of the public are more likely than healthcare workers to believe in a model of individual causation of medical errors and adverse events. However, many healthcare workers also adhere to the belief that individual performance is to blame for most safety problems. There is still a tendency in many organizations to identify and eliminate the “bad apples” from their practitioner pool, believing that this will improve the safety and quality of care. Accordingly, they believe that effective interventions to improve safety should focus on improving the knowledge and performance of individual providers. In contrast, it has been recognized since the 1990s that healthcare-induced injuries are caused by factors at multiple levels of the healthcare system and that the majority of incidents are caused by more than one contributing factor (Pronovost et al. 2006; Reason 1990a, 1990b; Vincent et al. 1998). Accordingly, preventive efforts must apply a multilevel framework of contributory factors to investigating specific incidents and subsequently act to make changes at all applicable levels of the system.

1.3 What constitutes “healthcare quality” and “patient safety”? |

5

Myth 3: Punishment deters quality and safety problems There is a tradition in healthcare to “name, blame, and shame” the individual provider judged to be responsible for an adverse event. As noted in the preceding paragraph, blame is the predominant response to error among healthcare providers, especially in respect to nurses. In the survey by Blendon et al. (2002) as noted above, members of the public and many physicians supported sanctions or other punishment of individual healthcare workers viewed as responsible for errors. However, fear of punishment has contributed to a norm of silence about errors. This leads to a vicious circle in which healthcare workers do not talk about errors and related concerns, leaving managers without information to manage with. This in turn leads to further safety problems. The desired climate is one in which it is safe to admit errors and learn from them. In a culture of safety, rather than a blame culture, healthcare workers understand that organizational flaws cause errors and harm, safety can be improved by reporting of errors, and reporting is rewarded rather than punished.

1.3 What constitutes “healthcare quality” and “patient safety”? Patient safety is a necessary but not sufficient condition for quality healthcare. Safety events result from either unpreventable (i.e. unpredictable accidents or predictable complications) or preventable (i.e. active and latent errors) occurrences across the continuum of healthcare provision (Hannawa and Roter 2013). Given the complexity of this phenomenon, it is useful to apply a standard set of definitions to delineate human errors from other factors related to patient safety. This helps to avoid confusion and allows comparisons to be made across different settings. With this in mind, the AHRQ Common Formats have been established (AHRQ 2014). Relevant terms include error, adverse event, preventable adverse event, sentinel event, bad outcome, negligence, patient safety event/incident, no harm event, close call hazard, and safety culture. Based in part on the AHRQ PSNet Glossary of Terms and Wu (2011), we provide definitions of these terms in Table 1.1. Tab. 1.1: Key terminology in patient safety. Key terms

Definitions

Error

An act of commission (doing something wrong) or omission (failing to do the right thing) that leads to an undesirable outcome or carries significant potential for such an outcome. Errors are commonly categorized as active versus latent. Active errors occur at the point of contact with the patient and generally involve a frontline caregiver. They are sometimes referred to as errors at the “sharp end.” Latent errors refer to less apparent failures of organization or design that contribute to close calls or adverse events. These occur at the opposite “blunt end,” distal from the frontline provider and patient. Errors can but do not necessarily lead to patient harm

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Tab. 1.1 (continued): Key terminology in patient safety. Key terms

Definitions

Adverse event

Patient injury caused by healthcare. Some adverse events are preventable others are not. Preventable adverse events are caused by active or latent errors. Nonpreventable adverse events are caused by inevitable harmful effects of treatment (i.e. unpredictable accidents or predictable complications/side effects)

Sentinel event

An adverse event in which there is death or serious, nonreversible harm to a patient that has been designated as particularly egregious and unacceptable. Examples include wrong-site surgery or inpatient suicide

Bad outcome

An undesirable outcome sustained by the patient. These may be intended or not intended, and may or may not be related to healthcare – they may also be a consequence of the natural history of disease

Negligence

A legal term that implies care by a medical professional deviates from a generally accepted medical standard of care. The concept hinges on attributing legal fault to an individual. The concept of legal fault is at odds with the conceptualization of errors and harm as properties of systems rather than individual practitioners

Patient safety incident

An event or circumstance that could have resulted, or did result, in unnecessary harm to a patient

No harm event

An incident that reached a patient, but with no discernable harm. This concept is related to “close calls” and “near misses”

Close call

An event that did not result in patient harm because it did not reach the patient, due to either by chance or capture before reading or, if it did reach the patient, due to robustness of the patient or timely intervention. Close calls include near misses, which did not “reach” the patient, and harmless hits, which reached the patient but caused no appreciable harm

Hazardous circumstance

A situation in which there was potential for harm, but no incident occurred. Includes hazards and unsafe conditions

Safety culture

Safety culture is an important concept in patient safety that originated in studies of high reliability organizations outside of healthcare (i.e. organizations that consistently experience few adverse events despite the conduct of high-hazard work). Key features include: (1) recognition of the high-risk nature of the organization’s activities and commitment to achieve consistently safe operations; (2) a blame-free environment where individuals are able to report incidents without fear of reprisal; (3) encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems; and (4) organizational commitment of resources to address safety problems. In healthcare, achieving a safety culture is seen as essential to minimizing patient harm and improving the quality of care

Note: Definitions were adapted from the AHRQ Patient Safety Network: Shojania KG, Wachter RM, Hartman EE. AHRQ Patient Safety Network Glossary. Available at: http://psnet.ahrq.gov/glossary.aspx.

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Making errors is a natural consequence of human fallibility. Identifying something as an adverse event does not imply error, negligence, or poor quality of care. Rather, it indicates an undesired or bad outcome that resulted from the provision of healthcare as opposed to the underlying disease process. Errors, bad outcomes, negligence, and malpractice suits are distinct entities that are often confused. Not all errors are negligent, not all errors cause harm, and malpractice suits may or may not occur in response to a bad outcome, and may occur even in the absence of any error. A visual delineation of these critical terms is illustrated in Figure 1.1.

Adverse Event Preventable Adverse Event

Bad Outcome

ERROR

No Bad Outcome

Close Call

Medical Care

Disease

Fig. 1.1: Relationships among errors, adverse events, close calls, and bad outcomes.

1.4 Principles of healthcare quality Opinions about the definitions of quality can differ depending on one’s perspective. One of the most influential frameworks for the assessment of healthcare quality was established by the IOM (2001) in its publication entitled “Crossing the Quality Chasm.” This framework includes six objectives for the healthcare system:

Principle 1: Safety Avoiding harm to patients from healthcare. Safety goes beyond competent and conscientious care delivered by individual providers. Safety must also be a property of

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the system that reduces errors and mitigates their effects to prevent people from being harmed.

Principle 2: Effectiveness Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (i.e. avoiding underuse and misuse/overuse, respectively). Care should be consistent with the scientific evidence to deliver the best and most appropriate practices for desired care outcomes.

Principle 3: Patient-centeredness Providing care that is respectful of and responsive to the individual patient’s preferences, needs, and values, and ensuring that patient values guide all clinical decisions. Care should take into account the patient’s social context, culture, and specific needs, and promote that patients play an active role in making decisions about their own care, to the extent desired.

Principle 4: Timeliness Reducing waits and sometimes harmful delays for both who receive and who provide care. Prompt attention benefits both patients and providers. However, the provision of care should also occur when it can provide the most benefit – providing a service before the patient can benefit from it, for example, is also undesirable.

Principle 5: Efficiency Avoiding waste, including waste of equipment, supplies, ideas, space, time, energy, and opportunities. Individual providers and larger elements of the system should seek to reduce waste and cost.

Principle 6: Equity Providing care that does not vary in quality because of a patient’s traits and personal characteristics such as gender, race, ethnicity, geographic location, income, and socioeconomic status. All patients should receive high-quality care so that the benefits of medical science reach everyone equally and achieve the best possible outcome.

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1.5 Principles in conflict There may be conflicts or tensions that arise in attempting to achieve all of these objectives simultaneously. For example, care that is efficient and timely may not be as safe compared to care that is delivered very carefully but more slowly. Influential research by Donabedian (1988) and others has led to a series of efforts to define measurable indicators of care quality. To date, the majority of these measures contain process variables. Although they may not necessarily be direct predictors of outcomes, they create opportunities for healthcare providers and organizations to seek and meet standards that are based on published, evidence-based research. For most patients and their families, being able to transparently view the quality metrics may not be as important as their own personal outcomes while in the care of a provider, healthcare team, or organization. In fact, Michael E. Porter, a noted healthcare economist, promotes that providers should seek to deliver healthcare “quality that matters to the patient” (ICHOM 2016). Certainly, individuals are most interested in receiving high-quality care, whether or not it contains all of the aforementioned dimensions.

1.6 Principles of patient safety James Reason developed a “Swiss cheese model” of accident causation for understanding and responding to safety problems in organizations (Reason 1990a, 1990b). Charles Vincent adapted this model to develop a framework of contributing factors that can be relevant to a specific healthcare incident (Vincent et al. 1998). This systems analysis approach describes factors that affect the safety of care at various levels of an organization or system. These levels include the patient (and family), the task being performed, the individual provider, team, work environment, organization, and the various institutional levels. Patient factors include the patient’s health condition, including its complexity and seriousness, limitations in language and ability to communicate, personality, and social determinants of health and well-being. Task factors refer to the design of what is being done and the clarity of the process to be completed, the availability and use of protocols, and the availability and accuracy of information for evaluating and monitoring the patient. Individual factors are related to the healthcare staff, including their knowledge, skill, motivation, personal health, and abilities. Team factors, which are increasingly important as healthcare becomes more complex, include verbal and written communication, coordination, team structure, supervision, and asking for assistance. Work environment refers to levels of staffing and skill mix, workload, scheduling, ergonomics, and availability and condition of equipment. Organizational factors include management, financial resources, goals, policies and standards, safety culture, and priorities. Finally, institutional factors include the higher level context, in-

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cluding economic and regulatory issues, payment schemes, malpractice schemes, and healthcare governance (Vincent et al. 1998). Some factors may contribute to the likelihood of failure, whereas others may mitigate these effects. A consideration of this framework of factors by researchers and risk managers allows for a systematic approach to error reduction and safety improvement. A mere focus on actions or omissions of individual providers is incomplete and unlikely to lead to useful interventions. Effective interventions take into account a more holistic focus on redesigning work and the system in which that work is performed.

1.7 Conclusion There are two main approaches to improving patient safety and quality of care – one approach that focuses on people and another one that focuses on systems. An important lesson is that safety is a property of systems to a much greater extent than a property of individual clinicians. The tendency to err is affected by work conditions and additional factors at multiple levels of a healthcare organization. At the same time, the systems-only approach leaves out important facets of individual agency if one does not acknowledge that individuals are indispensable components of the system. For that reason, a mixed-methods approach is beneficial for understanding the quality and safety of care. Investigations that consider either only the system or only individual providers and their failures will be insufficient. It is useful to take an approach to solutions that incorporate changes to both systems and the individuals functioning within them. Interventions that consist of blaming and punishing individuals, in particular, will not be effective in improving the quality and safety of care. Interventions can be applied at different levels of the system (Woodward et al. 2009). Although the majority of traditional interventions are directed at individual clinicians, including education and re-education, providing checklists and standard operating procedures, increased supervision, and removal from duties, interventions also need to be aimed elsewhere in the system. For example, interventions can also be directed at the patient and family by engaging them as active partners in their own care; the team by teamwork training; the local unit by changing culture and making workplace changes; and other elements of the system, for example, by providing better information technology. Some of the most promising interventions provide individuals with decision support, particularly just-in-time when needed, standardized communications and handoffs, simulating training, and forcing functions that automate processes or make it more difficult to do “the wrong thing.” As illustrated in this book, communication is a pervasive factor that both contributes to problems with safety and quality, and mitigates them. This book aims to inspire opportunities to improve communication and, in so doing, close some of the gaps in both communication and patient safety.

2 Myths and truths of human communication Annegret F. Hannawa, Ph.D.

2.1 Common myths about communication There are several incorrect assumptions or “myths” about human communication that are commonly shared by both patients and healthcare providers. Many of them are illustrated in the cases in Part II of this book. The failure by clinicians and patients to communicate successfully with each other is often the product of the following inaccurate beliefs:

Myth 1: Communication is a simple and functional task Across the cases in Part II of this book, care participants tended to assume that communication is a simple, almost automatic task that generally works well if left alone. There are several examples in the case scenarios where both providers and patients incorrectly assumed that communication is taking place (cases 30 and 36), taken care of (cases 6 and 11), understood (cases 35 and 38), and “passing” accurately from one person to the next (cases 23 and 35). In other words, care participants incorrectly conceptualized communication as a linear task of transferring a message, rather than as a complex, interactive meaning-making process. The truth is, however, that communication is an intensive, interactive, error-prone activity that often fails to accomplish its purpose of attaining a shared understanding. As a result, it has the potential to lead to patient harm. Because of this limited understanding of communication, care participants abdicated their responsibility for communication as soon as they “sent” it. Instead of thinking and acting out their communication objectives to the “end” (i.e. to the point where all participants share one perspective), they abandoned the communication process prematurely.

Myth 2: Communication equals words The participants in the case scenarios commonly interacted with one another under the incorrect assumption that communication is equivalent to conveying words. For example, they assumed that the necessary information could simply be passed through a series of people to an intended receiver. This assumption fails to recognize that such latent communication – communication that sequentially passes through a chain of several individuals – typically falls victim to a “game of telephone” (also DOI 10.1515/9783110455014-002

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referred to as a “rumor game”), whereby the quantity and quality of that information is degraded with repeated passage (cases 29 and 37). There were several cases of handoff in which this incorrect assumption led to a preventable patient safety event (cases 6, 22, and 24). Care participants also underestimated the role of nonverbal communication, including “nonbehavior” and “missing” verbal messages, as powerful carriers of message contents. “Nonbehavior” is a paradox, because there is no way to not behave. There are plenty of ways to misbehave and there are plenty of ways of engaging in one behavior when another behavior would have been more functional. But it is impossible to not behave. For example, a medical student who does not ask questions in class or during rounds is not “not behaving,” but is behaving in a way he should not. Even “non-communication” (such as silence or lack of contact) can convey a message in its own right. At numerous occasions, clinicians insufficiently decoded patients’ nonverbal messages for diagnostic and treatment purposes (cases 7, 12, 15, and 27), and both clinicians and patients assigned meaning to such “missing” communication (cases 13, 21, and 39).

Myth 3: Communication equals information transfer Care participants generally thought of communication as merely conveying factual information. In several of the cases, care participants did not understand that their communication also carries important relationship-defining messages that can affect the quality and safety of care and objective patient outcomes. For example, a clinician’s focus on factual information contributed to a young patient’s mother not feeling heard (case 7); a patient’s syncope as a result of low blood sugar and dehydration (case 20); a patient not daring to speak up to prevent wrong-site surgery (case 26); incorrect diagnosis (case 27); and unsuccessful discharge instructions (case 33).

Myth 4: Communication can be accessed, deposited, and delegated Care participants tended to view communication as containing reliable, accurate, static information that is accessible and recognized as “intended” by anyone who “sees” it. For example, they tended to think that “writing down” or “depositing” information into health records constitutes communication. They assumed but never verified that the words they wrote were received and understood correctly by other care participants. In other words, they assumed that communication is synonymous with understanding and retention. Even when information was properly deposited and documented, and even when receivers tried to access available information, a shared understanding of this information was rarely attained. The written documentation was in place to initiate com-

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munication, but the communication never actually occurred. As a result, the meaning of critical information remained within written words and was never advanced to a shared meaning-making process.

Myth 5: Communication is not about individual understanding Care participants generally failed to recognize that communication is an interpersonal meaning-making process that is essential for safe and high-quality care. Instead, they assumed incorrectly that sense-making occurs within people. What in fact resides within people, however, are perceptual biases and preconceptions that inhibit the co-establishment of a shared understanding (case 32). As a result, care participants often engaged in inadequate communication that established a porous “common ground” (which entails the sum of people’s shared knowledge, presuppositions, and beliefs; see Clark 1996), allowing critical information to fall through the cracks and triggering patient safety incidents. There are several instances in which care participants fell victim to this “common ground fallacy,” incorrectly assuming that others will understand their intentions, feelings, thoughts, and meanings. This implies that shared understanding is the goal, but a taken-for-granted common ground is often an obstruction to achieving that goal.

Myth 6: More communication is better The case scenarios evidence a general belief among providers that communication is linearly related to competence. Providers tended to assume that more communication is better communication. The truth, however, is that the functional form of the association between communication skills and competence is an inverted U, with both too little and too much of any given behavior being perceived as inappropriate and ineffective in most healthcare interactions (e.g. case 8; see also Spitzberg 2000). This recognition is in line with the notion of both “underuse” and “overuse” being problematic issues in the healthcare literature.

Myth 7: Communication “breaks down” A meta-assumption that encompasses the six myths outlined before is that care participants attributed “failed communication” to a “breakdown” in communication. This analogy is based on the assumption that communication generally works, but “breaks down” at times as a result of at least one of the care participants not communicating. This perspective is problematic because it mistakenly implies that communication failure equates to a mere lack of communication rather than incompetent com-

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munication. Furthermore, it reinforces the mistaken belief in individual causation of adverse events, which perpetuates a “blame culture.” It is also based on an incorrect understanding of communication. Across the 39 cases, poor outcomes were the result of no established shared understanding. What was never established cannot “break down.”

2.2 Principles of human communication There are a number of widely accepted principles of human communication. In contrast to the myths described in the last section, this section elaborates nine such core “truths” of human interaction to inform the cases in Part II of this book, and to promote a better understanding of how competent communication – interpersonal processes that are both appropriate and effective (see Spitzberg 2001) – can enhance the safety and quality of patient care. Table 2.1 cross-references the respective cases in Part II of this book with these principles and illustrates applied examples. Nine core principles of human communication: Principle 1: Communication varies between thought, symbol, and referent Principle 2: Communication is a non-summative process Principle 3: Communication is functional Principle 4: Communication is more than words Principle 5: Communication entails factual and relational information Principle 6: Communication is contextual Principle 7: Preconceptions and perceptions vary among communicators Principle 8: Redundancy in content and directness in channel enhance accuracy Principle 9: Communication is equifinal and multifinal

Principle 1: Communication varies between thought, symbol, and referent The first principle of human communication is that communication is fundamentally an interactive meaning-making process. Humans “make meaning” through the joint creation and interpretation of symbols, which comprise words, gestures, images, sounds, and artifacts. Communication starts with a thought (i.e. “reference”) that a person has in mind. If a person wants to convey that thought to others, then the person “makes meanings” by creating and attaching “symbols” to that thought. In other words, the original thought is encoded into symbols and behaviors (Ogden and Richards 1946; de Saussure 1959).

2.2 Principles of human communication

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These “symbols” have no intrinsic meaning of their own. They become “symbols” only when humans invest them with meaning (i.e. by attributing them with a thought they have in mind). In other words, symbols are chosen arbitrarily to refer to a signified thought, known as a “referent,” or a concept that the symbol stands for (de Saussure 1959). People assign symbols to their thoughts based on the conceptual world with which they are familiar. In semiotic terms, no two languages or cultures categorize such a reality in precisely the same way. As such, the symbolization process is not a consequence of some predefined structure that is inherent in a given language or culture. Rather, language is a vehicle that humans use to construct a shared reality. We even use this kind of symbolization in this book. We use icons on top of each chapter in Part II of this book as symbols that resemble a referent. For example, we use an icon that symbolizes two figures – one with a stethoscope and one sitting on a bed – to resemble a care situation we have in mind in which a physician communicates with a patient. We assume that there will be sufficient common ground for conveying that thought, but we use a variety of other ways of communicating to try to facilitate a shared understanding. In summary, the first principle of human communication demonstrates the inherent challenge of “making meaning” – the challenge of coming to a shared understanding based on arbitrary symbols. This is a complex process that requires high accuracy in terms of people’s encoding and decoding of such symbols. This interpretive process is further challenged by significant “between-subject variance.” As a result of people’s dissimilar personal and cultural backgrounds, as well as their own idiosyncrasies, the accomplishment of a complete “shared understanding” is an unlikely, error-prone (due to perceptual biases), and effortful intersubjective task.

Principle 2: Communication is a non-summative process Human communication is an interpersonal process that involves much more than a mere sum of its components. Whereas the assignment of symbols to thoughts happens within individual people, the meaning-making process (i.e. communication) of such symbols occurs between people. This notion implies that communication is an interactive process through which people approximate their attributions between referents, symbols, and thoughts so that they become equivalent. Sufficient efforts at skilled communication are needed to achieve this goal of a shared understanding. Based on this notion, communication does not “fail” or “break down” in the same way as an engine breaks down or a telephone fails to operate – a conduit metaphor that is common in the medical literature and in everyday use. When a car breaks down, it no longer functions to do what it is intended to do. When a light bulb burns out, it stops being a light bulb. It ceases to function. If someone drops a cellphone during a conversation and it breaks, that is the end of that conversation on that phone at that

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time. Communication cannot break down in this way. Communication malfunctions, but it cannot stop functioning at all. Not saying something or saying something that is not fully understood is still a process of communication – communication that is functioning poorly. Along the same vein, most critical incidents in healthcare do not occur because communication stopped. They occur because communication stopped working competently. Problems in healthcare interactions generally arise from both insufficient (in quantity) and poor quality communication that fails to establish a shared understanding. Shared understanding emerges from a complex, interactive meaning-making process that takes place in the space between people and generally constitutes an outcome that is different from the sum of its parts.

Principle 3: Communication is functional It is challenging to establish a shared understanding of original thoughts in interaction with others, particularly when the content entails more than mere factual information. The process becomes even more challenging when people interact for communicative functions that do not prioritize a shared understanding. Whereas shared understanding is enhanced by a transactional exchange of clear and accurate messages, people frequently interact for functions that are not facilitated by clear and accurate symbolization. More often than not, people engage in sarcasm or humor, persuasion, or various forms of deception (including exaggerations and understatements) to avoid conflict, be polite, maintain relationships, “save face,” and appear competent. Some of these communicative functions are attained through strategic vagueness or purposeful ambiguity in the symbolization process that make the establishment of a shared understanding more difficult to attain. In the healthcare context, for example, nurses often do not “speak up” to physicians in clear and straightforward ways to avoid conflict and save face. Similarly, physicians sometimes communicate in “soft” rather than straightforward ways with colleagues and patients to maintain good relations and avoid getting sued. Such “soft” ways of communicating can have “hard” outcomes – in case 11, for example, a physician’s prioritization of maintaining good relationships with a colleague over establishing a shared understanding led to a patient’s death.

Principle 4: Communication is more than words Communication is often thought of as an exchange of words. However, all behavior types – even passiveness or silence – have the potential to communicate volumes. For example, a physician making rounds with an intern who does not talk with a patient is still communicating to that patient. Along the same vein, not visiting a patient can

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communicate a lack of concern for the patient. In turn, others cannot “not respond” to messages – even silence, withdrawal, and immobility can elicit an interpretation. For example, a patient’s silence in the face of a clinician’s inquiry “says” something even in the absence of words. Verbal messages are always accompanied by nonverbal characteristics such as pitch, pace, intensity, and inflection of the voice, as well as facial expressions and gestures – all of which can influence the intended meaning of a verbal message. Nonverbal communication can repeat, illustrate, augment, accentuate, or contradict the words it accompanies. It can also disrupt the decoding process by distracting attention from words or contradicting their content. Furthermore, nonverbal behaviors can precede words, inflect, substitute, or override them, and become “message bearers in their own right” (Burgoon and Hoobler 2002). Thus, in everyday interactions, the transmission and reception of any message depend on what we simultaneously say, hear, see, and show. Generally, when verbal and nonverbal messages contradict each other, people tend to believe the nonverbal more than verbal messages (see Seiler and Beall 2000). Because nonverbal behaviors are perceived as more valid than verbal communication, they must be recognized as a core mode of human interaction.

Principle 5: Communication entails factual and relational information In the same way that verbal messages are always accompanied by nonverbal messages, factual messages are always accompanied by relational messages (i.e., messages about the nature of the interactants’ relationship with each other, their status in that relationship, and the social context within which their interaction occurs; see Watzlawick et al. 2014). This can be seen, for example, in a medical error disclosure to a patient – while the disclosure may primarily contain factual information about the events leading up to the mistake and implications for the patient’s health, the clinician’s attentiveness to the patient and calming tone of voice communicate concern for the patient. In contrast, a neglect of such relational emphasis might communicate relational distance and disregard to the patient. Similarly, at first glance, an anesthesiologist’s question to a surgeon of whether she can prepare the next patient seems purely informational. However, depending on the way in which the question is stated, it may come across as either caring or critical (e.g., suggesting that the surgeon is not working fast enough). It is important for providers to understand that their communication conveys both factual and relational messages to other care participants. They need to understand the constraining and enabling potential of such relational messages in communication with both colleagues and patients. With respect to colleagues, this recognition can enhance a shared understanding and prevent conflict escalation. With respect to patients, ample evidence has established measurable “placebo” effects of relational

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messages on care outcomes. For example, studies have found that relational communication can enhance patients’ course of recovery, decrease their anxiety, decrease the need for postoperative pain medication, and lead to earlier hospital discharge (e.g. DiMatteo and Taranta 1979; Egbert et al. 1964; Ben-Sira 1976). Thus, this principle is directly relevant to the quality and safety of care.

Principle 6: Communication is contextual The meaning of a communicated message largely depends on the context in which it is encoded and received. Such context contains multiple layers (see Spitzberg 2000): – Functional context (the goals people pursue in their interaction) – Relational context (people’s relational history or composition) – Environmental context (the physical setting in which an interaction takes place) – Chronological context (the sequencing, timing, timeliness, available time, and duration of an interaction) – Cultural context (people’s cultural rules, norms, and belief systems) Communication in clinical encounters is particularly context-dependent. Care participants’ (i.e. clinicians, patients, and care companions) failure to recognize the constraining and facilitating effects of these contextual dimensions on establishing a shared understanding can directly compromise the safety and quality of care. For example, across the cases in Part II of this book, care participants communicated with the wrong target (misuse of functional context), allowed relational biases and professional hierarchies to compromise safety-relevant care processes (overuse of relational context), did not allocate the necessary time to communicate with each other (underuse of chronological context), and neglected to recognize that working in a new organization requires adapting one’s learned communication protocols to the new institution’s communication standards and norms (underuse of cultural context). These failures to recognize that communication is contextual contributed to numerous patient safety events (Table 2.1 lists the respective cases).

Principle 7: Preconceptions and perceptions vary among communicators Individuals’ life experiences contribute to idiosyncratic preconceptions and perceptions of communicated messages and behaviors. Such dissimilarities between people are rooted in personal traits (e.g. age, sex, culture, intelligence, religion, attitudes, beliefs, likes/dislikes), brain functioning (e.g. processing speed and memory abilities), thinking and speech differences (e.g. speed of thought, hormonal, emotional states), daily life interferences (e.g. financial concerns, children, political events), differential word definitions (e.g. emotional abstractions and multiple meanings; Mahaffey 2010),

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and incompatible cultural, family, and personal rules (e.g. values, morals, opinions, power distance, privacy boundaries). Communication is an interactive negotiation to bridge these differential preconceptions and perceptions and establish a “common ground,” which – as mentioned before – entails the sum of the knowledge, presuppositions, and beliefs that a person shares with another (Clark 1996), as a foundation for co-constructing a shared understanding. Particularly in high-stakes contexts such as healthcare, people’s failure to recognize this important principle of human interaction often leads to insufficient communication based on the assumed preconception that “others will understand,” which can have detrimental effects on the safety and quality of care. This is exemplified on several occasions across the cases in Part II of this book, where assumptions that another care participant will interpret a message using the same perceptual lens as the sender (e.g. assumed familiarity with clinical terminology and equivalent understanding of a symbol) commonly led to patient harm (see Table 2.1). The 39 cases illustrate that dissimilar preconceptions and perceptions among communicators commonly contribute to misunderstandings, which – in the context of healthcare – can directly compromise patients’ health outcomes. At the same time, recognition of this principle can enhance the safety and quality of care, because it is only through communication that people can recognize and bridge differential preconceptions and perceptions to establish a common ground and shared understanding.

Principle 8: Redundancy in content and directness in channel enhance accuracy Message redundancy (i.e. appropriate repetition of content) and channel richness (i.e. face-to-face rather than asynchronous, mediated communication) generally facilitate accuracy because they advance an overlap of perspectives and provide a rich resource for successful transactional sense-making (i.e. both verbal and nonverbal messages, written and spoken, and reinforced by several persons). Thus, redundancy and directness together provide an opportunity to avoid and reduce misunderstandings, and to intervene with patient safety events. This function is further enhanced if the interactants take into account appropriateness (see Spitzberg 2000), by perhaps repeating their message in a slightly different tone, repeating it with appropriate patience, empathy, and skillful nonverbal manner. So in addition to “say again” or “repeat back” protocols that are frequently used in healthcare and aviation, which merely increase the quantity of communication and structure of information exchange, the quality of the communication is an important factor, because it either enhances or compromises the accuracy of understanding.

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Principle 9: Communication is equifinal and multifinal Communication is complex and at times chaotic. However, it is not random. There may be many different communicative messages (e.g. benefits of intervention, negative consequences of inaction, and appeal to authority) to persuade a patient to adhere to a therapeutic regimen. Depending on the situational and sociocultural complex, one or another of these messages may be most effective. At the same time, using a given tactic that works the vast majority of the time may fail with a specific patient. For example, disclosing the occurrence of a medical error may have different consequences for different patients. For some, this may lead to great emotional distress, while for others it may lead to greater empathy between the patient and provider. This principle implies that providers must be aware of the ways in which a situation can evolve over time. No single tactic works all the time, and in any given situation, any number of potential tactics may work (Spitzberg 2013). There are many possible paths to the same outcome (equifinality), and many possible outcomes to the same path (multifinality; von Bertalanffy 1968; Wilden 1972). One of the cases in Part II of this book demonstrates this principle (case 13). Here, a fortunate combination of poor communication in the execution of a misunderstood treatment plan ended up preventing a patient’s death.

2.3 Principles in sequence and combination The cases in Part II of this book demonstrate that the core principles (or “truths”) of human communication are interlinked. For example, the redundancy principle for accuracy only works if the informational content that is being communicated is complete. Redundancy does not aid accuracy if the information that is being repeated is insufficient (case 29). Directness in channel facilitates the function of contextualized communication (case 24). And dissimilar preconceptions and perceptions can stimulate communication redundancy that, in turn, enhances the accuracy of communication. These interlinkages between the principles demonstrate that human interactions are a complex sequential process that requires careful consideration and an advanced understanding as a prerequisite for improved quality and safety of care.

Cases

2, 31

1, 4, 5, 6, 9, 11, 14, 15, 22, 23, 24, 25, 28, 29, 30, 32, 33, 34, 35, 38

11

13, 15, 21, 34, 36

8, 20, 26, 27, 34

Principle of human communication

Principle 1: Communication varies between thought, symbol, and referent

Principle 2: Communication is a non-summative process

Principle 3: Communication is functional

Principle 4: Communication is more than words

Principle 5: Communication entails factual and relational information

Clinicians failed to attend to patient’s discomfort, to respect patients, and to adapt discharge instructions to patient’s personal life challenges and needs at home.

Clinicians trusted in nonverbal communication over written remarks; merely relied on verbal communication; failed to decode patients’ nonverbal behaviors. Patients attributed meaning to missing verbal communication.

Clinician was purposefully vague to avoid being perceived by a colleague as inappropriate.

Clinicians failed to establish a shared understanding in respect to patient’s medical history (e.g. medication allergies, medications, pregnancy, and information in medical charts or e-records) and treatment plans (e.g. orders, test results, needed interventions, anesthesia, incomplete handoffs, clarification of vague message regarding DNR codes, medication, and discharge instructions).

Patient’s family mislabeled patient’s medication; clinician wrote an ambiguous “d” on prescription order.

Applied examples

Tab. 2.1: Principles of human communication across the case studies in Part II of this book.

2.3 Principles in sequence and combination | 21

Cases

All cases except 3, 15, 26

Principle of human communication

Principle 6: Communication is contextual

Functional context: Clinicians ordered medication that was unsafe in the context of a patient’s pregnancy, pending lab test, or allergy; ordered treatment that was inaccurate in the context of a patient’s DNR code; failed to communicate something unusual about the patient; insufficiently emphasized a patient’s critical health condition; failed to establish communication in the context of a patient’s worsened health condition; failed to communicate within the context of an impending or recent surgery; forwarded messages to the wrong person; failed to identify a correct x-ray image; failed to communicate in recognition of incompatible objectives; failed to decode patients’ behaviors in the context of acute physiological symptoms. Relational context: Clinicians provided relationally biased care (i.e. prejudging a patient or a patient’s condition); provided care without recognizing the context of missing prior knowledge of the patient; failed to integrate family members for their knowledge of the patient; failed to communicate in the context of a colleague being new to the team. Chronological context: Clinicians provided care with: – Time delays (waited too long to clarify or raise an issue, waited to see the patient until the next day, failed to hand over medications on time, took too long to follow up with lab results, checked patient’s records too late, failed to intervene in a timely manner, and took too much time to send documentation); – Too little time (failed to take the needed time to properly decode an indicated infusion rate; failed to establish a shared understanding; and failed to attend to a family’s alerts); – Wrong timing (failed to recognize the time of the day at which a patient was presenting to the ER; administered medication too soon; and gave post-op instructions at the wrong time); – Inadequate duration (failed to recognize that treatment delays may cause a patient to faint; failed to explicate the expected timeframe for treatment). Environmental context: Clinicians failed to recognize that communication was taking place in a setting of an unusually busy night shift at the ED. Cultural context: Clinicians communicated with patients disregarding their lack of familiarity with clinical jargon; failed to communicate with colleagues in the context of a new organizational environment.

Applied examples

Tab. 2.1 (continued): Principles of human communication across the case studies in Part II of this book.

22 | 2 Myths and truths of human communication

6, 7, 8, 11, 13, 16, 19, 21, 22, 25, 27, 30, 31, 32

3, 5, 10, 14, 17, 19, 20, 23, 26, 29, 31, 32, 36

13

Principle 7: Preconceptions and perceptions vary among communicators

Principle 8: Redundancy in content and directness in channel enhance accuracy

Principle 9: Communication is equifinal and multifinal

A chain of communication errors during the execution of an uncorrected misunderstanding prevented a sentinel event.

Clinicians omitted information, provided inaccurate information, and incorrectly decoded information related to diagnosis, medication, treatment procedures, and discharge; clinicians failed to complete, clarify, and validate the accuracy of information in direct transactional (follow-up) communication.

Care participants commonly assumed but did not verify that they understood each other; clinicians and family members had dissimilar perceptions of a “larger area hospital”; a clinician’s preconceptions about a patient or family members triggered diagnostic bias; clinicians misperceived their colleagues’ communicated messages; clinicians failed to clarify uncertainties to establish a common ground; clinicians incorrectly assumed that others would understand their needs, abbreviations, unclear handwriting, and abbreviated communication; clinicians incorrectly perceived that communication had already “taken place”; care participants failed to recognize each other’s needs and expectations.

Applied examples

Abbreviations: DNR, do not resuscitate; ED, emergency department; ER, emergency room.

Cases

Principle of human communication

Tab. 2.1 (continued): Principles of human communication across the case studies in Part II of this book.

2.3 Principles in sequence and combination | 23

3 Communication topics in healthcare quality and patient safety Annegret F. Hannawa, Ph.D. The cases in Part II of this book cover seven common topics related to healthcare quality and patient safety.

3.1 Topic 1: “Time” The IOM’s Chasm Report (2001) identified timeliness as one of six domains of highquality care. Three topics related to “time” emerged from the cases in Part II of this book. In addition to timeliness, the chronological care context in these cases also entailed issues related to time allotment, timing, and duration of communication, indicating that any use of time communicates messages.

Timeliness Time delay was the most prominent chronological topic across the 39 cases. It was relevant to all care participants’ behaviors (i.e. clinicians, patients, and care companions). For example, clinicians took too much time to send documentation (case 25), added a patient’s medication to an allergy list too late (case 39), waited too long to talk to or see a patient (cases 4 and 11), took too long to communicate lab results to other providers (case 30), reviewed images, charts, and records too late (cases 4 and 10), and took too much time to follow up with test results (case 9). Clinicians, patients, and family members did not inform each other about medications on time (case 5), waited too long to raise issues (case 17), and were too slow to engage in communication with each other (cases 18), both for clarification (case 25) and given the medical urgency of a care episode (case 13).

Time allotment Time allotment reflects the failure by care participants to devote the necessary amount of time to engage in successful communication. It emerged as the second most frequent topic within the chronological context of care. Examples of time allotment problems included clinicians not taking the necessary time to properly review records (case 22), to communicate with other care participants (cases 16 and 20), to attend to patient’s or families’ alerting requests (case 20), and to properly decode treatment orders (case 16). DOI 10.1515/9783110455014-003

3.2 Topic 2: “Patient-centered care” | 25

Timing Timing encompasses care participants’ failure to recognize and frame their behaviors within the clinical context of a given care setting. Timing issues were common in incidents where care participants either communicated at the wrong time or failed to understand their communication in respect to its timing. Examples of timing include clinicians’ lacking recognition of the time of the day at which a mother brought a young patient to the ER (case 20), their failure to decode messages within the context of an impending or recent surgery (cases 23 and 36), their failure to recognize in a conversation that a team member would no longer be at the institution at the time of a planned surgery (case 38), and their inattention to the fact that a patient was still groggy from anesthesia and unable to process information (case 35). Timing also included examples of behavior that was encoded “too early” (in contrast to the “timeliness” notion discussed before). For example, clinicians provided post-op instructions prior to surgery, but not after (case 35) and switched a patient’s medication without receiving pending lab results (case 37).

Duration Duration also reflects an important notion of “time” within the chronological care context. Duration refers to the amount of time that patients wait for a conversation, the length of time patients wait to see a clinician, and the amount of time care participants allow for any given communicative episode. Duration emerged as an issue in only one case. In case 20, clinical staff inaccurately stated the timeframe within which a physician will come to see the patient, which would have been important for the patient’s mother to know in the context of her observation that the patient was about to faint.

3.2 Topic 2: “Patient-centered care” The IOM Chasm Report (2001) also included patient-centeredness as one of its six dimensions of quality care. In theory, care is “patient-centered” if clinical decision-making and treatment are “respectful of and responsive to patients’ preferences, needs, and values” (IOM 2001). In practice, this means that clinicians and patients must engage in communication to establish a shared understanding of what the patient’s needs and values are. Otherwise, clinicians may incorrectly assume that they are being patient-centered in their care for a patient. Another communicative challenge is the delineation between what a patient needs and wants. And then, it is often not clear whether, when, and under what circumstances clinicians need to prioritize what the patient needs (in terms of improved health outcomes) over what the patient values and wants (in terms of consenting to

26 | 3 Communication topics in healthcare quality and patient safety

needed treatment). This challenge emerges from several cases in Part II of this book, evidencing that patients’ needs versus wants often conflict (cases 13, 14, and 17) and that their delineation is not always clear to clinicians or even patients themselves. In light of this conceptual challenge, three important points can be made regarding how to operationalize patient-centered care: 1. 2.

3.

Patient-centered care is not about doing things to a patient, but doing things better with the patient. Competent interpersonal communication, particularly communication that is spontaneously responsive and adaptive toward patients’ explicitly (i.e. verbally) and implicitly (i.e. nonverbally) expressed needs and expectations, is the vehicle through which patient-centered care is attained. A particular communicative skill set that is most relevant for patient-centered care is interpersonal adaptability. This skill enables all care participants to flexibly “converge” with (i.e. approach or embrace) their conversational counterparts in a way that attends to their ad-hoc needs and expectations. This particular communicative skill is not only important for understanding a patient’s needs and wants as a foundation of patient-centered care, but it also facilitates a shared understanding among all involved care participants. In other words, interpersonal adaptability is a skill that also facilitates “other-centered care” (beyond “patientcentered care”) as a process that prioritizes quality and safety.

In summary, patient-centered care does not center solely on the patient. It is accomplished through appropriate and effective interpersonal sense-making. For example, it is perfectly clear for a physician to tell a patient that she will die in a month, but there are more and less appropriate ways of explaining this. Inattention to the appropriateness makes the rest of the care delivery process more complicated and, likely, more error-prone. Such appropriateness is facilitated by interpersonally adaptive communication among all care participants (also among clinicians), not by merely focusing on the perceived wants or needs of the patient, which – as evident across the cases in Part II of this book – too often represent providers’ perceptions rather than a transactionally established common ground.

3.3 Topic 3: “Sound-alikes” The cases in Part II of this book encompass several incidents where uncorrected misinterpretations at the most fundamental level of communication – the unclear use and attribution of a symbol – led to medication misuse (i.e. use of a wrong medication) by both clinicians and patients (e.g. case 2). In the medical literature, this issue is commonly blamed on system errors related to the “sound-alike” naming and “look-alike” packaging of distinct medications (e.g. Aspden et al. 2007; Institute for Safe Medica-

3.4 Topic 4: “Safety culture” |

27

tion Practices 2015). While this is certainly a factor that can contribute to misunderstandings, here the medication misuse itself was a direct result of care participants’ failure to clarify perceived ambiguities and uncertainties regarding a given medication through successful communication. In other words, medication misuse was caused by care participants’ failure to establish a shared understanding about a given prescription, not by the prescription label itself. This again underlines the fundamental notion that communication lies between people, not within people. Inadequate communication of a prescription between care participants can cause misunderstandings and result in medication misuse. Of course, excessive similarity increases the probability that this kind of misunderstanding will occur. However, most often, communication sufficiency errors occur on a transactional dimension where care participants fail to establish a shared understanding because they do not use their communications skills sufficiently to clarify uncertainties and validate the accuracy of a presumed medication and its use.

3.4 Topic 4: “Safety culture” The term safety culture connotes an organizational culture within a healthcare institution that prioritizes structures and processes that optimize the safety of patient care. Key features of a “culture of safety” include acknowledgement of the high-risk nature of the industry and a determination to consistently deliver safe patient care, a blame-free environment in which safety means to report errors, and a commitment to see and explore safety-enhancing solutions. Focal areas of safety culture include transparency and disclosure in both inter-staff and provider-patient interactions, the concept of “just culture” (which balances no-blame with maintaining individual accountability), interdisciplinary training, and issues related to burnout. The cases in Part II of this book demonstrate several challenges related to healthcare institutions’ safety culture. The cases imply that competent communication is a necessary element of a culture of safety. In other words, communication (evident in the process of care) is a prerequisite for patient safety (as an outcome of care). Many of the cases demonstrated a lack of communication that, as a result, imposed a severe threat to patient safety. Interestingly, the time and efforts that were required to respond to a preventable adverse event was often much greater than the time that would have been required to establish sufficient communication to prevent the adverse event. Thus, from a managerial perspective, more sufficient (in quantity of content) and better (in quality) communication at the beginning of a patient’s care episode can have measurable value.

28 | 3 Communication topics in healthcare quality and patient safety

3.5 Topic 5: “Digitization of care” Numerous cases in Part II of this book highlight challenges related to the digitization of healthcare. The cases predominantly reference electronic health records (EHRs). In several instances, patient harm resulted from clinicians delegating important communication to an EHR or medical chart, substituting face-to-face communication with an automated system that merely deposits (rather than communicates) information (cases 4, 9, 12, and 15). Clinicians commonly failed to recognize that a shared understanding cannot be “delivered” by such a system but must be co-constructed between care participants through skillful and effortful communication (case 16). A digitized system could, at best, be used to validate that a message was received, which it did not accomplish in many of the cases (e.g. case 38). However, the co-creation of shared understanding of the message contents remains a crucial interpersonal task (case 9). There are three reasons why EHRs often fail to facilitate or improve safety-promoting communication among care participants: 1. Even when a message contains pure informational contents, more than half of the meaning of such a message is derived from the sender’s nonverbal behavior (Philpott 1983). In other words, the informational content itself comprises less than half of the meaning in a message, compared to the way in which that information is conveyed. EHRs do not store this important layer of nonverbal content, making it difficult to convey information that would be communicated in face-toface interactions. Furthermore, they often lack sufficient resources for accurate message decoding (see case 12). 2. Care providers commonly rely on patient notes in an EHR without questioning their completeness and accuracy. This constitutes a critical safety threat in healthcare. It rests on the assumption that the digitization of communication facilitates a more complete information exchange. In the case scenarios, the unquestioned reliance on EHRs as a solution to an endemic lack of information exchange worsened the problem and introduced new risks, because it distracted from the fact that it is not the lack of information as much as the lack of shared understanding that triggers patient safety events. EHRs merely contain information, but they do not establish a shared understanding. 3. EHRs can hinder rather than aid the establishment of a shared understanding due to both structural challenges (e.g. complex or non-intuitive layouts causing decoding errors) and process elements (e.g. the records not always being as updated as what is known to the clinician). Clinicians tended to assume that their colleagues will “get a hold of” information they deposited in an EHR (cases 23 and 38). In addition, the digitization of care forces clinicians to focus on computer screens and patients’ verbal information, reducing their attention to patients’ nonverbal expressions as a critical source of safety-relevant information

3.6 Topic 6: “Patient/Family engagement” | 29

(see case 34). As a result, EHRs commonly provided added opportunities for information to fall through the cracks in a digital world that attempts to connect, but fails to overlap human minds. The core lesson taken from these examples is the recognition that information does not equal communication. EHRs can work well as tools to facilitate access to patient information. All relevant information regarding a patient’s care episode can be accurately and properly documented in EHRs. The meaning of this information, however, remains within people until a shared understanding of this information is established through transactional communication between all involved care participants. In other words, despite the fact that information lies in records and providers can access this information, the required common ground between providers and patients that is necessary for them to establish a shared understanding of this information is not automatically attained. The written documentation may be in place to attempt such communication, but that communication does not take place until care participants actively engage in communication about the deposited content. In summary, digitization of care does not always help to facilitate information exchange as a way to promote a shared understanding for safer, higher quality care. EHRs (and simple handoff heuristics) may take care of some of the “low-hanging fruit” of communication errors, but they (a) cannot mitigate them all, and (b) inadvertently contribute their own errors (see also IOM 2011; Meeks et al. 2014). Clinicians can deposit data and information in EHRs, but doing so alone does not facilitate the communication process. In the future, EHRs may be best used to perform a “reminder function” that implies that communication should be taking place. But the quality and success of that communication remains in the hands of the providers – it will depend on their ability to establish a shared understanding through effective and appropriate transactional communication.

3.6 Topic 6: “Patient/Family engagement” Another prevalent theme across the cases in Part II of this book is the need and benefit of engaging patients and family members as active partners for ensuring safe and high-quality care. The cases demonstrate how patients can prevent critical incidentsin-the-making by verifying, for example, that care providers received and properly understood their handwritten notes (case 1); by providing rich descriptions of how their body feels and to what extent their experiences are “different than usual” (case 3); and by validating the accuracy of medical practice and clinicians’ medication prescriptions (cases 3 and 19). In other words, patients and family members can contribute crucial value to the transactional communication process with and between clinicians to build a common ground and shared understanding as a foundation for safe and high-quality care.

30 | 3 Communication topics in healthcare quality and patient safety

3.7 Topic 7: “Handoffs” Handoffs pose a continual safety issue that also appeared as a recurrent theme across the 39 cases in Part II of this book. A critical issue regarding the handoffs in these cases regarded clinicians’ exclusive reliance on latent communication among several members of the healthcare team. Such “latent communication” – meaning communication that passes through several individuals – is commonly compromised by a “game of telephone” effect, in which information is lost in transition as it passes through multiple receivers (see case 29). Message redundancy, transactional follow-up, and communication with rather than through other providers can enhance the direct validation of message contents and facilitate communication accuracy (see case 4). Thus, similar to the topics discussed before, “safe handoff” should be considered a direct outcome of competent interpersonal interaction. In other words, message encoding, message decoding, and transactional communication that are adequate in both quantity and quality optimize the likelihood of coordinated and consistent care via safe handoffs.

3.8 Summary The seven topics discussed in this chapter illustrate that effective and appropriate communication is the vehicle through which safe and high-quality patient care takes place. If the vehicle is functional and competently driven, it facilitates positive care outcomes. If parts of the driving vehicle are disconnected, it can severely compromise the safety and quality of care. In a “normal” interpersonal context, misunderstandings can result in interpersonal conflict and are eventually corrected and resolved. In the context of healthcare, however, that same type of misunderstanding can compromise a patient’s well-being and safety. This implies that interpersonal communication skills must be considered a core standard for safe and high-quality care.

4 Interpersonal communication: Challenges, processes, and issues Annegret F. Hannawa, Ph.D. We spend 80%–90% of our waking hours communicating (Klemmer and Snyder 1972; Barker et al. 1981). In fact, we derive almost everything that matters to us from communication with others. For example, we learn the rules and norms of our language and cultures, establish and negotiate relationships, organize collective activities, and find meaning in the things we do entirely through the process of communication. Just because we communicate a lot, however, does not mean that we communicate well. A sizeable percentage of the average population lacks fundamental communication skills and experiences difficulties negotiating the necessities of everyday life through their interactions (Basset et al. 1978; Ilott 2001; National Center for Education Statistics 2003). As a result, we commonly encounter disruptive “dark side” experiences in our communication with others, such as expressions of anger, bullying, hurt feelings, social rejection, sexual harassment, shyness, social stress, threats, and troublesome relationships (see Spitzberg and Cupach 2007 for a review). At the same time, social support and competent communication can have positive health effects that are as substantial as almost anything that modern medicine can offer in terms of extending people’s lifespans (e.g. Holt-Lunstad et al. 2015; Nyquist et al. 2014; Pinquart and Duberstein 2010; Shor et al. 2013). In high-risk industries, poor communication has the potential to threaten and harm life. In the airline industry, 70% of accidents result from pilot errors (Jones 2003). In healthcare, the annual count of patients harmed by human error equates to the number of fatalities that would be incurred by at least three jumbo jets crashing every 2 days (Kohn et al. 2000). Communication is the most frequently reported causative factor in both industries, implying that incompetent communication commonly harms and threatens human life. The ubiquity with which people encounter communicative challenges on a daily basis suggests that there is a pressing need for improved interpersonal skills, especially in an era in which features of modern society pose additional challenges to social interactions – the rapid evolution of information technology as a medium for communicating imposes both opportunities and barriers that require new communicative skill sets (Hwang 2011; Kelly et al. 2010; Ledbetter 2009; Lee 2010; Spitzberg 2006). Unfortunately, communication problems are often viewed as aberrant behavior that needs to be eliminated (Coupland et al. 1991). There is a proliferation of appeals to effectiveness, efficiency, appropriateness, and satisfaction to avoid “destructive incidents” of communication failure. This tendency evolves logically from the common assumption that miscommunication is a risk-bearing phenomenon that needs to be avoided at all cost. However, the literature evidences that miscommunication – like DOI 10.1515/9783110455014-004

32 | 4 Interpersonal communication: Challenges, processes, and issues

human error – is inevitable for two reasons: (1) a “common ground fallacy” and (2) the difficulty of establishing a shared understanding. The next section discusses these two challenges in detail.

4.1 Two core challenges of interpersonal communication Challenge 1: Establishing a common ground Objectively, humans seem very similar to one another. In fact, on average only 0.1% of genes differ between two human beings (Beatty and Pascual-Ferrá 2015). However, even identical twins have different life experiences that influence their communication (Mustajoki 2012). As discussed in Chapter 2, people vary in respect to their personal traits, perceptions, brain functioning, speech patterns, word definitions, and cultural, family, and personal rules. In light of these common interpersonal discrepancies, a full correspondence between the “mental worlds” of two individuals is impossible. This is the inherent flaw behind the common assumption that the ideas we signify by our communication are the same as the ideas that others signify (Mortensen 1997). Two persons’ understandings of the same words and gestures can never be identical, because each of them holds a unique point of view based on their own personal life experiences, cognitive background, as well as their physical, social, and mental states (Verdonik 2010). Communication, then, needs to be seen as an ongoing interactive negotiation between two or more people to minimize their interpersonal discrepancies and optimize the likelihood of establishing a “common ground.” Competent communication is the primary pathway to establish this common ground as a necessary basis for co-creating shared understanding. Particularly in healthcare, unresolved perceptual differences can reinforce biases that have the potential to cause disastrous results. One example of a common ground fallacy in this book includes a clinician’s perceptual bias that the patient’s family was using pharmaceutical language correctly (case 2). The clinician failed to recognize that family members were not familiar with clinical terminology and that their usage of such terms required validation.

Challenge 2: Co-creating a shared understanding A general purpose of communication is the creation of mutual understanding (Weigand 1999) or a “shared meaning” (Duck 1994) that transcends people’s interpersonal difference and builds on a pre-established common ground. Communication is needed because such “meaning” lies between (not within) people and is generally different from the sum of its parts.

4.1 Two core challenges of interpersonal communication

| 33

“Coming to an understanding” is a complex and difficult task for many reasons. Our lives are full of uncertainties, paradoxes, ambiguities, and contradictions that confound our individual efforts to achieve clear and complete communication (Mortensen 1997). Furthermore, what we are meaning to say is often merely a sketch of the full content we want to express. Every utterance a speaker encodes is only an approximation of the concrete thought the speaker has in mind (Clark 2003; Jucker et al. 2003). Finally, and importantly, people commonly communicate in pursuit of interpersonal goals that do not necessarily prioritize clarity and accuracy and thus hinder the establishment of a shared understanding. Miscommunication can be intentional, in service of strategic motivations to camouflage or conceal true intentions, wants, needs, or goals (Mafela 2013). For example, people often engage in deception (e.g. demeanor bias; see Bond et al. 1985), intergroup integration (e.g. signal amplification bias; see Vorauer 2005; Vorauer and Sakamoto 2006), politeness (e.g. use of ambiguous speech), and positive face maintenance (e.g. use of metaphors and figurative speech, see Mustajoki 2012) to appear competent or to achieve their conversational objectives. Therefore, people not only cannot achieve perfect-shared understanding, but this is also not even the main goal or function of many interactions. Like other activities in life, the communication process is also inevitably tainted by human fallibility (Hannawa 2015). Despite dedicated efforts, people make mistakes in respect to communicating clearly, accurately, and sufficiently to contribute to a shared understanding. In light of these facts, it is incorrect to conceptualize communication failures in terms of “breakdowns” that ought to be prevented. Instead, miscommunication (rather than successful communication) needs to be embraced as a normative standard that accompanies all human interactions. As Mortensen (1997) put it, we simply “cannot pretend to be able to understand other people completely – without flaw, error, mistake or miscalculation.” Shared understanding is a necessary, high-quality standard that we can only attain through laborious joint efforts of competent interaction. While human error and miscommunication cannot be completely avoided, their incidence and deleterious effects can be reduced. Competent communication is the pathway through which people can effectively (1) establish a common ground and (2) co-create a shared understanding with each other. In other words, communication competence functions as the mechanism through which interpersonal gaps that cause miscommunication can be reduced and shared common ground can be expanded. Communication competence also constitutes the means through which human errors in communication (e.g. in encoding, decoding, and transactional sense-making) can be minimized. Moreover, when errors do occur, as they will, communication competence is the means by which the deleterious effects of such errors can be minimized. In that sense, peoples’ inability or unwillingness to make well-reasoned sense together constitutes a severe liability (Mortensen 1997) – if we do not invest the necessary labor for attaining a mutual understanding, miscommunication will penetrate and compromise everyday social interactions with the potential of causing harm.

34 | 4 Interpersonal communication: Challenges, processes, and issues

4.2 The processes of interpersonal communication As discussed before, the two core challenges of interpersonal communication encompass the utilization of communication skills to (1) establish a common ground and (2) co-construct a shared understanding. “Mis-”communication is broadly characterized as communication that does not achieve this purpose (Weigand 1999). Miscommunication comprises an incomplete understanding that manifests itself as a mismatch between the speaker’s and recipient’s attributed intentions, feelings, thoughts, and meanings (Coupland et al. 1991). It is often used as an umbrella term to encompass various types of communication failures. The cases in Part II of this book, for example, encompass examples of misunderstanding, nonunderstanding, misinterpretation, misconception, mishearing, and misperception. The processes of communication entail participants’ individual encoding, decoding, and transactional (i.e. mutually negotiated) sense-making activities (Barnlund 2008; Berlo 1960; Shannon and Weaver 1949). As illustrated in the traditional model of human communication (Figure 4.1), all actors involved in a communication episode (1) abstract (i.e. encode) complex thoughts, intentions, meanings, or feelings they have in mind into written, oral, and nonverbal messages; (2) reassemble (i.e. decode) the written, oral, and nonverbal messages they “received” to match the sender’s originally intended thoughts, intentions, meaning, or feelings; and (3) engage in mutual negotiation (i.e. transactional communication) of these expressed thoughts, intentions, meaning, or feelings to co-create a shared understanding.

Encoding

Decoding Shared Meaning

Decoding

Encoding

Fig. 4.1: Traditional model of human communication.

Across the 39 cases in Part II of this book, care participants committed 222 distinct communication errors. Within this total count, 103 were encoding errors, 54 were decoding errors, and 65 were transactional communication errors. Both encoding and decoding errors were most frequently related to the provision and extraction of information, and to participants’ sense-making of that information. The second most frequent theme was related to the chronological context of communication, that is, its timeliness, timing, allocation, and duration. The third most frequent theme regarded communication that encompasses patients and care companions. Tables 4.1 and 4.2

4.2 The processes of interpersonal communication

| 35

Tab. 4.1: Themes related to care participants’ communication encoding errors (N = 103). Themes

Communication encoding errors

Frequency

Information (N = 37)

Insufficient information provision Failure to include contextually relevant information Generic information provision Insufficient information extraction Insufficient instructions for information handoff

23 6 4 2 2

Time (N = 15)

Wrong timing of communication Failure to allocate time for communication Failure to indicate duration for communication Delayed communication

Medication (N = 14)

Ordering wrong medication Failure to continue correct medication

Clarity (N = 9)

Mislabeling Illegible handwriting Vague instructions

2 2 5

Approach (N = 10)

Communicating with the wrong person Wrong approach to communication given the context

6 4

Patient (N = 7)

Failure to integrate the patient Failure to be attentive to the patient Failure to be respectful to the patient

2 3 2

Treatment (N = 5)

Ordering unindicated treatment Failure to prescribe indicated treatment

4 1

Contact (N = 4)

Failure to establish communication

4

Diagnosis (N = 1)

Expressing a wrong diagnosis

1

Speaking up (N = 1)

Failure to speak up

1

3 2 1 9 13 1

show the frequencies and themes related to care participants’ encoding and decoding errors in Part II of this book. Care participants’ transactional communication errors were most frequently related to the interactive verification of the receipt, completeness, and accuracy of information. Similar to the encoding and decoding errors, the second most frequent theme related to the transactional sense-making of information for the purpose of establishing a shared understanding. The remaining errors encompassed care participants’ neglect of the chronological context of their interaction, and their failure to integrate the patient into the care process. Thus, all of the examples of communication errors – in encoding, decoding, and transactional communication – showed a similar pattern of themes. The themes and frequencies of the transactional communication errors in Part II of this book are summarized in Table 4.3.

36 | 4 Interpersonal communication: Challenges, processes, and issues Tab. 4.2: Themes related to care participants’ communication decoding errors (N = 54). Themes

Communication decoding errors

Frequency

Information (N = 21)

Failure to decode full information Failure to access/extract additional information

11 10

Sense-making (N = 13)

Drawing incorrect conclusions Misjudging Misinterpreting Misattributing Misreading

3 2 3 2 3

Time (N = 8)

Failure to decode on time Not taking the time to decode Failing to decode within the timing of the care setting

4 2 2

Care companions (N = 5)

Failure to facilitate the role of care companions

5

Patient (N = 4)

Lack of perspective-taking

4

Bias (N = 2)

Decoding with relational bias Decoding with diagnostic bias

1 1

Difference (N = 1)

Failure to decode in light of cultural differences

1

Tab. 4.3: Themes related to care participants’ transactional communication errors (N = 65). Themes

Transactional communication errors

Frequency

Verification (N = 26)

Failure to verify receipt Failure to verify accuracy of understanding Failure to verify completeness of the EHR Failure to verify the accuracy of a procedure Failure to verify treatment accuracy Failure to verify medication accuracy Failure to verify diagnostic accuracy

7 2 2 1 5 5 4

Sensemaking (N = 22)

Failure to establish a complete understanding Failure to establish a shared understanding of full clinical details Failure to establish a shared understanding of full procedural details Failure to establish a shared understanding of implications Failure to correct misunderstandings Failing to reduce uncertainty/ambiguity Failure to overcome perceptual gaps

4 5 3 2 1 4 3

Time (N = 7)

Failure to communicate cognizant of the timing within the care context Failure to communicate with each other on time

2 5

Constraints (N = 4)

Failure to address contextual constraints

4

Coordination (N = 3)

Failure to coordinate care

3

Patient (N = 3)

Failure to flexibly adapt to the patient Failure to coordinate care within the context of a patient’s wishes

2 1

4.3 Error-prone aspects of human communication

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4.3 Error-prone aspects of human communication The way in which people communicate can be assessed in terms of the quantity and quality of their communication. The incidents of miscommunication in this book reflect care participants’ efforts to achieve comprehensive communication (quantity of communication) and also their efforts to communicate in a way that is clear, accurate, contextualized, and interpersonally adaptive (quality of communication) – both in terms of their encoding, decoding, and transactional sense-making. The following paragraphs summarize and explain the core aspects of care participants’ communication quantity (sufficiency) and quality (clarity, accuracy, contextualization, and interpersonal adaptation) across the 39 cases.

4.3.1 “Quantity” of communication Communication sufficiency Communication sufficiency refers to the extent to which care participants’ communication was comprehensive in terms of the quantity of content that was covered. Regarding the common ground problem, the question is whether there was enough information coverage to establish sufficient common ground. In terms of the challenge of co-creating a shared understanding, sufficiency relates to the extent to which participants covered enough information to arrive at a shared understanding. In concrete terms, communication sufficiency is the extent to which care participants encoded information (i.e. none, partial, or too much), decoded information (i.e. none, partial, or too much), and engaged in transactional communication (i.e. sufficient mutual verification or acknowledgment of message receipt and completeness of the message contents). In other words, communication sufficiency is the extent to which care participants communicate enough information (in quantity) to (1) establish a common ground and (2) co-create a shared understanding of each other’s intent, thoughts, feelings, and meanings. Communication sufficiency errors were the most frequent failures across the 39 cases (74 of 222 total errors). The cases illustrate incidents where information exchange was attempted but care participants never connected (e.g. cases 4 and 9), where understanding was assumed but never attained (cases 15, 21, and 23), where insufficient information was provided while handing off a patient (cases 6, 9, and 22), where information got lost between care providers (cases 2, 23, and 30), and where information passed unnoticed through several communication lines of defense (case 4). In all cases, care providers failed to establish a common ground and, as a result, compromised the safety of the patient. Table 4.4 shows the most common sufficiency-related healthcare themes that emerged from the 39 cases in Part II of this book. The cases illustrate that sufficiency is a prerequisite for communication to yield a shared understanding. Once a common

38 | 4 Interpersonal communication: Challenges, processes, and issues

Tab. 4.4: Safety and quality themes of care participants’ communication sufficiency errors across the 39 cases (N = 74) Communication sufficiency errors

Frequency

Information sharing/coordination Information provision Information seeking Partial information Failure to establish communication Failure to pass on information Failure to prescribe treatment Failure to speak up

26 21 9 10 4 2 1 1

ground is established, sufficient communication has to occur on such ground for care participants to reach a shared understanding of their intended meanings, intentions, thoughts, and feelings. Such sufficiency reaches beyond the individual care episode – it also applies to the communication after an event to exchange perspectives how communication failures that contributed to an adverse event might be transformed into functional learning processes, coping, and future prevention (e.g. case 5).

4.3.2 “Quality” of communication Preventing sufficiency errors alone does not guarantee successful interactions. The extent to which communication succeeds also depends on the quality of all care participants’ interactional contributions. Quality, as mentioned before, entails clarity, accuracy, contextualization, and interpersonal adaptation care participants engage during encoding, decoding, and transactional communication. Communication accuracy Communication accuracy refers to the extent to which care participants encode and decode a message correctly. Accuracy encompasses not only to the quality of the communicated content (i.e. whether the communicated message content was accurate or incorrect), but also to the quality of the encoding (i.e. accurate symbolization), decoding (i.e. the extent to which the message was decoded and decoded accurately), and transactional communication (i.e. the extent to which care participants verified the receipt of the correct message, the accuracy of the message contents, and the accuracy of their shared understanding). The key question is whether care participants’ communication was accurate enough to establish a (1) common ground and (2) shared understanding. The case scenarios in this book exemplify situations where inaccurate communication contributed to close calls (cases 2, 3, 6, 13, 14, 17, 18, 20, 23, 24, 31, and 38),

4.3 Error-prone aspects of human communication

|

39

adverse events (cases 5, 12, 19, 32, 35, 37, and 39), and sentinel events (cases 26, 29, and 36). Accuracy errors were the third most frequent communication errors (55 out of 222 total errors) across the 39 cases. Table 4.5 lists the safety and quality themes to which these accuracy errors were related. Tab. 4.5: Safety and quality themes of care participants’ communication accuracy errors across the 39 cases (N = 55). Communication accuracy errors

Frequency

Medication Treatment Diagnosis Interpretations/understanding Drawing conclusions Reading Attributions Judgments

19 12 6 6 5 3 2 2

Communication clarity While communication accuracy refers to the correctness of communicated message contents (e.g. validity of information), communication clarity refers to the extent to which interpersonal communication avoids strategical or inadvertent vagueness, ambiguity, and unclear language. In other words, accuracy relates to message contents, whereas clarity captures the quality of message delivery. In particular, the question is whether care participants’ communication is clear enough to establish a common ground and shared understanding of each other’s intent, thoughts, feelings, and meanings. The cases in this book illustrate the catalytic effects that one initial unclear message can have on subsequent interactions and, ultimately, patient safety (e.g. case 12). Clarity errors were the least frequent communication errors that emerged from the 39 cases. Only 12 of 222 total errors were clarity errors. These cases exemplify incidents where care participants encoded messages unclearly (cases 11, 12, 19, 22, 25, 31, and 35), decoded messages unorderly (e.g. case 38), and failed to transactionally engage in a joint effort to correct perceived uncertainties or a lack of clarity in their understanding of a message (cases 17, 35, and 39). All of these errors compromised the safety and quality of patient care. Table 4.6 shows the most common clarity-related healthcare themes that emerged from the 39 cases in this book.

40 | 4 Interpersonal communication: Challenges, processes, and issues

Tab. 4.6: Safety and quality themes of care participants’ communication clarity errors across the 39 cases (N = 12). Communication clarity errors

Frequency

Vague instructions Failing to reduce ambiguity/uncertainty Unclear handwriting

5 5 2

Communication contextualization As discussed in Chapter 2, people evaluate each other’s communicative competence based on the extent to which their behavior (i.e. verbal, written, or nonverbal communication) is both effective (i.e. in attaining desired goals) and appropriate (i.e. fit-to-context; see Spitzberg 2001). Any given healthcare communication is embedded within at least one of five contextual layers (i.e. functional, relational, chronological, environmental, and cultural; see Chapter 2) that influence people’s perceptions of the appropriateness of the enacted behaviors during that care episode, which in turn directly influence the effectiveness of the interaction. Communication contextualization then refers to the extent to which interpersonal communication is framed within the contextual layers in which the care episode is embedded. Regarding the common ground challenge, the question is whether the communication is adequately contextualized to establish a common ground between the care participants. In terms of the challenge of co-creating a shared understanding, the question is whether care participants contextualized their communication well enough to arrive at a shared understanding. Communication contextualization applies to encoding (i.e. none, not enough, or too much contextualization), decoding (i.e. none, not enough, or too much contextualization), and also to the transactional process of interpersonal interaction (i.e. establishing communication that is jointly framed within or removed of any applicable contextual layers for the purpose of co-creating a shared understanding). Communication contextualization errors were the second most frequent issues across the cases in this book (64 of 222 total errors). For example, the cases illustrated incidents where care participants communicated with the wrong target (functional context; e.g. cases 9, 10, 14, and 38), where clinicians or staff did not allocate the needed time, within the care episode’s chronological constraints, to properly communicate with each other or with the patient (chronological context; e.g. cases 1 and 4), where the timing or timeliness of a clinician’s communication compromised the safety of a patient (chronological context; e.g. cases 4, 9, 12, 13, and 34), where care outcomes were compromised due to relational (relational context; e.g. case 27) or diagnostic biases (functional context; e.g. case 7), where clinical staff’s failure to contextualize a message caused a patient’s death (functional context; e.g. case 10), and where hierarchical relational compositions (e.g. status or gender differences) among care partici-

4.3 Error-prone aspects of human communication

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Tab. 4.7: Safety and quality themes of care participants’ communication contextualization errors across the 39 cases (N = 64). Communication contextualization errors

Frequency

Delayed communication Contextually relevant information Bad timing Wrong target Facilitating care companions Allocating time Care approach given the context Performing within the function of care Cultural discrepancies Too early Perceptual bias Duration of time Care within context of patient’s preferences

18 10 7 6 5 4 3 3 2 2 2 1 1

pants either facilitated or constrained communication and, as a result, influenced the patients’ care outcomes (relational context; e.g. cases 20 and 21). A complete list of contextualization problems was provided in Chapter 2 (Table 2.1). The 39 cases in Part II of this book demonstrate how the failure to contextualize communication in any care setting compromises the likelihood of participants (1) co-establishing a common ground and (2) co-creating a shared understanding. The cases furthermore illustrate how context can both facilitate and constrain a care episode. For example, in case 26, a patient interpreted the relational context of her care episode (i.e. the nonverbally implied status and gender differences between the providers and the patient) as a constraint that prevented her from speaking up to avert wrong-site surgery. Similarly, in case 24, the relational context of a hierarchical communication setting, the functional context of two x-rays taken during the same afternoon, the chronological context of the timeliness of care, and the environmental context of a resident’s busy schedule due to a parallel emergency were barriers to care participants arriving at a shared understanding. These examples show that it is critically important for providers to become aware of the contextual features in any given care episode. Providers need to learn how to utilize their communication skills to optimize the safety and quality of care by prioritizing communication that is “fit-to-context.” Table 4.7 shows the most common healthcare themes that emerged from the contextualization errors across the 39 cases. Interpersonal adaptation Interpersonal adaptation refers to the extent to which a care participant spontaneously adapts to the needs and expectancies that are expressed ad hoc (verbally or

42 | 4 Interpersonal communication: Challenges, processes, and issues

nonverbally) by another care participant during an interaction. This communicative skill closely resembles the clinical concept of patient-centered care, but stretches that concept to a skill set that also applies to inter-provider communication. This skill set also differentiates itself from the notion of patient-centered care because it focuses on the space between people as the center of an interactive meaning-making process, rather than on a patient’s desires and expectations (see “patient-centered care discussion” in Chapter 3). Interpersonal communication is interpersonally adaptive if care participants (e.g. clinicians, patients, and care companions), in any given encounter, recognize and spontaneously accommodate each other’s explicitly (verbally) or implicitly (nonverbally) expressed needs or expectations. Such a need or expectation can be evident in an emotional expression (e.g. tears expressing sadness, which could be adapted to either verbally by discussing support or nonverbally by handing a tissue), a cognitive discrepancy such as an informational void (e.g. an implicit expression of uncertainty or an explicit request to clarify information), or in the delivery style of a message (e.g. an implicit expression of misunderstanding, an explicit request to slow down the rate of speaking, or to repeat message contents for clarification). With respect to the common ground challenge, the question is whether the communication was interpersonally adaptive enough to facilitate the establishment of a common ground between the care participants. In terms of the challenge of co-creating a shared understanding, the question is whether the care participants adapted their communication to each other enough to attain a shared understanding. Interpersonal adaptation applies to encoding and decoding (i.e. none, not enough, or overdone adaptation to the other’s verbally or nonverbally expressed predispositions and ad hoc needs such as literacy, cognitive processing speed, emotionality, etc.), and also to the transactional process of interpersonal communication (i.e. establishing a shared understanding via interpersonally adaptive sense-making of message contents and their connotations/ implications). For example, in case 33, the challenge was to ensure that a patient fully understood discharge instructions, and knew how to apply them in his daily life. Interpersonal adaptation errors were the fourth most frequent issue across the 39 cases in the book (17 of 222 total errors). The cases illustrate incidents where clinicians failed to (1) recognize that the patient is blind, (2) personalize generic discharge instructions to a patient’s needs, and (3) decode and respond to other care participants’ cognitive, emotional, informational, and professional needs. These incidents demonstrate the crucial importance of adaptive communication to (1) co-establish a common ground and (2) co-create a shared understanding. The measure of quality here is the degree to which communication takes place with other care participants in a way that is flexibly adaptive and focused on the concrete purpose of generating a shared understanding. Particularly in communication with patients, interpersonal adaptation enables care providers to co-interpret mean-

4.4 Summary

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ing “together with” the patient (see case 33 and discussion in Chapter 3), to “step into the decoding cycle” with the patient and jointly complete the sense-making process. Table 4.8 shows the most common themes that emerged from the interpersonal adaptation errors across the cases in Part II of this book. Tab. 4.8: Safety and quality themes of care participants’ interpersonal adaptation errors across the 39 cases (N = 17). Interpersonal adaptation errors

Frequency

Failure to integrate the patient’s perspective Generic information provision Lack of attentiveness Lack of respect Lack of ad hoc behavioral adaptation/flexibility Common ground fallacy

4 4 3 2 2 2

4.4 Summary The communication challenges and issues summarized in this chapter indicate that each care participant’s communicative contribution is highly relevant to establishing positive health outcomes as a direct consequence of the quality (i.e. appropriateness and effectiveness) of their interactions. It is important to note, however, that shared understanding does not imply agreement. It merely establishes a foundation on which meaningful communication can occur. In healthcare, care participants have limited time to invest the effort required for establishing successful interactions. This task is facilitated if all care participants learn to see themselves and others as fallible human beings and actively invest themselves into establishing a common ground with colleagues and patients. In other words, human error and miscommunication need to be rescued from their exile as “deviant” behaviors, and understood as normal and expected. Doing so allows for exploration of their potential to contribute to safer, higher quality care. Such a transformation will yield the opportunity for a genuine form of competent sense-making practice, where error management and interpersonal skills contribute to a greater and more accurate shared understanding. When this fundamental communication objective is established, it becomes easier to express oneself clearly and to interpret others accurately. From an organizational point of view, communicating competently may take a little more time than communicating incompetently in the moment. But, in the long run, communicating incompetently will cost the individual, the patient, and the institution

44 | 4 Interpersonal communication: Challenges, processes, and issues

far more than if that little extra time had been taken at the front end to communicate well. In other words, competent communication may take marginally more time than not communicating competently, but what it saves in inefficiency and grief later is well worth the investment.

5 The Hannawa SACCIA Typology of Communication Errors in Healthcare Annegret F. Hannawa, Ph.D. Across the cases in Part II of this book, care participants commonly experienced problems with respect to the quantity and quality of their communication. Particular error-prone aspects related to the sufficiency, accuracy, clarity, contextualization, and interpersonal adaptation of their communication, which are defined as follows: 1.

2.

3.

4.

5.

Sufficiency The extent to which an adequate amount of information was verbally and nonverbally provided, accessed, extracted, and/or transactionally exchanged. Accuracy The extent to which message contents and behaviors were used, identified, interpreted, and judged correctly, and/or transactionally validated as such. Clarity The extent to which verbal and nonverbal communication was concrete and precise, avoiding strategic or inadvertent vagueness, ambiguity, or sloppiness. Contextualization The extent to which communication was verbally and nonverbally adjusted to the functional, relational, chronological, environmental, and cultural context that may constrain or facilitate an interaction. Interpersonal adaptation The extent to which care participants were spontaneously reactive to each other’s explicitly or implicitly expressed needs and expectations during an interaction.

Chapter 2 introduced the conceptual dimensions of communication competence, explaining that competent communication involves interpersonal processes that are perceived as both appropriate and effective by all involved participants (Spitzberg 2001). Combining this model with the abovementioned error-prone aspects of healthcare interactions yields the following conceptualization of safe and high-quality communication: Safe and high-quality communication consists of all verbal and nonverbal behaviors that, through adequate quantity (i.e. sufficiency) and quality (i.e. clarity, accuracy, contextualization, and interpersonal adaptation), optimize the likelihood of achieving the most appropriate and effective care outcomes.

DOI 10.1515/9783110455014-005

46 | 5 The Hannawa SACCIA Typology of Communication Errors in Healthcare

Chapter 4 highlighted that human interactions entail both individual and joint efforts during the encoding, decoding, and transactional sense-making of verbal and nonverbal message contents. Combining these communication processes with the five previously mentioned aspects of error-prone healthcare communication implies that care participants commit encoding, decoding, and transactional communication errors of sufficiency, accuracy, clarity, contextualization, and interpersonal adaptation. The fields of healthcare quality and patient safety have been accustomed to using different sets of measures to categorize error types. For example, Brook et al. (1990) published one of the first articles to evaluate quality of care in terms of underuse, overuse, and misuse. The patient safety discipline commonly dichotomizes root causes of critical incidents into errors of omission and commission. Given the objective of this book to develop a common ground for marrying the nomenclature of two disciplines, the existing concepts from healthcare quality and patient safety will be incorporated to describe the abovementioned communication processes. The communication errors in this book consist of errors of omission (i.e. complete failure to engage in communication), underuse (i.e. too little use of communication), misuse (i.e. wrong or inadequate use of communication), overuse (i.e. too much use of communication), or commission (i.e. unindicated use of communication). In other words, care participants either omitted, underused, misused, overused, or committed nonindicated communication during the processes of encoding, decoding, and transactional sense-making. Such errors were related to their communication sufficiency, accuracy, clarity, contextualization, and interpersonal adaptation in the following ways. Care participants encoded, decoded, and/or engaged in transactional communication: 1. not at all (errors of omission) – such as failing to convey relevant information (sufficiency), failing to validate the accuracy of communicated contents (accuracy), failing to clarify ambiguous message contents (clarity), failing to adjust communication to the context of a situation (contextualization), and failing to adapt to another person’s expectancies or needs (interpersonal adaptation). 2. not enough (errors of underuse) – such as including too few contents (sufficiency), not validating the correctness of communicated information enough (accuracy), being too vague in encoding, decoding, or transactional sense-making of a message (clarity), investing too little effort into framing an interaction within its care context (contextualization), and not adapting enough to accommodate another care participant’s expectations or needs (interpersonal adaptation). 3. too much (errors of overuse) – such as conveying too much information (sufficiency), paying excessive attention to already validated correctly communicated message contents (accuracy), being overly precise in verbal or written communication to an extent that it becomes a distraction (clarity), overusing context to an extent where it biases an interaction (e.g. hyperfocus on one aspect of the illness

5.1 Communication errors across the cases

4.

5.

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and judging a patient to be hypochondriacal based on relational history; contextualization), and being overly adaptive and over-compensating for perceived needs and expectations of another person (e.g. talking too loudly to an elderly or reacting to another’s expressed emotion so that it is demeaning; interpersonal adaptation). improperly (errors of misuse) – such as including irrelevant contents in a message (sufficiency), misinterpreting, misreading, or misjudging a behavior or message (accuracy), sending a contradictory message or prescription with illegible handwriting or ambiguous meaning (clarity), addressing an inappropriate person in a conversation or communicating at an inadequate time (contextualization), and inadvertently addressing another person in an offensive or disrespectful way (interpersonal adaptation). unindicated (errors of commission) – such as communicating information that should not have been conveyed (sufficiency), providing or confirming incorrect information or ordering unindicated medication or treatment (accuracy), encoding a purposefully unclear, ambiguous, or sarcastic message (clarity), abusing contextual constraints or facilitators for a strategic purpose (e.g. being disrespectful to someone to retaliate for a perceived offense; contextualization), and engaging in communication that is purposefully not meant to adapt to another person’s needs and expectations (interpersonal adaptation).

A conceptual integration of the previously mentioned error categories yields the Hannawa SACCIA Typology of Communication Errors in Healthcare (SACCIA Sufficiency, Accuracy, Clarity, Contextualization, Interpersonal Adaptation). Grounded in a communication science perspective, this typology introduces a first evidence-based categorization scheme that aids a comprehensive understanding of human communication errors in healthcare, informing five critical aspects of interpersonal sensemaking in safety- and quality-compromised care situations (Table 5.1).

5.1 Communication errors across the cases Among the 222 communication errors in Part II of this book, the most common errors were errors of underuse (106), followed by errors of omission (57), errors of misuse (42), errors of commission (20), and errors of overuse (4). Errors of underuse mainly encompassed communication contextualization (47) and sufficiency errors (41), followed by errors of interpersonal adaptation (14) and accuracy (4). This suggests that the main problem across the cases was that care participants communicated too little within the context of the care episode and also simply did not communicate enough information. Errors of omission mainly encompassed communication sufficiency errors (35), followed by errors of accuracy (14), contextualization (4), clarity (3), and inter-

48 | 5 The Hannawa SACCIA Typology of Communication Errors in Healthcare

Tab. 5.1: The Hannawa SACCIA Typology of Communication Errors in Healthcare. S

Sufficiency Definition: The extent to which communication is sufficient in terms of the amount of information that is verbally and nonverbally provided, accessed, extracted, or exchanged.

Encoding error of sufficiency ↑ ↑ ↑ Decoding error of sufficiency ↑ ↑ ↑ ↑ ↑ ↑ Transactional communication error of sufficiency ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↓ ↓ ◻ ◻ ◻ Error of omission ◻ ◻ ◻ Error of underuse ◻ ◻ ◻ Error of overuse ◻ ◻ ◻ Error of misuse ◻ ◻ ◻ Error of commission

A

Accuracy Definition: The extent to which behaviors and message contents are used, identified, interpreted, and judged correctly, and transactionally validated as such.

Encoding error of accuracy ↑ ↑ ↑ Decoding error of accuracy ↑ ↑ ↑ ↑ ↑ Transactional communication error of accuracy ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↓ ↓ ◻ ◻ ◻ Error of omission ◻ ◻ ◻ Error of underuse ◻ ◻ ◻ Error of overuse ◻ ◻ ◻ Error of misuse ◻ ◻ ◻ Error of commission

C

Clarity Definition: The extent to which verbal and nonverbal messages and cues are concrete and precise, avoiding strategical or inadvertent vagueness, ambiguity, or sloppiness.

Encoding error of clarity ↑ ↑ ↑ Decoding error of clarity ↑ ↑ ↑ ↑ ↑ ↑ Transactional communication error of clarity ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↓ ↓ ◻ ◻ ◻ Error of omission ◻ ◻ ◻ Error of underuse ◻ ◻ ◻ Error of overuse ◻ ◻ ◻ Error of misuse ◻ ◻ ◻ Error of commission

C

Contextualization Definition: The extent to which communication is verbally and nonverbally adjusted to the functional, relational, chronological, environmental, and cultural context that constrains or facilitates an interaction.

Encoding error of contextualization ↑ ↑ ↑ Decoding error of contextualization ↑ ↑ ↑ ↑ ↑ Transactional communication error ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ of contextualization ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↓ ↓ ◻ ◻ ◻ Error of omission ◻ ◻ ◻ Error of underuse ◻ ◻ ◻ Error of overuse ◻ ◻ ◻ Error of misuse ◻ ◻ ◻ Error of commission

IA

Interpersonal adaptation Definition: The extent to which interactants are spontaneously reactive to each other’s explicitly and/or implicitly expressed needs and expectations.

Encoding error of interpersonal adaptation ↑ ↑ ↑ Decoding error of interpersonal adaptation ↑ ↑ ↑ ↑ ↑ Transactional communication error ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ of interpersonal adaptation ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↑ ↓ ↓ ↓ ◻ ◻ ◻ Error of omission ◻ ◻ ◻ Error of underuse ◻ ◻ ◻ Error of overuse ◻ ◻ ◻ Error of misuse ◻ ◻ ◻ Error of commission

Abbreviations: SACCIA, Sufficiency, Accuracy, Clarity, Contextualization, Interpersonal Adaptation.

5.1 Communication errors across the cases |

49

personal adaptation (1). Again, this pattern suggests that care participants did not communicate enough, both in quantity and quality, to gain a (a) common ground and (b) shared understanding as a prerequisite for safe and high-quality care. A different pattern emerged for errors of misuse and errors of commission. In both of these categories, care participants predominantly committed communication accuracy errors. Finally, the four errors of overuse were exclusively communication contextualization errors – care participants’ overuse of context that constrained (mostly in form of perceptual biases) their potential to establish a shared understanding. Tables 5.2– 5.6 summarize the frequencies of the different error types in Part II of this book. Tab. 5.2: Frequencies of communication errors of underuse (N = 103). Communication errors of underuse

Frequency

Contextualization Sufficiency Interpersonal adaptation Accuracy

46 39 14 4

Tab. 5.3: Frequencies of communication errors of omission (N = 57). Communication errors of omission

Frequency

Sufficiency Accuracy Contextualization Clarity Interpersonal adaptation

35 14 4 3 1

Tab. 5.4: Frequencies of communication errors of misuse (N = 40). Communication errors of misuse

Frequency

Accuracy Contextualization Clarity Interpersonal adaptation

19 10 9 2

Tab. 5.5: Frequencies of communication errors of commission (N = 18). Communication errors of commission

Frequency

Accuracy

18

Tab. 5.6: Frequencies of communication errors of overuse (N = 4). Communication errors of overuse

Frequency

Contextualization

4

50 | 5 The Hannawa SACCIA Typology of Communication Errors in Healthcare

5.2 Errors within principles of human communication The Hannawa SACCIA Typology of Communication Errors in Healthcare emerged from an analysis of the 39 cases in Part II of this book using a communication science perspective. In the discussion following each of the cases, these communication errors will be summarized and discussed based on the corresponding principles of human communication introduced in Chapter 2. Table 5.7 shows the Hannawa SACCIA communication errors as they relate to the respective principles of human communication.

5.3 Summary This chapter introduced the Hannawa SACCIA Typology as an evidence-based categorization scheme of human communication errors in healthcare that informs five critical aspects of interpersonal sense-making in safety-compromised care episodes. Throughout this book, clear lines have been drawn between categories of themes, types of events, phases of care, and the typology of errors introduced here. It is important to note, however, that actual errors in practice are not necessarily so easily “boxed.” Errors may emerge from accumulations of slight and subtle miscues, involving multiple parties and crossing multiple stages of care. The typology of communication errors introduced in this chapter represents a significant improvement over existing conceptualizations. At the same time, great pedagogical value can be gained from examining cases to identify the ways in which additional factors can either add to, mitigate, or prevent the errors that are being categorized. In other words, much of the value provided in this chapter will arise from discussions that consider the interplay of factors, rather than merely attempting to fit a given case into a particular box.

Principle 3: Communication is functional

Clinicians ordered inaccurately to prepare patients for inpatient admission, treatment, or surgery (who should have never been admitted, treated, or operated).

Accuracy

A clinician intentionally communicated vaguely to avoid being perceived as inappropriate by a female colleague.

Clinicians failed to adapt their communication to the needs of new colleagues (who joined from an institution with different communication protocols) and patients (providing generic instead of personalized medication and discharge instructions).

Interpersonal adaptation

Clarity

Clinicians did not access or properly decode safety-relevant information on consent forms, in medical charts, or in EHRs (e.g. infection control alerts and pending lab test results). Clinicians communicated and coordinated safety-relevant information insufficiently with colleagues (e.g. documentation and diagnostic information during a patient’s transfer to another institution; administered or discontinued medication; identification of multiple x-ray images; and comprehensive information during handoff). Clinicians communicated with patients and family members insufficiently to establish a shared understanding of a patients’ health condition, home medications, treatment preferences (e.g. advanced directives), procedures (e.g. operative plan), and discharge instructions.

Sufficiency

Clinician wrote an ambiguous “d” on a prescription order to indicate “day” versus “dosage”.

Clarity

Principle 2: Communication is a non-summative process

Family members recalled the name of a patient’s home medications inaccurately and mislabeled the medication as a sound-alike drug.

Accuracy

Principle 1: Communication varies between thought, symbol, and referent

Select examples from the cases

Communication errors

Principle of human communication

Tab. 5.7: Hannawa SACCIA communication errors within principles of human communication.

5.3 Summary |

51

Contextualization Clinicians processed a family’s home medication list without validating the accuracy of the mentioned drugs, disregarding the context of the family members’ lack of familiarity with pharmaceutical labels. Clinicians ordered medications that were unsafe in the context of the patient’s medical condition (e.g. pregnancy and pending lab results). Clinicians did not take the needed time or waited too long to send documentation, raise issues, follow up with each other, check a patient’s records, and to see, talk to, or treat a patient (in the context of busy shifts or patients’ pressing health conditions). Family members waited too long to convey treatment-relevant information (e.g. medications taken at home and indications of depression). Clinicians judged patients’ conditions with a relational and diagnostic bias (in the context of their previous knowledge of the patient and/or the patient’s preexisting medical conditions as a constraining rather than facilitating factor). Clinicians passed on lab results or communicated information to the wrong target (e.g. the wrong colleague for the purpose of the communication). Clinicians communicated with patients at an inappropriate time (when patients were not able to process information).

Principle 6: Communication is contextual

Clinicians failed to adapt to a young patient’s need to be treated quickly because his great discomfort would lead him to faint. Clinicians inadequately adapted their communication with a patient’s mother to embrace her needs and expectancies regarding the care of her child. Clinicians did not adapt their communication sufficiently with patients’ ad-hoc needs and expectancies (e.g. a patient being blind and living alone; referring to the patient as a “subject”; and not greeting a patient properly when entering the room), intimidating patients from speaking up about an error.

Interpersonal adaptation

Clinicians judged a patient’s condition incorrectly due to insufficient attention to the patient’s nonverbal displays. A nurse incorrectly interpreted a resident being on the phone as an indication that the resident was informing the other care providers about a patient’s acute condition. A patient inaccurately interpreted the fact that he received no dinner as an indication that “not eating dinner” was part of his treatment regimen. A patient did not follow up with his providers to validate that he was not supposed to be getting any medication overnight.

Accuracy

Principle 5: Communication entails factual and relational information

Clinicians verbalized incomplete information; did not follow up with one another to complete missing information in patients’ records; attributed meaning to nonverbal communication they perceived as evident in a missing DNR form; merely relied on verbal communication alone to determine a patient’s condition; and failed to decode from a patient’s behavior that the patient was blind.

Sufficiency

Principle 4: Communication is more than words

Select examples from the cases

Communication errors

Principle of human communication

Tab. 5.7 (continued): Hannawa SACCIA communication errors within principles of human communication.

52 | 5 The Hannawa SACCIA Typology of Communication Errors in Healthcare

Clinicians inaccurately decoded patients’ pain experiences as nonserious, incorrectly assumed that family members’ accounts of patients’ unusual behaviors were incorrect, and incorrectly interpreted the intended meaning of a colleagues’ or patients’ communication (e.g. desired DNR status, handwritten orders, and indication of someone else being at the bedside). Clinicians submitted prescription orders with illegible handwriting or ambiguous notations. Clinicians failed to communicate with one another to clarify uncertainties or ambiguities regarding an unclear message or intended procedure. Clinicians communicated vague instructions to patients (e.g. a handwritten “do as instructed” note on a generic discharge handout).

Accuracy

Clarity

Interpersonal adaptation

Clinicians insufficiently accommodated family members’ needs and expectations. They often assumed to know, but failed to verify patients’ and family members’ care preferences. Clinicians provided generic handouts (e.g. medical-surgical discharge instructions) instead of engaging in communication that responded to patients’ personal needs and expectations.

Contextualization Clinicians failed to frame written transfer communication within the context of a patient’s health condition (urgency) or treatment preferences (patients’ wishes for intubation and life-sustaining care). Clinicians did not frame postoperative care orders within the context of their colleague being new to the institution and thus being unfamiliar with communication protocols.

Clinicians, patients, and family members established insufficient common ground with regard to care preferences, treatment options, and implications. Clinicians paid insufficient attention to patients’ implicit and explicit expressions of atypical pains. Clinicians invested insufficient time to read medical records and pathology reports. Clinicians commonly assumed but failed to verify that others were aware of important information (e.g. an infection control alert).

Sufficiency

Principle 7: Preconceptions and perceptions vary among communicators

Select examples from the cases

Communication errors

Principle of human communication

Tab. 5.7 (continued): Hannawa SACCIA communication errors within principles of human communication.

5.3 Summary | 53

Clinicians committed a complicated chain of communication errors throughout a care episode that paradoxically nullified misunderstandings and prevented a sentinel event.

Clinicians were ineffective in their communication with one another to clarify their perceived ambiguity of contradictory messages (e.g. DNR/no-DNR code status and indicated need of a VTE prophylaxis).

Clarity

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Clinicians failed to engage in adequate communication with each other and with patients to validate the accuracy of suspected diagnoses, medication, labels, prescription dosages, advanced directives, treatment plans, and planned surgical procedures.

Accuracy

Principle 9: Communication is equifinal and multifinal

Clinicians failed to mention details about a patients’ medical history, decoded ultrasound images insufficiently, neglected to add DNR codes to patients’ records, and failed to follow up with one another to verify receipt and understanding of important messages and respective implications. Clinicians relied on EHRs but failed to verify with their colleagues the completeness of such records. Clinicians engaged in insufficient communication with colleagues and patients to establish a shared understanding of planned procedures and discharge instructions. Clinicians failed to gather enough information to make important care decisions (e.g. patient’s desire for intubation and life-sustaining care). Clinicians often failed to speak with one another directly.

Sufficiency

Principle 8: Redundancy in content and directness in channel enhance accuracy

Select examples from the cases

Communication errors

Principle of human communication

Tab. 5.7 (continued): Hannawa SACCIA communication errors within principles of human communication.

54 | 5 The Hannawa SACCIA Typology of Communication Errors in Healthcare

6 Lessons from communication science Annegret F. Hannawa, Ph.D. There are a number of lessons that a communication science perspective can contribute to enhancing patient safety and the quality of care. These relate to being communicative, initiating communication, achieving a shared understanding, being accurate, being digital, being contextual, being patient-centered, and being efficient.

6.1 On the challenge of being communicative 1. 2.

All behavior has the potential to communicate a message. All communication has the potential to convey relationship-defining information.

6.2 On the challenge of initiating communication 3. 4. 5.

Never assume that communication has taken place. Never assume that communication, even if it has taken place, has resulted in shared understanding. Never assume that information has been “sent,” received, and processed by other people.

6.3 On the challenge of achieving a shared understanding 6. Communication lies between people, not within people. 7. Communication is a joint meaning-making process. 8. Communication does not equal information. It is the vehicle to establishing a shared understanding of information. 9. Always assume that communication starts at a point of “no common ground.” 10. Always assume that a shared understanding has to be co-established through a sequence of interactions. 11. Enough communication is the fundamental prerequisite for attaining a shared understanding. 12. Safe communication does not end with the sending or depositing of information. It is a dynamic process that must be carried through to the end, where a shared understanding has been accomplished among all care participants. 13. Redundancy in content generally facilitates a shared understanding because it advances an overlap of perspectives. 14. Redundancy in content can work adversely; if it is overused, then it may be perceived as patronizing and constrain the potential to achieve shared understanding. DOI 10.1515/9783110455014-006

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15. Direct communication is generally safer in terms of facilitating a shared understanding, because it provides more, and more valid, data to decode. 16. Direct follow-up to verify the completeness and accuracy of a perceived message is generally the safer way to establish a shared understanding – even if information has been exchanged, it does not mean that the information was understood as intended, and that this understanding was shared by all participants.

6.4 On the challenge of being accurate 17. Transactional communication is a process of validation. 18. Redundancy in content can reduce uncertainty and correct inaccuracy. 19. An initial communication inaccuracy can only be corrected through subsequent communication. 20. Both the quantity and quality of informational content are compromised as a message passes through multiple receivers. 21. Communication among fewer individuals allows for a direct validation of message contents and thereby facilitates accuracy. 22. Communication among multiple individuals can provide multiple validation checkpoints that facilitate accuracy. 23. Communication among too many individuals can diminish the value of redundancy.

6.5 On the challenge of being digital 24. Shared understanding cannot be “delivered” by a system but must be co-constructed between care participants through skillful and effortful interpersonal communication. 25. Digital technologies can help to ensure that a message has been received, but the co-creation of shared understanding remains between people.

6.6 On the challenge of being contextual 26. Relational structures (e.g. hierarchical differences due to status or gender) among care participants can either facilitate or constrain communication and directly influence patients’ care outcomes. 27. Failing to frame any given care interaction within its functional, relational, chronological, environmental, and/or cultural context can directly compromise the safety and quality of care. 28. Contextual barriers to a shared understanding can only be overcome through contextualized communication.

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6.7 On the challenge of being patient-centered 29. Interpersonally adaptive communication is the primary vehicle for attaining patient-centered care.

6.8 On the challenge of being efficient 30. Successful communication is cost effective. It takes more time upfront, but saves both time and cost in the end. Part II of this book covers real clinical cases to illustrate how communication processes can compromise and facilitate the safety of patient care. Each case chapter contains a “diagnostic” section that (1) identifies (e.g. ™, š, ›), (2) labels (e.g. “communication encoding error of sufficiency”), and (3) analyzes the Hannawa SACCIA communication errors that contributed to the respective close call or adverse event. Brief subsequent discussion sections position the communication errors within applicable principles of human communication. Each case chapter in Part II of this book also contains a “communication lessons” activity. A number-coded box entitled “Communication Lessons for Safer, Higher Quality Care” (see example below) is provided after each case discussion and encourages readers to revisit the “Lessons from Communication Science” that were introduced in this chapter. Great pedagogical value can be gained from cross-referencing the applicable communication lessons to each case chapter as illustrated below:

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| Part II: Case studies across six stages of care

Stage 1: Medical history taking Medical history taking is the process of obtaining information about a patient by asking specific questions, either to the patient or to other people who know the patient and can give useful information. The primary aim is to provide information to help formulate a diagnosis and recommend a treatment plan. Almost all medical encounters involve medical history taking, which is often followed by a physical examination of the patient. The medical history varies in degree of length, depth, and focus, based on the goals for the encounter. A complete history would include the major health problem or concern, details about its time course and correlates, review of different organ systems, past medical history, family, and social situation, including health-related behaviors and medications used.

DOI 10.1515/9783110455014-007

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Case 1: Penicillin allergy Provider-patient interaction Medication misuse, Adverse event Clinical context: Acute inpatient admission for general surgery (appendicitis) Communication context: Interaction between an anesthesiologist and a patient Incident: Communication error leading to clinician’s medication misuse Patient safety outcome: Adverse event Case written by Annegret F. Hannawa, Ph.D., Wolfram Heipertz, M.D., and Wolfgang Krüger, M.D.

A 40-year-old male is experiencing acute pains in his right lower abdomen and is running a fever. His primary care physician identifies a rebound tenderness at the right lower quadrant of his abdomen. The physician diagnoses an acute appendicitis and immediately refers the patient to the hospital for urgent surgery. The patient is scheduled to be operated on the same day. In the hospital, he first completes an informed consent form, in which he declares that he is allergic to penicillin. He returns the completed consent form to the anesthesiologist. The anesthesiologist does not ™ confirm any potential allergies by properly š reviewing the consent form or › explicitly asking the patient about possible allergies. After the anesthesia is induced and before the surgery begins, the anesthesiologist gives the patient the usual antibiotic-prophylaxis (Ampizillin plus Sulbaktam). Within two hours after the surgery, the patient develops a severe skin rash (redness and itchiness) all over his body. He was treated with medication for a H1–H2 blockade (blockade for histamine receptors 1 and 2) plus oral steroids. The patient did not suffer any circulation side effects or any other impairments as a result of the allergic reaction. However, the skin rash reduced his post-operative well-being for two days. On the third day, the rash disappeared and the patient was discharged from the hospital as planned.

Communication Principles 1. Communication is a non-summative process In this case scenario, lack of communication sufficiency led to an adverse event. First, the anesthesiologist committed a š communication decoding error of sufficiency (error of omission) by not accessing and decoding the patient’s written in-

Case 1: Penicillin allergy

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formation on the consent form. This incident demonstrates an example of attempted communication in which information was encoded intentionally by the sender (patient) but not decoded by the receiver (anesthesiologist). Second, the anesthesiologist committed a › communication encoding error of sufficiency (error of omission) by not directly asking the patient about potential allergies. Third, both the anesthesiologist and the patient committed a ™ transactional communication error of sufficiency (error of omission) by not verifying both the receipt and understanding of the information the patient had handwritten on the consent form. As a result of these three sufficiency errors, communication was attempted but actually never took place. The necessary starting point for preventing this adverse event would have been the recognition that interpersonal communication is a transactional process that requires sufficiency as a foundation for a successful co-creation of shared understanding. 2. Communication is contextual Interpersonal communication is nested within several contextual layers. One of these layers is the chronological context within which an interaction takes place. In this case, the emergent nature of the encounter shortened the available timeframe for safe communication. In other words, the context of the patient’s condition in this particular clinical scenario was a barrier to communication with the patient. Safe communication could have occurred if the anesthesiologist had allocated the time, within these chronological constraints, to properly process the consent form and/or discuss its contents with the patient.

Discussion This case demonstrates that communication is an interactive, collaborative meaningmaking process that requires all actors to participate in co-creating a shared understanding. Furthermore, this case illustrates how communication is often constrained by contextual barriers. In this particular case, successful communication – defined as accomplishing a shared understanding of the intended message contents – was never attained. Successful communication would have required, at a minimum, that the anesthesiologist both (1) read and (2) fully comprehend (i.e. both decoded and interpreted accurately, as intended by the patient) the patient’s handwritten notes on the consent form. It is important to note that preventing sufficiency errors does not alone guarantee successful communication. The extent to which communication succeeds also depends on the quality of all participants’ contributions. In this case, for example, such

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quality included the readability of the patient’s handwriting, the patient’s perceived appropriateness of the anesthesiologist’s tone of voice, and both of their interpretations of each other’s messages. The mere fact that sufficient (i.e. “enough”) information exchange takes place does not mean that it is going to be successful. Quality indicators, such as the richness of the communication channel (i.e. direct face-to-face rather than written communication), the clarity and accuracy of participants’ contributions, and their spontaneous adaptability to each other’s needs directly enhance the success of any communicative encounter. This case further demonstrates that communication competence is a necessary element of a culture of safety. From an economics perspective alone, the time that was lost in the aftermath of this adverse event was much greater than the time it would have taken to communicate sufficiently with the patient. This case also demonstrates the importance of active patient involvement for the quality and safety of care – the adverse event could have been prevented if the patient had followed up to verify that the anesthesiologist read and properly understood his handwritten message.

Alternative Strategies Several behaviors could have prevented or intervened with the adverse event: – The anesthesiologist and the patient could have been mindful that their communication is a process that requires their active participation. – The anesthesiologist could have read, processed, and reacted to the patient’s handwritten communication on the consent form indicating an allergy to penicillin. – The anesthesiologist could have personally checked with the patient about allergies before administering the prophylactic antibiotic. – The patient, as an active participant, could have verified with the anesthesiologist that he read and understood the patient’s handwritten message on the consent form.

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Select the communication lessons from Chapter 6 that best apply to this case and mark the respective circle(s) in this graph. Explain your choices and discuss how the lessons you selected inform this particular case. Compare your choices with the responses provided in the answer key on page 252. Are there any discrepancies? Discuss how any alternative lessons that you may have chosen or disregarded apply to this case.

Discussion Questions 1.

What distinguishes successful communication from sufficient communication?

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How can a provider or patient use the “read back” or “check back” strategy (i.e., asking the receiver to repeat what was said) most competently (i.e. effectively and appropriately) to assure that their message was received and understood as intended?

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What steps could be taken to prevent this kind of error from being repeated in the future?

Exercises 1.

Role play Re-enact an alternate script for this case, demonstrating successful communication (i.e. shared understanding). In this role-play, maintain one detail from the original case: that the patient does not check that the anesthesiologist is aware of the allergy. Doing so will encourage us to think about provider-initiated methods of preventing adverse events.

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Script writing For each of the characters in this case, write out a script for questions that they could pose that (1) would be likely to be effective at capturing the patient’s allergy history, and (2) might be ineffective at identifying it.

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Case 2: Reconciling records Provider-family interaction Medication misuse, Near miss Clinical context: Acute ED visit with subsequent inpatient admission for cardiac surgery Communication context: Interaction between ED staff and the patient’s family Incident: Communication error almost leading to clinician’s medication misuse Patient safety outcome: Near miss Case reprinted with permission of AHRQ WebM&M. Singh H, Sittig DF, Layden M. Reconciling records. AHRQ WebM&M [serial online]. November 2010. Available at: https://psnet.ahrq.gov/webmm/case/ 229.

At a local teaching hospital, a family had ™ given incorrect data to the ED staff (including listing the patient as being on š prednisolone rather than prednisone – a long acting oral steroid only used for short-term, rather than chronic treatment), and the physicians caring for the patient had › simply checked off the option to continue the home medications. When the records were carefully reviewed by a physician consulting for an upcoming cardiac procedure, almost all of the medications were found to be incorrect. Had the cardiologist assumed that the other physicians and nurses had accurately entered the medications, the errors would have gone undetected, and the patient’s chronic steroid dependence might have not been appropriately addressed perioperatively. Fortunately, no harm occurred.

Communication Principles 1. Redundancy in content and directness in channel enhance accuracy The family committed a ™ communication encoding error of accuracy (error of commission) by providing incorrect information about the patient to the ED staff. In the same way, the physicians committed a › communication encoding error of accuracy (error of commission) by simply ordering to continue the patient’s (incorrectly listed) home medications.

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The physicians committed a › transactional communication error of accuracy (error of omission) by not communicating with the patient and the family to validate the accuracy of the provided information. 2. Communication varies between thought, symbol, and referent The family committed a š communication encoding error of accuracy (error of misuse) by mislabeling the patient’s medication, stating that the patient was on prednisolone rather than on prednisone. 3. Communication is contextual The physicians caring for the patient committed a › communication decoding error of contextualization (error of misuse) by decoding the family’s medication list verbatim, disregarding the context of the family using a pharmaceutical language they might not be accustomed to (cultural context).

Discussion This case conveys three important challenges for safe and high-quality medicine. First, the incident demonstrates how communication accuracy is enhanced by appropriately redundant communication that occurs through direct channels, with faceto-face communication providing the richest potential for accurate decoding. In this particular case, the accuracy of the medication information that was exchanged between the family and the ED physicians could have been enhanced if the family had communicated with the physicians more than once (redundancy) in face-to-face interactions (directness) rather than merely submitting a handwritten list. Fortunately, the cardiologist lent a critical eye to this process and turned the transcription and prescribing errors into a near miss. Second, the case illustrates the importance of contextualizing communication. Patients and their families typically are not medical experts and thus may be unfamiliar with the proper usage of clinical terminology that accurately signifies, in this case, a specific medication. A contextualization of the clinicians’ communication with the family in light of this barrier could have prevented the initial error. Instead, the physicians assumed that the family was correct in their use of the medical terminology. This common ground fallacy led to a near miss for the patient. Third, this case illustrates how miscommunication can be triggered by uncorrected misinterpretations on a most fundamental level of communication – here, the unclear use of a symbol. In this event, the patient’s family had an object in mind (i.e. their thought of the patient’s home medication) and assigned a symbol (what they thought was the correct prescription label) to that reference to identify the signified medication to the physicians. Their use of the wrong symbol for the referent that they

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had in mind constitutes a signification error. This then triggered a misinterpretation and a subsequent inaccurate prescription order that threatened the safety of the patient. In summary, both the clarity and the shared knowledge of symbols that humans commonly assign to particular referents are a critical prerequisite for optimizing communication accuracy and increasing the likelihood of reaching a shared understanding.

Alternative Strategies Several behaviors could have prevented or intervened with the near miss: – The family could have provided their information about the patient’s home medication to the ED staff accompanied by a qualifier (“I think he is taking pred. . . – something – prednisolone? I’m not sure”) that clarifies their uncertainty about the medication. – The physicians could have viewed the written information provided by the family with a more critical eye and validated the accuracy of that information in direct conversation with the family and the patient. – The physicians could have decoded the family’s provided medication list carefully with awareness of potential sound-alike medications in light of the family’s nonmedical background.

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Discussion Questions 1.

When receiving a medical history from nonclinical family members on behalf of a patient, how can providers respectfully take cultural context into account?

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As patients often interact with multiple providers, how can the providers use redundancy as a tool to ensure accuracy?

Exercises 1.

Script writing Write an alternate script for the initial interaction between the family and the ED staff as they shared the patient’s medication list. What probing questions might the ED staff members have asked?

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Identifying analogous situations In this case, acting within the common ground fallacy caused a near miss. Name three other clinical situations in which the common ground fallacy could cause errors and potential harm.

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Case 3: Not a miscarriage Team interaction Incorrect diagnosis, Medication misuse, Harmless hit Clinical context: Acute outpatient obstetrics and gynecology (OBGYN) clinic visit (high-risk pregnancy) Communication context: Interaction between an OBGYN intern and an OBGYN attending Incident: Communication error leading to wrong diagnosis and subsequent clinician’s medication misuse Patient safety outcome: Harmless hit Case reprinted with permission of AHRQ WebM&M. Learman LA. Not a miscarriage. AHRQ WebM&M [serial online]. June 2003. Available at: https://psnet.ahrq.gov/webmm/case/18.

A 32-year-old woman, gravida 3, para 1, with a history of Type 2 diabetes mellitus on metformin, presented at 7 and 2/7 weeks by last menstrual period. The patient reported a history of a primary low transverse cesarean section and a bicornuate uterus. Formal ultrasound revealed an intrauterine gestational sac, with no embryo, and a bicornuate uterus. Beta hCG was 1009 mIU/mL. Hgb A1C was 9.4 g/dL. Her metformin was discontinued, and insulin was started. She was scheduled for a repeat scan approximately 48 hours later, when her hCG would be expected to be over 2000 mIU/mL. At that time, she was spotting (a small amount of bleeding), and instead presented to the gynecology clinic. She was seen by an intern who presented the case to an attending and mentioned that the patient had already been found to have an intrauterine pregnancy (IUP) on formal sonogram, but ™ failed to mention her history of a bicornuate uterus. They performed a transvaginal ultrasound, š found an empty uterus with a thin stripe, and › diagnosed the patient as having a completed spontaneous abortion. At that time, they œ restarted her metformin. Several weeks later, the patient went to the family planning clinic for follow-up on a Friday afternoon, at which time a urine pregnancy test was positive. An hCG was checked and found to be 40,000 mIU/mL. She was given a lab slip to return on Monday (before the results were back), as it was unclear whether the urine pregnancy test was positive from an ongoing pregnancy or if she was pregnant again. Her hCG increased, and she was again seen in the gynecology clinic that day, where an ultrasound confirmed a 13 and 3/7 week IUP in the right uterine horn. The patient was then admitted for insulin therapy.

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Communication principle 1. Redundancy in content and directness in channel enhance accuracy The intern committed a ™ communication encoding error of sufficiency (error of omission) by not mentioning the patient’s history of a bicornuate uterus to the attending. The intern and the attending committed a š communication decoding error of sufficiency (error of underuse) by not decoding the ultrasound of the patient’s full uterus. The intern and the attending also committed a š transactional communication error of sufficiency (error of omission) by not discussing the patient’s bicornuate uterus with each other while evaluating the ultrasound. The intern and the attending committed a › transactional communication error of accuracy (error of omission) by not engaging in communication with each other and with the patient to jointly validate the accuracy of their suspected diagnosis that the patient was having a completed spontaneous abortion. The intern and the attending committed a › communication encoding error of accuracy (error of commission) by communicating that the patient had a completed spontaneous abortion. The intern and the attending committed a œ communication encoding error of accuracy (error of commission) by incorrectly ordering to restart the patient on metformin.

Discussion This case illustrates how information getting lost between care providers can endanger the safety of a patient. In this case, a combination of communication sufficiency errors (in terms of both passing on information and validating the accuracy of information) led to the patient’s high-risk pregnancy remaining undetected and the patient receiving an unsafe medication. This incident can be informed by the communication principle: “Redundancy in content and directness in channel enhance accuracy.” The attending was relying on the information provided by the intern, but could have questioned the patient directly, especially given the context of treating a high-risk patient. At the least, the attending could have reviewed the patient’s records himself to gain a more complete understanding of the patient’s history and condition. He should not have settled with the information he received from the intern’s report. This case also shows the importance of involving patients as active partners for safe and high-quality care. Patients can provide rich descriptions of how their body feels to them, and to what extent their experiences are “different than usual.” These descriptions convey crucial information for clinicians to co-establish a more complete

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understanding of the patient’s medical history and current condition. Patients can be a valuable resource to validating the accuracy of medical practice. In this case, engaging the patient in the conversation could have prevented the harmless hit.

Alternative communication strategy Several behaviors could have prevented or intervened with this harmless hit: – The intern could have informed the attending about the patient’s history of a bicornuate uterus. – The attending could have gathered additional information about the history of the patient beyond the intern’s report (e.g. consulted the patient’s records). – The attending could have asked the intern whether he had covered all information known to him that might be relevant to the presenting history for the patient. – Had the bicornuate uterus been brought to the attention of the attending, he could have discussed the significance with the intern while evaluating the ultrasound. – The intern and the attending could have communicated with each other and with the patient to jointly validate the accuracy of their suspected diagnosis that the patient was having a completed spontaneous abortion. – The intern and the attending should not have restarted the patient on metformin until alternative explanations had been jointly discussed and a complete medical history of the patient had been reviewed.

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Discussion Questions 1.

What methods can providers use in daily practice to engage patients and encourage them to participate as active partners in their own care?

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Exercises 1.

Script writing In most medical incidents, there are multiple opportunities to avoid harm from errors. Write a script beginning at Point 3 in the case that inserts a new interaction between the attending, intern, and patient after diagnosis of the completed spontaneous abortion and prior to restarting metformin.

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Script writing Write two questions that the attending could have asked the other people involved in this case to help avoid the errors that occurred.

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Case 4: Sick and pregnant Interprofessional interaction Medication misuse and Near miss Clinical context: Acute-on-chronic outpatient ED visit (pregnancy and chronic asthma) Communication context: Interactions between an ED physician, ED nurse, on-call internist, and admitting nurse Incident: Communication error regarding the patient’s medical history leading to clinician’s medication misuse Patient safety outcome: Near miss Case reprinted with permission of AHRQ WebM&M. El-Ibiary S. Sick and pregnant. AHRQ WebM&M [serial online]. November 2008. Available at: https://psnet.ahrq.gov/webmm/case/190.

A 35-year-old woman with chronic asthma presented to the emergency department (ED) with difficulty breathing. The patient informed the staff that she was 17 weeks pregnant and had an obstetrician on staff at another hospital. A urine pregnancy test was ordered and was positive. ™ The result was documented in the electronic medical record. The patient was treated with inhaled bronchodilators, but her respiratory distress persisted. š The ED physician contacted the on-call internist to admit the patient for continued therapy. › The internist agreed to admit the patient, but he was not told that the patient was pregnant. š The admitting nurse received a report from the ED nurse, but again, the patient’s pregnancy status was not mentioned. On admission, the œ patient was ordered to receive intravenous corticosteroids, nebulized bronchodilators, and intravenous levofloxacin (a pregnancy category C antibiotic).  In the morning, the internist saw the patient. She informed him that she was pregnant. The internist reviewed the patient’s medication administration record and determined that she received one dose of levofloxacin. He discontinued levofloxacin and ordered an alternate antibiotic that was pregnancy category B. A maternal-fetal specialist was consulted and reported that one dose of levofloxacin could have no adverse effects on the fetus.

Case 4: Sick and pregnant | 75

Communication Principles 1. Communication is a non-summative process This case demonstrates how insufficient inter-staff communication can compromise the safety of a patient and an unborn child. The information that the patient was pregnant passed unnoticed through several communication lines of defense. First, both the admitting nurse and the on-call internist committed a ™ communication decoding error of sufficiency (error of omission) by not accessing the EHR of the patient. Although the laboratory staff encoded a message (positive pregnancy test) for the frontline clinicians, their intended communication actually never took place (“attempted communication”). At the same time, the ED physician did not inform the on-call internist and the ED nurse did not inform the admitting nurse that the patient was pregnant. Both of them committed š communication encoding errors of sufficiency (error of underuse) by insufficiently encoding this safety-relevant information to their colleagues, hindering the establishment of a shared understanding regarding the patient’s complete health condition. 2. Communication is contextual Another reason for the near miss in this case was that several actors did not contextualize their communication. Based on insufficient information, the on-call internist committed a œ communication encoding error of contextualization (error of commission) by ordering a medication that was unsafe given the patient’s pregnancy (functional context). He also committed a  communication encoding error of contextualization (error of underuse) by waiting to talk to the patient until the next day (chronological context). In addition, the on-call internist, the ED physician, and the pharmacist committed ›œ transactional communication errors of contextualization (errors of omission) by not discussing the fit of the intended medication order with the context of the patient’s pregnancy (functional context). This transactional communication error was the last line of defense that could have prevented the near miss. These three communication errors demonstrate how missing (or neglecting) the notion of “context” in any given care interaction – in this case, the patient’s pregnancy and the timing and timeliness of the clinician’s communication – can compromise patient safety.

Discussion The main communication issue in this case was incomplete information sharing. For example, the laboratory staff’s attempted communication to convey the positive urine pregnancy test result was never received by any of the clinical staff members. More-

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over, although the patient had already informed the ED front office staff that she is pregnant, those staff members never communicated that critical information to the on-call internist and admitting nurse. Furthermore, the on-call internist did not ask the admitting nurse, or the patient, about the patient being pregnant prior to ordering the antibiotic. A core problem that caused the insufficient information exchange in this case was the fact that the internist exclusively relied on latent communication among several involved staff members. He never actually saw or spoke to the patient himself prior to prescribing the antibiotic. The issue here is that latent communication – meaning communication that passes through several individuals – is typically compromised by a “game of telephone” whereby the quality and quantity of that information get lost in transition. Communication among fewer individuals, on the other hand, allows for a direct validation of the message contents and facilitates communication accuracy. A unique characteristic of this case is that the communication errors were preceded by other kinds of human errors. For example, the clinician’s failure to access the EHRs could have been triggered by a lack of motivation, knowledge (e.g. not knowing that new content had been added to the records), skills (e.g. not knowing how to access the records), and/or time pressure. Thus, this case shows how a chain of intraand interpersonal errors can interactively contribute to a near miss, with insufficient communication being the ultimate failed line of defense.

Alternative Strategies In this case, several behaviors could have prevented or intervened with the near miss: – ED admission clerks could have communicated the patient’s pregnancy directly to the ED medical team. – The laboratory staff could have verified with the ED medical team that they received and accurately understood the newly added test results in the patient’s electronic record. – The pharmacy could have verified with the clinician that the patient is not pregnant. – The on-call internist could have allocated time to talk to the patient face-to-face right after the patient’s arrival. – The staff could have been mindful of the necessity to access the patient’s EHR, and of their (lack of) knowledge, motivation, and/or skills related to this task. – All actors could have assumed no common ground as a baseline for their interactions. They could have engaged in sufficient and contextualized communication to co-establish a shared understanding.

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Discussion Questions 1.

What forms of context were disregarded in the communication in this case?

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Exercises 1.

Policy making For situations with multiple providers and inevitable latent communication, describe one institution-wide system or policy that could help providers avoid degradation of quality and quantity of information as it is passed on.

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Identifying failure points Re-read the case and identify points in which actors could have ensured receipt and mutual understanding between one another. For each point, describe one action that could have helped to accomplish this collective goal.

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Case 5: Medication reconciliation pitfalls Cross-professional interaction Medication overuse and Adverse event Clinical context: Acute ED visit with subsequent inpatient admission for orthopedic surgery (hip fracture) Communication context: Interactions between an ED triage nurse, orthopedic surgeon, consulting hospitalist, intensive care unit (ICU) nurse, and consulting cardiologist Incident: Communication error leading to clinician’s medication overuse Patient safety outcome: Adverse event Case reprinted with permission of AHRQ WebM&M. Weber, R. Medication Reconciliation Pitfalls. AHRQ WebM&M [serial online]. February 2010. Available at: https://psnet.ahrq.gov/webmm/case/213.

A 90-year-old woman who lived alone suffered a mechanical fall with subsequent hip fracture and was brought to the ED by her daughter. The patient had a past medical history of hypothyroidism, osteoarthritis, and hypertension. The patient’s medication bottles were given to the ED triage nurse and were used to generate a list of home medications. Among others, ™ the list included “Toprol-XL 75 mg po daily.” An orthopedic surgeon admitted the patient to the hospital and wrote orders to continue all of her home medications at their prior dosages. The surgeon also š requested an internal medicine consultation for “preoperative clearance.” The patient denied any history of arrhythmia, syncope, presyncope, dementia, or prior falls. Her medications were placed in an opaque, plastic personal belongings bag along with her clothes, and she was moved to the orthopedic floor. Several hours later, the consulting hospitalist performed an evaluation and › confirmed the patient’s home medications and their dosages. Other than her leg trauma and a mild hearing deficit, the patient’s examination was normal. œ She did not inform the hospitalist that the medications were in her hospital bag; in fact, she may not have even realized that her daughter had left them there with her. The hospitalist noted a heart rate of 75 beats per minute with a systolic blood pressure (BP) of 170 mmHg. BP readings had been high since admission.  An order was written to increase Toprol-XL from 75 to 100 mg daily.

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While being prepped on the operating room table several hours later, the patient developed asystole, underwent successful resuscitation, and was transferred to the ICU. Upon transfer, an ž ICU nurse handed the plastic bag of medications to the consulting cardiologist, who noted that the patient’s home dosage of Toprol-XL was 25 mg daily. The error was reported to the hospital pharmacy. Ÿ Only by coincidence did the hospitalist who had increased the Toprol-XL dosage learn of the error. The hospitalist apologized to the patient and her family, and assured them that the case would be carefully reviewed to ensure that a similar error would not happen again. The patient made a full recovery and had no recurrent vital sign instability. Myocardial infarction was ruled out, and an echocardiogram was normal. After observation in the ICU for several days, she underwent repair of her hip fracture and was discharged to home without further complications.

Communication Principles 1. Redundancy in content and directness in channel enhance accuracy The ED triage nurse committed a ™ communication decoding error of accuracy (error of misuse) by misreading the dosage of Toprol-XL on the patient’s medication. The ED triage nurse committed a ™ communication encoding error of accuracy (error of commission) by inaccurately writing on the home medications list that the patient was taking “Toprol-XL 75 mg po daily.” The internal medicine consultant committed a š transactional communication error of accuracy (error of omission) by not discussing and validating, in direct conversation with the patient and her daughter, the accuracy of the medication labels and dosages that had been written on the list. The internal medicine consultant committed a › communication encoding error of accuracy (error of commission) by confirming the patient’s home medications and their dosages. The internal medicine consultant committed a  communication encoding error of accuracy (error of commission) by submitting a written order to increase Toprol-XL from 75 to 100 mg daily. 2. Communication is a non-summative process The patient’s daughter committed a œ transactional communication error of sufficiency (error of omission) by not establishing a shared understanding with her mother and the internal medicine consultant that she had left the medication bottles in her mother’s hospital bag. The responsible staff committed a Ÿ communication encoding error of sufficiency (error of omission) by not informing the hospitalist of the error.

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3. Communication is contextual The clinical staff committed a ž communication encoding error of contextualization (error of underuse) by handing the plastic bag of medications to the consulting cardiologist too late (chronological context) for him to determine for himself that the medication dosage had been documented inaccurately on the list.

Discussion This case illustrates numerous incidents of inaccurate communication contributing to an adverse event. All care participants, including the patient and her daughter, contributed to the inaccurate communication in this episode. The case demonstrates the importance of communication as an interactive meaning-making vehicle that requires active skillful contributions from all care participants to optimize information accuracy as the basis for a common ground that can function as a foundation for establishing a shared understanding. In this case, because of too much inaccurate encoding, decoding, and transactional communication, critical information fell through the cracks, causing the patient harm. The case also illustrates sufficiency as a prerequisite for communication to yield a shared understanding. Once a common ground is established, sufficient communication has to occur on such ground for care participants to reach a shared understanding of their intended meanings, intentions, thoughts, and feelings. Such sufficiency reaches beyond the individual care episode – it also applies to the communication after an event, both with the family and among the clinicians and administrators, to exchange perspectives how communication failures that contributed to the adverse event can be transformed into functional learning lessons, coping, and future prevention.

Alternative Strategies In this case, several behaviors could have prevented or intervened with the adverse event: – The ED triage person could have engaged in accuracy-promoting redundancy by comparing the label and dosage that she had written on the list with the label and dosage on each prescription. – The ED triage nurse could have verbally confirmed the accuracy of the medication and dosage the patient was actually taking with the patient and her daughter. – The internal medicine consultant could have engaged in direct conversation with the patient and her daughter, and double-checked the contents of the plastic bag to validate the accuracy of the medication labels and their prior dosages with the ones that had been written on the list.

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The internal medicine consultant should have made sure that a common ground for this decision had been established through direct communication with the other involved care participants before ordering the increased dosage. The patient’s daughter could have established a shared understanding with her mother and the internal medicine consultant that she had left the medications in her mother’s hospital bag. The clinical staff could have made sure that the consulting cardiologist receives the plastic bag in time (chronological context) for him to validate the medication dosage that had been documented on the list. The hospitalist could have been informed about the error in a timely manner to promote a learning experience that could prevent a similar error from recurring in the future.

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Discussion Questions 1.

What were three opportunities in this case for using redundancy to promote accuracy?

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In this case, how could any of the providers have encouraged the patient and caregiver to share the bag of medications as a valuable tool to avoid error?

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Exercises 1.

Script writing Write out a script for things healthcare providers could say to patients and caregivers to involve them as active members of the healthcare team and to accomplish successful medication reconciliation.

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Identify points to intervene Re-read the case and identify points in which actors could have ensured receipt and mutual understanding between one another. For each point, describe one action that could have helped to accomplish this goal.

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Case 6: Omitted history of cerebral edema Inter-institutional interaction Incomplete handoff, Delayed treatment, and Harmless hit Clinical context: Acute ED visit with subsequent inpatient transfer to a tertiary clinic for specialized critical care (heroin overdose and aspiration pneumonia) and neurosurgical intervention (cerebral edema) Communication context: Interactions between an ED physician, ED staff, critical care specialist and ICU residents, a tertiary clinic, and staff at an additional hospital Incident: Communication error leading to incomplete handoff and delayed treatment Patient safety outcome: Harmless hit Case written by Robert S. Juhasz, D.O.

A 30-year-old woman presented to the ED unresponsive with a history of narcotic overdose. The ED physician gave her naloxone. Intravenous fluids were started and laboratory testing confirmed that the young woman had overdosed on heroin. Her blood urea nitrogen, creatinine, and creatine kinase were found to be elevated. She also appeared to have a small right lower lobe infiltrate, rhabdomyolysis, and aspiration pneumonia. Her pupils were fixed and dilated, and a computed tomography (CT) scan of the brain showed evidence of cerebral edema. The young woman’s ™ family requested that she be transferred to a larger area hospital where she might have access to more advanced specialists and treatments. š The ED physician contacted the transfer center and secured a potential bed for the young woman at a tertiary hospital about 60 miles away. › The family requested that she be transferred closer, and the œ ED physician was put in contact with a critical care specialist to see if he can receive the patient in transfer. The specialist told that the patient was a young woman who had a heroin overdose with aspiration pneumonia and accept her for transfer to his ICU. While she was in transit, the  residents in the receiving ICU called the ED of the sending hospital for report and received the additional history that the patient likely had cerebral edema and may need neurosurgical intervention. This might have complicated the care at the receiving hospital where there was no neurosurgeon on staff. On arrival, the young woman was intubated to protect her airway and improve her ventilation. Then, she was promptly transferred to another hospital with neurosurgical staffing and the potential for neurosurgical intervention if needed.

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Communication Principles 1. Preconceptions and perceptions vary among communicators Differing preconceptions and perceptions among communicators commonly contribute to misunderstandings, which in turn can compromise patients’ health outcomes. This acute care scenario illustrates how this communication principle can manifest itself in daily practice. When requesting the transfer, the ED physician had a different picture in mind than the family had of a “larger area hospital.” Three core communication errors failed to correct this lack of common ground and caused a significant treatment delay for the patient: First, the family committed a ™ communication encoding error of sufficiency (error of underuse) by insufficiently expressing their vicinity preference to the physician. At the same time, the ED physician committed a ™ communication decoding error of interpersonal adaptation (error of underuse) by insufficiently decoding the family’s communication conistent with the family’s needs and expectations. In addition, both parties shared the common ground fallacy by committing a › transactional communication error of interpersonal adaptation (error of omission), assuming but not verifying that “the other knows” their preferences. 2. Communication is contextual The ED physician committed a š communication encoding error of contextualization (error of underuse) by insufficiently framing his communication with the referral center within a relational context (i.e. the need of the family for the patient to be nearby) chronological context (i.e. the time delay that would be caused by a transfer to a clinic that is 60 miles away), and functional context (i.e. the implications of such a time delay for the patient’s urgent health condition). This communication error contributed to a significant time delay that led to the near miss. 3. Communication is a non-summative process The case also illustrates the importance of sufficient communication during patient transfers. The physician committed a significant œ communication encoding error of sufficiency (error of underuse) by not mentioning the suspected brain edema and need for neurosurgery to the critical care specialist. 4. Redundancy in content and richness in channel enhance accuracy The residents in the receiving ICU  corrected the previously mentioned communication encoding error of sufficiency (i.e. the ED physician’s failure to inform the critical care specialist about the edema) by calling the ED staff of the sending hospital. Their complete and clear communication enabled a prompt intervention and prevented additional treatment delays for the patient. Their communication exemplifies how re-

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dundancy in content and richness in channel can enhance accuracy. In this case, additional persons (i.e. the ICU staff) reinforced and validated the message contents (redundancy) via direct communication (richest channel available) to ensure communication sufficiency (information completeness). As a result, the ICU and ED staff succeeded in establishing a shared understanding.

Discussion Several communication errors in the provider-family and inter-provider interactions in this case caused unnecessary treatment delays and potentially harmful consequences for the patient. 1. Provider-family communication The initial communication between the patient’s family and the ED physician was insufficient, causing a significant delay in the patient’s transfer to a tertiary care center. The ED physician could have refocused his perspective to recognize that the proximity of the tertiary center would be an important criterion to consider – both for reasons of access (so that the family can be close to the patient) and timeliness (so less time would be lost with the patient’s transfer, facilitating a more timely treatment execution). More complete and adaptive communication between the ED physician and the family could have avoided this unnecessary delay, because a shared understanding about these issues could have been established prior to making the initial transfer choice. 2. Inter-provider communication The communication between the ED physician and the critical care specialist at the tertiary clinic was incomplete. The ED physician’s report was missing a critical component of his diagnosis (i.e. the probability of brain edema) and also his recommended treatment plan for the patient (i.e. the potential necessity of a neurosurgical intervention). Significant time could have been saved if the ED physician had communicated these two important details to the critical care physician. The interpersonal processes that would have been needed to overcome these perceptual differences and contextual constraints never took place. Instead, most of the communication remained on a level of mere information transfer. There was no focus on skillfully using the conversations as a process to establish a shared understanding. The time that would have been required for this successful (contextually situated and complete) communication would have been less than the time that was lost, in the end, for a corrective phone call to the referral center and an unplanned second trans-

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fer to a tertiary clinic that had a neurosurgeon on staff. Such communication would have prioritized patient safety by facilitating a timely treatment of the patient’s critical condition.

Alternative Strategies In this case, several behaviors could have prevented or intervened with the harmless hit: – The initial communication between the ED physician and the patient’s family could have been interactively adaptive to both the clinical and family’s perspectives. Particularly, the ED physician could have: ∙ Extracted the patient’s and her family’s expectations in terms of the transfer. ∙ Discussed the optimal next step for the indicated medical treatment of the patient given the expectations of the patient’s family. ∙ Discussed how both the family’s expectations and the medical necessities can be optimally integrated. – The ED physician could have ensured complete information coverage when communicating with the critical care specialist (i.e. consider the need to establish a common ground). Particularly, the ED physician could have: ∙ Been mindful of the knowledge gaps between himself and the critical care specialist. ∙ Been mindful of the context in which the critical care specialist was situated when called. ∙ Considered how to best communicate with the critical care specialist, within this context, in a way that he would fully comprehend the information and understand the indicated treatment he had in mind for the patient.

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you selected inform this particular case. Compare your choices with the responses provided in the answer key on page 252. Are there any discrepancies? Discuss how any alternative lessons that you may have chosen or disregarded apply to this case.

Discussion Questions 1.

What important elements of context were disregarded in this case?

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How could viewing communication as a complete process, rather than acting from one immediate interaction to the next, have helped to avoid error?

Exercises 1.

Script writing Write a script for points 1–3 for a better interaction between the ED physician and the patient’s family.

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Script writing Write a script beginning at Point 4 for a more competent interaction between the ED physician and the critical care specialist receiving the request.

Stage 2: Diagnosis Medical diagnosis is the process of determining the explanation for a person’s symptoms and the signs that they exhibit. The information needed for diagnosis generally entails medical history taking, physical examination, and diagnostic tests. Diagnosis is often difficult and involves the consideration of several possible explanations.

DOI 10.1515/9783110455014-008

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Case 7: Delayed treatment of rectal cancer Provider-patient interaction Inaccurate diagnosis, Delayed treatment, and Sentinel event Clinical context: Acute-on-chronic outpatient gastroenterological care visit (abdominal pains) Communication context: Interactions between a gastroenterologist and a patient Incident: Communication error leading to inaccurate diagnosis and delayed treatment Patient safety outcome: Sentinel event Case written by Annegret F. Hannawa, Ph.D. and Thomas Hannemann, M.D.

A 48-year-old male presented with diffuse abdominal pains for several weeks. His gastroenterologist noted no blood in the stool. With these results and ™ years of history of seeing him as a patient, the physician was š convinced that the pain was not serious and simply indicative of an irritable colon. During his more recent visits, the patient › appeared to be hunched over and uncomfortable, and he repeatedly complained that his pain feels atypical. The gastroenterologist selectively conducted a colonoscopy and took several biopsies from a slightly mutated area. Having already š mentally checked the issue off as an irritable colon, the gastroenterologist œ skimmed the pathology report that arrived a few days later and saved it to the patient’s records. One year later, the patient returned to his office, still with pains, but this time also with severe problems related to intestinal voiding. The stool test for blood was now positive. The gastroenterologist performed another colonoscopy. He detected a large tumor in the rectum and took biopsies. The patient went home and, that same night, suffered an acute intestinal obstruction that required emergency surgery. At the hospital, the entire tumor and a piece of the rectum were removed. While the surgery went without complications, the tumor was too close to the anus and the patient now has to live with an artificial anus for the rest of his life. The tumor had not metastasized, but because of its size, the patient had to undergo chemotherapy with subsequent radiation. The prognosis is good. However, the artificial anus and the long-term damages that are commonly incurred by chemotherapy will compromise the patient’s professional and personal quality of life for a lifetime.

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Communication Principles 1. Communication is contextual The gastroenterologist in this case committed a ™ communication decoding error of contextualization (error of overuse) by overly framing his encounter with the patient within the context of their existing relationship (relational context). In other words, the gastroenterologist overused his existing relational history with the patient in interpreting the visit communication, which ended up constraining rather than facilitating the establishment of a shared understanding. This initial communication error caused a chain of additional communication errors that ended in a sentinel event for the patient. 2. Preconceptions and perceptions vary among communicators Nested within the initial error of contextualizing his visit communication with the patient, the gastroenterologist’s perceptual bias about the patient caused him to commit three consecutive communication errors. First, he committed a š communication decoding error of accuracy (error or commission) by decoding the patient’s pain as nonserious. Second, biased by his perception of the patient’s condition being harmless, he committed a › communication decoding error of sufficiency (error of underuse) by insufficiently decoding the patient’s nonverbal (hunched-over) appearance and complaints about atypical pains. Third, the gastroenterologist committed a severe œ communication decoding error of sufficiency (error of underuse) by merely skimming over the initial pathology report. These three communication errors illustrate the fundamental communication principle of preconceptions and perceptions varying among communicators. As demonstrated in this case scenario, the principle implies that competent communication is needed to establish a common ground as a necessary foundation for co-creating a shared understanding. Maintained perceptual differences, on the other hand, can support biases that have the potential to cause disastrous results.

Discussion This case demonstrates how care participants can both limit and enable patient safety through their individual and joint contributions to competent communication, which in turn directly determines their likelihood of establishing a shared understanding. In particular, the case shows how a person’s perceptual biases can initiate a chain of communication errors that have the potential to severely harm, in different ways, both patients and providers. Here, a simple perceptual bias that was evident in the provider’s over-contextualization of his visit communication with the patient (i.e. his

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previous knowledge of the patient causing him to judge the care episode as harmless) ended up compromising the accuracy and clarity of the provider’s visit communication and directly impacted the patient’s care outcomes. The chain of errors in this care episode shows the crucial importance of contextualizing communication in any care setting, because it directly affects the likelihood of participants co-establishing of a common ground for shared understanding. Thus, this constitutes one of the core communicative challenges for any healthcare episode.

Alternative Strategies In this case, several behaviors could have prevented or intervened with the sentinel event: – The gastroenterologist could have recognized the potential for his relational history with the patient to bias his medical judgment and accuracy in both positive and negative ways. – The gastroenterologist could have recognized his perceptual bias regarding the patient as potentially dangerous and, as a result, de-biased himself, separating this particular care episode from his previous relational history with the patient. – The gastroenterologist could have focused on optimizing his communication with the patient (i.e. establishing a shared understanding through competent communication) rather than on his preconception of the patient in terms of his preexisting condition. – The gastroenterologist could have approached the communication with the patient and with the laboratory (in reading the pathology report) under the assumption of no pre-established common ground, viewing it as an opportunity to advance a shared understanding of a new and detached care episode with this patient.

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you selected inform this particular case. Compare your choices with the responses provided in the answer key on page 252. Are there any discrepancies? Discuss how any alternative lessons that you may have chosen or disregarded apply to this case.

Discussion Questions 1.

How can providers with a long history of caring for a patient avoid overusing relational history to the point that current patient concerns or long-standing issues are overlooked (perception bias)?

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Patients may struggle to confront a physician when their complaints are not addressed, rationalizing it as being due to the differential in clinical expertise. How can providers foster a “safe space” in which patient complaints and descriptions of symptoms are heard and acted upon?

Exercises 1.

Role play Write an alternate script and re-enact the patient-provider interaction in this case, in which the gastroenterologist takes into account his relational history with the patient, but does not dismiss the patient’s complaints.

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Nonverbal communication List and demonstrate three kinds of nonverbal cues that can inform providers about a patient’s experience of a medical condition.

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Case 8: The “customer” is always right Provider-family interaction Missed diagnosis, Delayed treatment, and Harmless hit Clinical context: Acute outpatient family care visit (rash and diarrhea) Communication context: Interactions between two physicians and the patient’s mother Incident: Communication error leading to a missed diagnosis and delayed treatment Patient safety outcome: Harmless hit Case reprinted with permission of AHRQ WebM&M. Sehgal NL. The “customer” is always right. AHRQ WebM&M [serial online]. February 2007. Available at: https://psnet.ahrq.gov/webmm/case/143.

An 18-month-old female was brought to the family medicine clinic with a chief complaint of “rash and diarrhea.” Five days earlier, the patient’s mother noted a rash on her daughter for which she was advised to administer diphenhydramine (Benadryl) as needed. While the rash improved, the patient developed diarrhea and a low-grade fever, prompting a visit to the clinic. During the visit, the mother also revealed that her daughter had fallen from a 1.5-foot-high bed a few hours earlier and appeared unsteady. The mother expressed concern that the child might have a fracture and requested an x-ray. The physical exam revealed a fussy child with normal vital signs and no evidence of ecchymosis, edema, or localized tenderness in the extremities. The child was somewhat unsteady when placed on the floor to stand, and remained uncooperative with an attempt to demonstrate her gait. The resident physician’s diagnosis was a ™ “viral syndrome” causing the diarrhea and low-grade fever. He š attributed the child’s unsteadiness to the Benadryl, perhaps exacerbated by the viral infection. He › advised the mother that a fracture was unlikely based on the exam findings. The resident discussed his findings with the attending physician, although he œ did not specifically mention the mother’s request for an x-ray. Later that evening, the mother returned to the ED to request an x-ray because of her daughter’s inability to bear weight. An x-ray was performed, which showed a nondisplaced fracture of the tibia, requiring placement of a cast. Frustrated with the sequence of events, the  mother felt that her concerns at the first visit were not heard.

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Communication Principles 1. Preconceptions and perceptions vary among communicators The resident physician committed a › communication decoding error of accuracy (error of commission) by concluding that the mother’s concern about her child having a fracture was inaccurate. The resident physician also committed a ™ communication encoding error of accuracy (error of commission) by communicating that the child had a “viral syndrome,” causing a delayed correct diagnosis, extended suffering for the child and the mother, and inefficient care signified by a preventable readmission of the child just a few hours later. In the same vein, the resident physician committed a œ transactional communication error of accuracy (error of omission) by not talking to the attending physician about the mother’s concerns, both to validate the accuracy of his understanding of the child’s symptoms and to discuss the fact that he did not gather further diagnostic evidence (i.e. an x-ray) to exclude the possibility of a fracture. 2. Communication is contextual The resident physician committed a š communication decoding error of contextualization (error of underuse) by insufficiently decoding the mother’s request in the context of her being the person closest to the child (relational context) and, thus, being likely to recognize something unusual about the way the patient was behaving (functional context). 3. Communication entails factual and relational information The resident physician committed a  transactional communication error of interpersonal adaptation (error of underuse) by insufficiently adapting his communication to the mother’s cognitive and emotional needs and expressions (i.e. her being sure of her assessment of the situation and emotional about the well-being of her child). His communication contained not only factual information regarding his diagnosis of the child’s symptoms, but also relational content that was strongly perceived by the mother as an indication of “not feeling heard.”

Discussion This case contains four key points that illustrate how any interpersonal healthcare setting contains multiple complex communication layers that can challenge the participants’ co-establishment of a shared understanding. First, the episode shows how communication is an interactive meaning-making process that is greatly influenced by the context within which it is situated. Communication skills are needed to establish shared meaning within such contextual con-

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straints to overcome them. Context can both facilitate and constrain such communication. Thus, it is critically important for providers to become aware of any contextual elements in any given care setting. This particular care episode, for example, entailed an emotionally close relationship between a mother and her young child. This relational context facilitated (i.e. was an asset to) care because the mother brought a validating perspective (i.e. her knowledge of the child’s “normal” behavior) to the diagnosis. Second, the communication in this case exemplified how multiple perception checks can correct a diagnostic error-in-the-making. The resident physician in this case could have taken the opportunity to engage in such “perspective checking” by communicating with the attending physician and taking the mother’s concern about a possible fracture as important information to consider for an accurate diagnosis. Third, the case shows how adaptive communication is the only vehicle for attaining patient-centered care. A core principle of human communication states, “communication entails both factual and relational information.” It is critically important for providers to understand that their communication inevitably contributes to both of these layers. In this case, the resident physician was not mindful of the relational message he inadvertently encoded to the mother when conveying his diagnosis. The mother, in turn, received a strong and clear message from his communication, which, from his point of view, may have been merely informational, but it was nonadaptive to the mother’s needs, making the mother feel disregarded. Fourth, the importance of appropriateness as a dimension of communicative competence is demonstrated by this case. The mother engaged herself as an active care participant to prevent a diagnostic error-in-the-making. She followed the redundancy principle of communication by trying to enhance the accuracy of the diagnosis by repeatedly raising a concern. This case illustrates how appropriateness is an important moderator: The resident perceived too much redundancy from the mother as inappropriate and, as a result, shut down to her. In other words, the mother’s assertiveness turned into a constraint rather than a contribution to an accurate and timely diagnosis. This issue illustrates how the relationship between communication skills and competence perceptions often follows an inverted U – with too little and too much of any given behavior being perceived as inappropriate and ineffective in most healthcare interactions.

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Alternative Strategies In this case, several behaviors could have prevented or intervened with the harmless hit: – The resident physician could have taken the mother’s concerns more seriously as they contained important information from the person closest to the patient. – The resident physician could have clearly communicated his diagnosis with a qualifier that he did not order x-rays and thus cannot exclude the mother’s expressed concern about her child having a fracture. – The resident physician could have discussed the mother’s concern with the attending to validate his judgment that no x-ray is needed to verify the mother’s concern. – The resident physician could have framed his communication with the mother contextually acknowledging both the potential benefit and threat of the mother’s relational closeness to the child for the diagnosis. – The resident physician could have flexibly accommodated his communication with the mother to her ad-hoc cognitive and emotional expressions, needs, and expectancies.

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Discussion Questions 1.

What important element of context did the resident physician fail to take into account for his diagnosis?

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What interactions throughout the case could have served as checkpoints for accurate perceptions to prevent an incorrect diagnosis?

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How could patients and their families be trained to communicate more effectively with healthcare providers?

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Script writing Write an alternate script of the initial visit, for a new interaction between the mother and the resident that demonstrates interpersonally adaptive communication. How can what the resident said originally be changed to be more adaptive to the ad-hoc expressed needs of the mother?

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Script writing Write an alternate script for how the mother might have interacted with the resident in a way that could have promoted greater consideration of her concerns.

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Case 9: A seasonal care transition failure Team interaction Delayed diagnosis and Adverse event Clinical context: Routine outpatient primary care visit (prostate cancer screening) Communication context: Interaction between departing and oncoming residents Incident: Communication error leading to delayed diagnosis Patient safety outcome: Adverse event Case reprinted with permission of AHRQ WebM&M. Young JQ. A seasonal care transition failure. AHRQ WebM&M [serial online]. July 2011. Available at: https://psnet.ahrq.gov/webmm/case/247.

A 70-year-old healthy man presented to his primary care physician– a third-year internal medicine resident – for routine follow-up. The resident was in his final month of training and would leave the institution for fellowship at the completion of his residency. After discussion, the provider sent off a prostate-specific antigen (PSA) test to screen the patient for prostate cancer. The patient’s past PSA tests had always been normal. Unfortunately, this time his PSA returned markedly elevated at 83 ng/mL – a level at which cancer is a near certainty. The ™ patient was not immediately notified as the electronic alert (via an existing EHR) š was sent to the patient’s primary care provider (PCP). However, because this provider had graduated and left the program before the alert returned, and there was › no system to ensure smooth handoffs to new residents, the œ alert went unread. Eight months later, the patient presented with new onset low back pain. Imaging tests confirmed metastatic prostate cancer and also uncovered the missed follow-up of the elevated PSA.

Communication Principles 1. Communication is contextual This case illustrates a chain of communication errors that caused a preventable adverse event. Three of these errors reflected failures to contextualize communication: First, the communication of the PSA test result to the patient was delayed because of a ™ communication encoding error of contextualization (error of underuse) on the part of the laboratory staff. The laboratory staff could have communicated the re-

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sults in a more timely manner (chronological context), given the prognostic importance of the test result (functional context). The laboratory staff committed another š communication encoding error of contextualization (error of misuse) by sending the results to the wrong target (functional context, i.e. a resident who had already left the institution). Third, the organization committed a › communication encoding error of contextualization (error of underuse) because their communication with oncoming residents was insufficient for ensuring smooth handoffs (functional context). 2. Communication is a non-summative process Another way to look at the organization’s failure to produce effective handoffs between outgoing and incoming residents is from a communication sufficiency perspective. Acknowledging that communication is a co-constructed, interactive process for establishing a shared understanding, the organization committed a › communication encoding error of sufficiency (error of underuse) by not conveying enough information about the procedure for handing off care, including the communication of test results, when residents rotate away from a particular service or institution. In addition, the organization committed a › communication encoding error of interpersonal adaptation (error of underuse) because their hand-off communication to the oncoming resident was not adapted to the newcomer’s informational needs. These preceding communication errors cumulatively led to a œ communication decoding error of sufficiency (error of omission) that left the alert unread, constituting a case of “attempted communication”.

Discussion This case illustrates how a chain of communication errors in the context of the simple reporting of a patient’s test result can cause a severe adverse event. A core error in this case was the laboratory staff’s delegation of important communication to an EHR. In other words, face-to-face (or other direct) communication was substituted by an automated system. In turn, that automated system could not identify the appropriate recipient for the information after the ordering physician left the institution. The abovementioned organizational communication errors contained errors of contextualization, sufficiency, and adaptation. These three error categories require advanced interpersonal communication skills that cannot be delegated to an automated system that is merely designed to “transfer” information. The contextualization errors in particular demonstrate the importance of framing behaviors and message contents within various contextual layers of a given healthcare interaction. There is simply no black-and-white solution for “communication excellence” that could be attained through the implementation of automated protocols or other structuration devices. In

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addition, this case scenario demonstrates that communication competence requires flexibly adaptive behavioral skill sets that are responsive and proper in situations arising ad-hoc within any given conversation. The fundamental principle of human communication being “a non-summative process” implies that a shared understanding cannot be “delivered” by a system but must be co-constructed between actors. Because each person harbors varying (at times incompatible) interpretive frames and perspectives within differing contexts, a solid common ground has to be established as a prerequisite for attaining a shared understanding. Therefore, direct interpersonal communication (ideally face-to-face) is indispensable to achieve handoffs that promote the safest and most consistent patient care. It is tempting to think that communication, which is a critical skill in healthcare and for which there seems to be limited time and skills, could be delegated and “taken care of” by an automated system. However, communication is an interactive meaningmaking activity that too often harms the health of patients. An e-system could be used to ensure that a message was received, but the co-creation of shared understanding remains between people and their cognitive and behavioral frames.

Alternative Strategies In this case, several behaviors could have prevented or intervened with the adverse event: – The laboratory staff could have framed the communication of the diagnostic test results to the patient’s primary care physician contextually – both in terms of the message’s chronological (timeliness) and functional context (i.e. making sure that the primary physician is still the appropriate receiver for the message). – The laboratory staff could have thought the communication process through to the end (i.e. to the patient’s receipt of its communication, rather than only to the receiving physician), for example, by following up with the patient’s primary care physician to ensure that the message was received and understood accurately by the patient. – The laboratory staff could have communicated the test results directly to the patient and his family, creating a parallel channel of communication that bypasses the potential for failure by the patient’s physician to receive it. – The organization could have ensured that the communication with the oncoming resident was contextualized (i.e. fulfilling the function of a safe handoff that optimizes care consistency), sufficient in coverage (i.e. complete content), and interpersonally adaptive (i.e. meeting the professional and informational needs of the specific oncoming resident).

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Discussion Questions 1.

What are some ways in which communication could be improved to solve the issue of loose ends left by a graduating physician, such as pending report results?

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Are there ways in which other elements of the healthcare system could be redesigned to prevent this kind of incident?

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With the advances in health information technologies, how can teams ensure that the EHR serves as a tool to facilitate communication, rather than as a substitute for effective face-to-face interaction?

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System design Describe a system that could ensure smooth handoffs from outgoing to incoming residents at the end of the academic year, including the follow-up of ambulatory test results.

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Timeline Create a timeline that includes patient visits for primary care, laboratory testing, and changes in primary care physicians related to the academic training calendar. Indicate points where there is an increased risk of communication error and suggest ways to reduce those risks.

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Case 10: Lost in transition Interprofessional interaction Delayed diagnosis and Sentinel event Clinical context: Acute ED visit with subsequent inpatient admission to internal medicine (mental status deterioration) Communication context: Interactions between ED physicians, laboratory staff, and an ED unit secretary Incident: Communication error leading to delayed diagnosis Patient safety outcome: Sentinel event Case reprinted with permission of AHRQ WebM&M. Beach C. Lost in transition [Spotlight]. AHRQ WebM&M [serial online]. February 2006. Available at: https://psnet.ahrq.gov/webmm/case/116.

A 41-year-old woman came to the ED with mental status changes. She had been diagnosed with a urinary tract infection (UTI) and started on oral ciprofloxacin 4 days earlier. She had fever, nausea, and vomiting in the days preceding presentation. She did not have headache, focal weakness, or numbness. The past medical history was otherwise unremarkable. On physical examination, the patient was afebrile, with sinus tachycardia (heart rate 123 beats per minute), and otherwise normal vital signs. Able to follow most commands, she was alert but oriented to person and place only. Neurologic examination was otherwise nonfocal. There were no signs of meningeal irritation. Approximately 40 minutes after the patient arrived, initial laboratory results returned and included white blood cell count 12.7 K/μL with 89% granulocytes, hematocrit 20.2%, glucose 204 mg/dL, blood urea nitrogen 36 mg/dL, and serum creatinine 1.4 mg/dL. Urinalysis showed moderate blood. Platelet count was pending at that time. Sixty minutes after arrival, the patient was admitted to the internal medicine service with a diagnosis of anemia and hematuria in the setting of a urinary infection. The medicine team completed the admission paperwork, with plans to administer empiric broad-spectrum antimicrobial agents and packed red blood cells for the severe anemia. The outgoing ED physician had just completed the shift and signed the patient out to the oncoming colleague as “admitted,” with care already transferred to the internal medicine service. Four hours after arrival, the laboratory called the ED to report a critical lab result, a platelet count of 4000/mm3 (normal range 150,000–400,000). The critical result was ™ received by the ED unit secretary. It is unclear whom this information was

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š passed on to, but neither the ED attending nor the internal medicine service was made aware of this lab result. › Sixteen hours after the patient presented to the ED, the internist noted the abnormal finding when checking the morning lab data. She made a tentative diagnosis of thrombotic thrombocytopenic purpura (TTP). The patient required transfer to the ICU because of progressive deterioration in mental status and was eventually intubated. Hematology consultation was obtained to initiate emergent plasma exchange for treatment of TTP. Despite these interventions, the patient’s status continued to deteriorate. The patient died the following day, within 48 hours of presentation to the ED.

Communication Principle 1. Communication is contextual In this case, a chain of contextualization errors on the part of the ED unit secretary severely compromised the safety of the patient. First, the secretary committed a ™ communication decoding error of contextualization (error or underuse) by insufficiently decoding the laboratory’s report properly in the context of its clinical urgency (functional context). Second, the secretary committed a š communication encoding error of contextualization (error of misuse) by forwarding the message to the wrong person (functional context). Third, the secretary committed a š transactional communication error of contextualization (error of omission) by not following up with the receiver to make sure that he was the correct person to receive and act on the lab results (functional context). As a direct result of these three errors, the internist committed a › communication decoding error of contextualization (error or underuse) by checking the records of the patient too late (chronological context). This diagnostic delay may have contributed to the patient’s death.

Discussion This case illustrates how a chain of communication errors in which only one member of the clinical staff fails to contextualize a message can contribute to a failure to diagnose and a patient’s death. The case also illustrates how a misdiagnosis can be prevented by understanding core principles of human communication. For example, an understanding of the principle “communication is a non-summative process” could have helped the ED unit secretary to understand communication as a co-constructed sense-making activity that entails more than linear information transfer. In addition, knowledge of the principle “redundancy in content and directness in channel enhance accuracy” could have motivated the ED unit secretary to communicate the critical lab

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results repeatedly and directly through different rich channels (e.g. both by phone and face-to-face) until she was certain that action had been taken on the laboratory report to treat the patient in a timely manner.

Alternative Strategies In this case, several behaviors could have prevented or intervened with the sentinel event: – Standard procedure for the laboratory could have been for a critical lab value to be communicated directly to the physician who ordered the test, rather than to a unit secretary. – The ED unit secretary could have followed up with the person to whom she forwarded the laboratory report to contextualize it – both in terms of function and timeliness – to make sure that the information was received by the correct person and that the patient gets treated promptly. – The on-call staff could have been alerted when updated results were available in the patient’s medical records.

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Discussion Questions 1.

What are strategies that the ED unit secretary could have used to ensure successful communication of the critical lab result to the right recipient? What steps might the institution need to take to assure that the secretary would reliably do so?

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How could viewing communication as more than mere “information transfer” have helped to avert error?

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What role could laboratory staff play in conveying information about “panic values” on lab tests?

Exercises 1.

Re-envision Describe an alternate line of action beginning at Point 1, in which the ED unit secretary ensured effective communication rather than mere information transfer.

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Identify failure points Identify the points in this case where the chronological context (need for timely care) could have been communicated along with the clinical data.

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Case 11: Communication with consultants Cross-professional interaction Delayed diagnosis and Sentinel event Clinical context: Acute ED visit with subsequent inpatient admission to primary medicine (suspicion of hematologic malignancy) Communication context: Interactions between an ED physician, hematologist, and primary medical team Incident: Communication error leading to delayed diagnosis Patient safety outcome: Sentinel event Case reprinted with permission of AHRQ WebM&M. Cohn SL. Communication with consultants. AHRQ WebM&M [serial online]. June 2016. Available at: https://psnet.ahrq.gov/webmm/case/379.

A 30-year-old pregnant woman presented to the ED with nausea, headaches, and fevers. Her laboratory studies were notable for a markedly elevated white blood cell count of 121,000 (normal is 5000–10,000, and routine infections virtually never raise the count > 25, 000, making this level highly suspicious for a hematologic malignancy). The ED physician contacted the hematologist on call regarding the abnormal complete blood count (CBC). The hematologist informed him that she would follow up the labs and ™ see the patient the following day. Later that afternoon, the patient was admitted to the hospital by the primary medical team and continued to worsen through the night. She became progressively tachypneic with an increasing oxygen requirement, ultimately requiring intubation and transfer to the ICU. The primary team š did not attempt to contact the hematologist again overnight, › assuming that the information about the patient’s tenuous clinical status and markedly elevated white blood cell count had been adequately conveyed by the ED provider and that no acute intervention was required overnight, which is why the hematologist had decided to see the patient the following day. In fact, the œ hematologist had been told only that the patient had an “abnormal CBC with a pending differential” and that her input might be helpful. She was  unaware of the urgent nature of the consult. ž The following day, the hematologist confirmed the diagnosis of leukostasis as a result of acute myeloid leukemia – an oncologic emergency for which treatment could have been initiated immediately. Although leukapheresis and induction chemotherapy were ordered, the patient had already developed multiorgan

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system failure because of the delay. She was transitioned to comfort measures and died shortly thereafter.

Communication Principles 1. Communication is a non-summative process The ED physician committed a ™ transactional communication error of sufficiency (error of underuse) by not engaging in enough communication for the hematologist to understand the nature and severity of the patient’s condition. 2. Communication is functional The ED physician committed a œ communication encoding error of clarity (error of misuse) by being vague in informing the hematologist that the patient had an “abnormal CBC with a pending differential” and merely stating that her input “might be helpful.” 3. Preconceptions and perceptions vary among communicators The primary inpatient team committed a › communication decoding error of accuracy (error of misuse) by misinterpreting the hematologist’s communication that she will see the patient the following day as an indication that the information about the patient’s tenuous clinical status and elevated white blood cell count had already been conveyed adequately by the ED provider and that no acute intervention was required overnight. 4. Communication is contextual The ED physician committed a ™œ transactional communication error of contextualization (error of underuse) by insufficiently emphasizing the patient’s critical (functional context) and urgent (chronological context) condition in response to the hematologist’s remark that she will see the patient “the next day”. The primary team committed a š transactional communication error of contextualization (error of omission) by not contacting the hematologist overnight for follow-up, given the patient’s worsened condition (functional context). The hematologist committed a ž communication encoding error of contextualization (error of underuse) by delaying her visit to the patient until the next day (chronological context).

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Discussion This case demonstrates the impending patient safety threat when providers assume rather than co-create a shared meaning through sufficient, clear, accurate, contextualized, and adaptive communication. The participants in this case engaged in too little communication with each other to establish a shared understanding. They did not engage in direct communication with each other to validate the accuracy of their perceived understandings of the others’ behaviors and message contents. In other words, they performed their clinical tasks based on an incorrect assumption that communication merely carries static information and that the meaning of such information lies within people. A core contributor to the sentinel event in the case was the care participants’ failure to contextualize their communication in the setting of the patient being on high risk (i.e. pregnant) and requiring immediate attention due to a markedly elevated blood cell count. Instead, the ED physician engaged in unclear communication, reporting to the hematologist that the blood count was “abnormal” (rather than critical) and suggesting that her input “may be helpful” (rather than urgently required). It is not clear why the ED physician communicated with such ambiguous language. One reason may have been that he did not want to “impose” an expectation on the hematologist, how busy she was. In other words, he may have chosen to communicate this way so not to be perceived as disrespectful or intrusive. This behavior of the ED physician illustrates the principle that “communication is functional.” People often do not engage in clear communication for strategic reasons; for example, to avoid conflict, to appear kind, to maintain their relationship with others, or to save face. The ED physician’s behavior did not contribute well to a shared understanding with the hematologist. However, it performed well in pursuing a different function – to attain a goal of relational maintenance, such as the hematologist not feeling pressured by the request. Thus, “communication is functional” means that a certain set of behaviors and message contents may perform well for one function, but not well for another. The challenge is to assess the appropriateness of such communication based on a shared objective, which – in the context of acute care – would primarily be the safety and health of a patient. In other words, communication is appropriate if it pursues the function of assuring the safety of the patient. In this case, the ED physician’s communicative tactics were inappropriate to this function. They prioritized the function of maintaining a respectful relationship with the hematologist over the function of protecting the patient’s and her baby’s lives, with horrendous consequences.

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Alternative Strategies In this case, several behaviors could have prevented or intervened with the sentinel event: – The ED physician could have engaged in enough communication with the hematologist to enable her to fully understand the patient’s condition. – The ED physician could have been clearer in his communication with the hematologist that her review of the labs was urgently required. – The ED physician could have validated the hematologist’s extent of understanding in respect to the patient’s critical condition in response to the hematologist’s remark that she would see the patient the following day. – The hematologist could have clarified the urgency of the matter with the ED physician and made time to see the patient right away, given her high-risk status due to her pregnancy. – The primary team could have immediately contacted the hematologist for followup in the context of the patient’s worsened condition.

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Discussion Questions 1.

In practical terms, what would “co-creating shared meaning” look like in this case?

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taining respect or professional collegiality, and appropriately communicating urgency?

Exercises 1.

Script writing Write an alternate script for a new interaction between the ED provider and the hematologist, in which the urgent nature of the consult is co-established.

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Flowcharting Draw an assumptions flowchart, outlining each interaction in this case and the underlying assumptions informing each actor’s behavior.

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Case 12: Techno trip Inter-institutional interaction Incorrect diagnosis, Delayed treatment, and Adverse event Clinical context: Acute community hospital visit with subsequent inpatient transfer to a large referral center for neurosurgical evaluation (subdural hematoma) Communication context: Interactions between a community hospital, radiologist, transfer center, surgeon, and neurologist Incident: Communication error leading to incorrect diagnosis and delayed treatment Patient safety outcome: Adverse event Case reprinted with permission of AHRQ WebM&M. Cook RI. Techno trip. AHRQ WebM&M [serial online]. March 2005. Available at: https://psnet.ahrq.gov/webmm/case/89.

A 70-year-old woman was admitted to a community hospital after developing confusion and right-sided weakness. A CT scan of her brain showed an acute subdural hematoma. The ™ hospital arranged a transfer to a large referral center for urgent neurosurgical evaluation. The radiology department at the community hospital had recently implemented an electronic picture archiving and communication system (PACS). Instead of printed films, the ™ patient was sent with a compact disk (CD) containing copies of relevant studies. On arrival at the referral center, a right-sided hemiparesis was confirmed on the physical examination. The accepting surgeon inserted the CD into a local computer. The CT image that appeared on the screen showed some brain atrophy, small, old strokes, and a large left-sided subdural hygroma, but no acute hemorrhage. š The surgeon felt that the patient had a stroke, admitted her to the stroke unit, and consulted neurology. › The next day, a consulting neurologist found a set of more recent images while scrolling through the PACS disk. These demonstrated the acute subdural hemorrhage for which the patient had been transferred. The subdural was urgently evacuated and the patient improved after a prolonged period of rehabilitation.

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Communication Principles 1. Redundancy in content and richness in channel enhance accuracy This case illustrates the domino effect that an initial message lacking clarity can have on subsequent interactions and, ultimately, the safety of a patient. In this case, the hospital staff initiated this process with a ™ communication encoding error of clarity (error of misuse) by referring the patient to a tertiary care center with a CD that contained multiple images, unaccompanied by other information to orient the receiver as to what it contained. The referral center staff did not look at the CD and arrived at the same diagnostic conclusion as the referring center after a physical examination. However, the accepting surgeon committed a š communication decoding error of accuracy (error of misuse) by decoding the wrong image on the CD. Both the tertiary center and the accepting surgeon committed a ™ transactional communication error of accuracy (error of omission) by not verifying receipt of the correct image and confirming the interpretation. Message redundancy (i.e., appropriate repetitions of content) and channel richness (i.e. direct rather than asynchronous mediated communication) generally facilitate accuracy. In this case, they could have broken the chain of communication errors. For example, in addition to the images on the CD, the referring hospital could have communicated the information to the surgeon both verbally and in writing, and at least one more person could have restated the message. 2. Communication is contextual This case also illustrates how communication that lacks contextual framing can directly affect the patient’s health. Although the consulting neurologist caught the transactional communication error between the surgeon and the referral center staff, he was involved in a › communication decoding error of contextualization (error of underuse) because he did not review the images until the next day (chronological context). Together with the misdiagnosis on the part of the surgeon, this allowed a treatment delay that ultimately prolonged the need for rehabilitation for the patient. This case demonstrates the importance of nesting both the encoding and decoding of communication within a context of time – both in terms of timely treatment, the timing of communication, and the use of time that are needed to communicate a message effectively and appropriately.

Discussion This case highlights several links between communication and patient safety. For example, it demonstrates how a face-to-face physical exam can lead to a more accurate diagnosis than a mere reliance on information from electronic records. From a communication science perspective, this is not surprising. Even when a message contains

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purely informational contents, more than half of the meaning of that message is derived from nonverbal behavior. In other words, the informational content itself is less than half as important compared to the way in which that information is conveyed. EHRs currently do not contain important nonverbal contents and thus make accurate decoding more difficult. Furthermore, the case illustrates that the design and structure of EHRs can directly affect decoding accuracy. In this case, the relevant information in the most recent CT scan was literally encoded on the CD in a way that made it difficult for that scan to be identified. The CD contained multiple images, imposing a more difficult decoding task (i.e. having to choose among images) for the referral center’s staff and the accepting surgeon, in the context of a medical emergency that reduced the time available for such added sense-making activities.

Alternative Strategies In this case, several behaviors could have prevented or intervened with the adverse event: – The hospital staff could have included only the most recent relevant image(s) on the CD, or marked them clearly to highlight the images most relevant to the current care episode. – The hospital staff could have accompanied the CD with a written note and a followup phone call to make sure that the accepting surgeon was viewing the correct image.

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Discussion Questions 1.

What are three ways in which the chronological context of the CT scans could have been more clearly communicated?

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With advances in health information technology, how can teams ensure that electronic PACS serve as facilitating tools, rather than as a source of insufficient communication?

Exercises 1.

Channel surfing Describe three opportunities in this case where “redundancy in content” and “directness in channel” could have been improved to enhance timely reception and understanding of critical information.

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Handoff design Describe two methods that could have increased the likelihood that the accepting surgeon would view the most recent CT images on initial review of the CD.

Stage 3: Treatment planning Treatment planning is the process in which clinicians, patients, and other involved individuals discuss and determine a plan for the attempted remediation of a diagnosed medical problem. Treatment can be classified by goals, methods, and location of treatment, among others. Treatment can be acute or on-going, and goals can be to cure disorders, to improve or maintain health and functioning, to prevent problems, or to ameliorate symptoms. Methods of treatment include drugs, devices, procedures, and counseling. Treatment may be based within hospitals, in an outpatient/ ambulatory setting, or in the patient’s home.

DOI 10.1515/9783110455014-009

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Case 13: Code status confusion Provider-patient interaction Misunderstanding about DNR status and Near miss Clinical context: Acute ED visit with subsequent inpatient admission (shortness of breath) Communication context: Interaction between an intern and a patient Incident: Communication error leading to a misunderstanding regarding DNR status Patient safety outcome: Near miss Case reprinted with permission of AHRQ WebM&M. Lo B, Tulsky JA. Code status confusion [Spotlight]. AHRQ WebM&M [serial online]. July 2003. Available at: https://psnet.ahrq.gov/webmm/case/25.

A 60-year-old woman with a long history of severe asthma without prior intubations presented to the ED with shortness of breath. Her exercise tolerance had been worsening gradually over 2 months prior to admission, with a marked decrease in her ability to complete her activities of daily living. On physical examination, her BP was 145/85, pulse 85, oxygen saturation of 94%, and a respiratory rate of 22. Her lung exam was significant for diffuse-end expiratory wheezes and decreased breath sounds at the bases. Despite having a long-standing relationship with a primary care physician, the patient had not designated a healthcare proxy or completed a living will prior to admission. Upon admission, the intern spoke with the patient about code status. The patient stated that she “would not want to be on a tube to breathe.” When asked about cardiopulmonary resuscitation (CPR), she stated she did not want “shocks to the heart or pressing on my heart.” She stated that if her breathing continued to be this difficult, and she could not live independently, she would rather not survive. ™ The intern interpreted these statements as indicating the patient’s desire for do-not-resuscitate (DNR) status, and š called the resident to discuss this issue › without filling out the hospital’s DNR form. A few hours after admission, the patient had sudden respiratory failure leading to pulseless electrical activity arrest. The nurse, who did not know the patient’s code status, called a code, and CPR was initiated. The code team found the intern’s initial assessment, which stated the patient’s preference for no resuscitation or intubation efforts; however, œ this was not corroborated by the requisite DNR/do not intubate (DNI) form. The resident had discussed the case briefly with the intern (including her interpretation that the patient wished to be a DNR), but neither the resident nor the at-

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tending had discussed code status with the patient yet. At this point, the patient’s BP was 90/palpable with a heart rate of 40 and an oxygen saturation of 92% with assisted bag-mask ventilation. The patient did receive CPR, including medications and chest compressions. In an effort to respect the patient’s preference to avoid invasive ventilation, she was started on noninvasive bi-level positive airway pressure (BIPAP) ventilation. Spontaneous respirations returned with BIPAP and the patient was stabilized. The following day, the patient was alert and was able to express her thoughts about the events of the previous night. She had not realized that intubation could be performed as a temporizing measure. The patient thought that initiation of intubation was synonymous with permanent respiratory support and stated that ™ she thought the discussion was about whether she would want to be kept alive if she was “a vegetable.” Furthermore, she had not realized that resuscitation attempts could be successful. After her experience, she stated that she did want aggressive interventions for reversible causes. Her status was changed to full code.

Communication Principles 1. Preconceptions and perceptions vary among communicators The intern committed a ™ communication decoding error of accuracy (error of misuse) by misinterpreting the intended meaning of the patient’s encoded message regarding her preferred DNR status. While the patient was talking about life-prolonging measures, the intern perceived that her communication also encompassed temporary interventions and assigned her the status of “DNR.” The patient and the intern committed a ™ transactional communication error of interpersonal adaptation (error of underuse) by insufficiently embracing their differential perceptions and establishing a common ground through their communication. The intern could have explained resuscitative measures in more detail, including the situations in which they might be used and their effectiveness. The patient would then have had the opportunity to present her understanding and goals for care. This failure allowed the intern’s message misinterpretation to go unchallenged and to progress to a misunderstanding (i.e. failure to establish shared understanding). More skillful dyadic communication would have been needed to validate and optimize the accuracy of the intern’s perceived meaning of the patient’s message. 2. Communication is contextual The intern called the resident to discuss the problem, but both of them committed a š transactional communication error of contextualization (error of underuse) by not discussing it enough within its chronological context – their discussion was not timely enough in the context of the patient’s unstable condition.

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Communication is more than words; Communication is equifinal and multifinal; Redundancy in content and richness in channel enhance accuracy The intern committed a › communication encoding error of sufficiency (error of underuse) by sending incomplete information – he could have accompanied his notes documenting the patient’s DNR preference with the required DNR form. This encoding error was not corrected by the nursing staff, which in turn committed a œ transactional communication error of sufficiency (error of omission) by not following up with the intern to complete the missing information in the patient’s records. These two communication errors exemplify three communication principles: Communication is more than words This episode constitutes an example of asymmetric communication (the verbal notes suggesting DNR and nonverbal communication evident in the missing DNR form suggesting the opposite). When communication is asymmetric, humans tend to trust nonverbal content more than verbal content. Similarly, the code team trusted the nonverbal communication (the missing DNR form) more than explicit communication that was noted in the patient’s records (the intern’s notes suggesting “DNR”). Communication is equifinal and multifinal Multiple communication pathways can lead to the same outcome. In this case, it was not good communication, but paradoxically a complicated chain of communication errors during that nullified the interns misunderstanding and prevented a sentinel event. Redundancy in content and richness in channel enhance accuracy A completed DNR form accompanying the intern’s notes in the records would have constituted a helpful redundancy in content that could have enhanced accuracy. In this case, such redundancy could have triggered the nursing staff at the time, and potentially the code team to directly contact the intern to clarify the intended meaning of his message. The latter was impractical in the setting of a needed resuscitation. It was good luck that the code team erred on the side of the noncommunication represented by the missing DNR form.

Discussion This case highlights the importance, complexity, and gray zones of interpersonal communication processes involved in the provision of safe and high-quality patient care. For example, the near miss in this incident was triggered by a common misunderstanding about CPR. In a “normal” interpersonal context, such a misunderstanding may have resulted in interpersonal conflict at worst and would have eventually been corrected and resolved. In the context of healthcare, however, that same type of misunderstanding almost killed a patient. Furthermore, the nonverbal message that was perceived from the missing DNR form prevented a severe error, showing the relevance

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of implicit communication for safe and high-quality care. Finally, it was the paradoxical but fortunate juxtaposition of bad communication in the execution of a misunderstood treatment plan that prevented the patient’s death. This combination of events illustrates that communication is much more than a linear transfer of health-related information among providers.

Alternative Strategies In this case, several behaviors could have prevented or intervened with the near miss: – The intern could have engaged in more skillful communication with the patient to explore and accurately express the patient’s true preferences for CPR and intubation. – The intern and the patient could have communicated together under the assumption of needing to establish a common ground. – The intern, resident, attending, and nurses could have engaged in immediate communication with one another and with the patient to understand and validate the patient’s DNR preferences. – The intern could have been aware that he communicated a message to the code team by not completing the DNR form. He also could have considered the possibilities of what that implied message could be, prior to deciding not to fill out the form. – Had time allowed it, the code team could have directly contacted the intern to reduce their uncertainty about the conflicting meaning they inferred from the intern’s initial notes versus the missing DNR form.

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Discussion Questions 1.

Patient preference is a growing focus of both research and clinical concern. In a fast-paced environment where time is both limited and of essence, how can providers build in opportunities to ensure that patient preferences are recognized, understood, and acted upon?

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Shared decision making is defined as “a process in which clinicians and patients work together to make decisions and select tests, treatments, and care plans based on clinical evidence that balances risks and expected outcomes with patient preferences and values” (National Learning Consortium). To what extent was shared decision-making achieved in this case?

Exercises 1.

Script writing Write a dialogue between the intern and the patient that could have established a shared understanding about the patient’s preferences on code status (start before Point 1 in the case).

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Flowcharting Draw an assumptions flowchart, outlining each interaction in this case and the underlying assumptions that informed each actor’s behavior.

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Case 14: Poorly advanced directives Provider-family interaction Inadvertent intubation and Harmless hit Clinical context: Acute ED visit (respiratory failure) Communication context: Interaction between an ED paramedic and the patient’s family Incident: Communication error leading to inadvertent intubation (treatment overuse) Patient safety outcome: Harmless hit Case reprinted with permission of AHRQ WebM&M. Anderson WG. Poorly advanced directives. AHRQ WebM&M [serial online]. February 2012. Available at: https://psnet.ahrq.gov/webmm/case/261.

Cared for at home by his wife and family, an 82-year-old man with multiple chronic medical conditions described his overall health as declining recently. He saw a primary care physician, received home nurse visits, and had recently been referred to a geriatrician. The primary physician realized the need for end-of-life discussions but always ran out of time due to the complexity and acuity of his medical conditions. One afternoon, the patient presented to the ED and was admitted to the hospital for delirium, an underlying infection, and acute kidney injury. During the hospitalization, the primary team engaged the patient and his family in advanced directive discussions, and the patient ultimately decided (with his family’s blessing) on a DNR/DNI order. After treatment for his infection, he returned to his baseline health status and was discharged home. The change in code status was communicated to the patient’s primary physician. Two days later, the patient returned to the same ED with altered mental status and impending respiratory failure. En route, the ™ paramedic asked the distraught family members about advanced directives and they š expressed a desire that “everything be done” to save their loved one. › Despite the previously documented DNR/DNI order, the patient was intubated and remained on mechanical ventilation for 3 days. The family ultimately decided to withdraw life-sustaining interventions, and the patient died peacefully soon afterward.

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Communication Principles 1. Communication is a non-summative process The paramedic committed a š transactional communication error of sufficiency (error of underuse) by communicating insufficiently with the patient’s family to understand what the patient himself wanted, in the face of the wish that “everything be done” to “save their loved one.” The paramedic committed a ™ communication decoding error of sufficiency (error of underuse) by not accessing other resources beyond the patient’s family members (such as the DNR/DNI form in the patient’s records at the ED) to find out about the patient’s advanced directives. Both of these were made more difficult given the patient’s rapid deterioration. 2. Redundancy in content and directness in channel enhance accuracy The paramedic committed a ™ transactional communication error of accuracy (error of omission) by not verifying with the ED staff that the patient indeed had no advanced directives on his records. The paramedic committed a š transactional communication error of accuracy (error of underuse) by insufficiently validating during his conversation with the patient’s family that their response accurately represented the wishes of the patient. The paramedic committed a › communication encoding error of accuracy (error of commission) by ordering to intubate the patient and to place him on mechanical ventilation. 3. Communication is contextual The paramedic committed a ™ communication encoding error of contextualization (error of misuse) by addressing the wrong persons about the advanced directives – the family members were emotionally distraught by the patient’s condition (relational and chronological context) and thus evidently had objectives on their mind that were at odds with the expressed wishes of the patient (functional context).

Discussion This case illustrates how a patient suffered a harmless hit as a direct result of poor communication among the involved care participants. Three core principles of human communication explain how the communication was flawed. First, the paramedic failed to frame his communication with the patient’s family within three contextual layers: Given the patient’s acute critical condition, it was both inappropriate and ineffective for the paramedic to ask the patient’s close family members (relational context) at that point in time (chronological context) about a highly

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emotional decision that entailed allowing the patient’s life to end (functional context). The family was the wrong receiver in light of the function of this communication being a mere extraction of advanced directives. Second, the care participants in this case did not establish a shared understanding of the most fundamental information needed to treat the patient’s condition. For example, the paramedic failed to retrieve the advanced directives from another source besides the family, such as the most evident place where such directives would be deposited if they existed (i.e. the patient’s records at the ED). More practically, he did not ask the family directly if the patient had an advanced directive. Furthermore, the paramedic did not establish a shared understanding with the family members on what they meant by “everything needing to be done” to “save their loved one” in concrete clinical terms. Third, appropriately redundant communication through more direct channels could have enhanced the accuracy of the interactions in this case. For example, the paramedic could have directly followed up with the ED staff to find out about the patient’s directives. In addition, he could have followed up with the patient’s family to make sure that their emotional desires actually reflected the will of the patient.

Alternative Strategies In this case, several behaviors could have prevented or intervened with the harmless hit: – The paramedic could have asked the family members if the patient had an advance directive. – The paramedic could have clarified with the patient’s family precisely what they meant by their response that “everything be done” to “save their loved one” in terms of concrete actions (i.e. DNR/DNI). – The paramedic could have accessed other resources beyond the patient’s family members (such as the DNR/DNI form in the patient’s records at the ED) to find out about advanced directives. – The paramedic could have verified with the ED staff that the patient indeed had no advanced directives on his records. – The paramedic could have validated with the patient’s family that their response accurately represented the wishes of the patient.

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Discussion Questions 1.

Patient preference is a growing focus of both research and clinical concern. In a fast-paced environment where time is both limited and of essence, how can providers build in opportunities to ensure that patient preferences are recognized, understood, and acted upon?

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Shared decision making is defined as, “a process in which clinicians and patients work together to make decisions and select tests, treatments, and care plans based on clinical evidence that balances risks and expected outcomes with patient preferences and values” (National Learning Consortium). Was shared decision making achieved in this case?

Exercises 1.

Script writing Write a dialogue between the paramedic and the patient’s family that could have established a shared understanding about the patient’s preferences on code status (start before Point 1 in the case), within the context of the time constraint inherent in the need for urgent action.

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Flowcharting Draw an assumptions flowchart, outlining each interaction in this case and the underlying assumptions that informed each actor’s behavior.

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Case 15: Discharge against medical advice Team interaction Inadvertent discharge and Harmless hit Clinical context: Acute-on-chronic inpatient admission (chronic dementia and acute delirium) Communication context: Interaction between a primary medical team and a night float covering resident Incident: Communication error leading to inadvertent discharge Patient safety outcome: Harmless hit Case reprinted with permission of AHRQ WebM&M. Hwang SW. Discharge against medical advice. AHRQ WebM&M [serial online]. May 2005. Available at: https://psnet.ahrq.gov/webmm/case/96.

A 50-year-old man with a history of alcohol dependency and alcohol-induced dementia was admitted to the medical service with mild alcohol withdrawal. He was also found to have a proximal humeral fracture, and the orthopedic consult recommended surgical repair. The patient was treated with benzodiazepines for his alcohol withdrawal and remained medically stable. After hearing the risks and benefits of surgery from the physicians, the patient refused. In light of the patient’s chronic dementia and acute delirium due to alcohol withdrawal, formal mental status testing was performed, which indicated that the patient lacked the capacity to make medical decisions. A psychiatry consultation supported this determination. On hospital day 4, at approximately midnight, the patient stated to his nurse that he wished to leave the hospital. ™ Neither the floor nurse nor the charge nurse was aware that the patient had been found to lack decision-making capacity. They contacted the night float covering resident and informed her that the patient wished to leave. š The resident glanced at the chart, › asked the patient a few questions, and œ allowed him to leave against medical advice. The primary medical team was informed the following morning about the discharge. They  had no contact information for the patient and he could not be located. What happened to him is unknown.

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Communication Principles 1. Communication is a non-summative process The night shift team committed a ™ communication decoding error of sufficiency (error of omission) by not accessing and decoding the information about the patient’s decision-making capacity in the medical records. In the same vein, the primary medical team committed a ™ transactional communication error of sufficiency by (error of omission) by not verifying the night shift team’s receipt and understanding of this important information that had been documented in the patient’s records. Thus, communication was assumed, but never attained. The resident committed a š communication decoding error of sufficiency (error of underuse) by merely glancing over the patient’s medical chart. Reviewing the chart more thoroughly could have facilitated a shared understanding that would have been necessary for her to make the correct decision. Instead, with her perception of the patient that she formed based on an insufficient reading of the medical chart, the resident inappropriately allowed the patient to be discharged against medical advice. This decision placed his safety at significant risk. Sufficient information exchange was also not attained in direct interaction with the patient. The primary medical team committed a  communication encoding error of sufficiency (error of underuse) by not obtaining contact information for the patient. In the end, this additional error put the patient at risk because the team was unable to locate and treat the patient after his inadvertent discharge. 2. Communication is more than words The resident made a œ communication decoding error of sufficiency (error of underuse) by relying on verbal communication alone (i.e. asking the patient a few questions) to determine his condition. She then committed a œ communication decoding error of accuracy (error of misuse) by misjudging the patient’s condition – likely because she did not attend sufficiently to the patient’s nonverbal displays. Given the patient’s cognitive incapacity, this could have provided more accurate information than the contents of his verbal response alone.

Discussion This case demonstrates that interpersonal communication in healthcare interactions is a complex process that occurs between rather than within people. The resident quickly pulled bits of information that she deemed relevant from the medical chart and asked the patient a few questions to confirm the impression she had already formed from skimming the chart. The resident neglected the patient’s nonverbal behaviors as a core element of communication. The primary medical team also relied

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solely on the chart as the only source of information. None of the clinicians in this case understood communication as a mutual meaning-making process. Because of this, communication with the patient never took place.

Alternative Strategies In this case, several behaviors could have prevented the harmless hit: – The night shift team could have reviewed the primary medical team’s notes more closely. – The primary medical team, ideally in a face-to-face handoff, could have conveyed the patient’s decision-making incapacity to the night shift team. – The resident could have assessed the patient’s condition more holistically – she could have reviewed the records more closely and attended to the patient’s nonverbal behavior. – The medical record might have highlighted the patient’s mental status more clearly.

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Discussion Questions 1.

When a patient is found to lack decision-making capacity, could providers continue to prioritize the “co-creation of shared meaning?” If yes, how might this be accomplished?

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In a fast-paced clinical environment, how can nonverbal cues help avoid medical errors?

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What methods can clinical staff use to consistently account for nonverbal communication from patients?

Exercises 1.

Flowcharting Draw an assumptions flowchart, outlining they key interactions in this case and the underlying assumptions informed each actor’s behavior.

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Write a sign out Describe what the primary medical team might have done to successfully convey the patient’s decision-making incapacity at sign-out to the night shift team.

Case 16: Eptifibatide epilogue | 131

Case 16: Eptifibatide epilogue Interprofessional interaction Medication underuse and Adverse event Clinical context: Acute inpatient admission (acute coronary syndrome) Communication context: Interaction between an intern, a pharmacist, and three nurses Incident: Communication error leading to medication underuse Patient safety outcome: Adverse event Case reprinted with permission of AHRQ WebM&M. Churchill WW, Fiumara K. Eptifibatide epilogue. AHRQ WebM&M [serial online]. April 2009. Available at: https://psnet.ahrq.gov/webmm/case/198.

A 62-year-old man was admitted at 11:00 PM on a Saturday night with the provisional diagnosis of acute coronary syndrome. Serial testing for markers of cardiac injury was begun, and he was treated with a beta-blocker, enoxaparin, and a statin. At 6:00 AM on Sunday, the patient’s troponin was elevated, and the diagnosis was upgraded to non-ST segment elevation myocardial infarction. The intern entered an order for intravenous eptifibatide (a powerful anticlotting agent given by intravenous drip) into the computerized order entry system in anticipation of expedited coronary intervention on Monday morning. The intern entered the correct weight-based dosage of eptifibatide (a loading dose, followed by a maintenance infusion of 2 μg/kg/min) into the order template. Because of a forcing function in the template, he also had to enter a maintenance infusion rate in milliliters per hour (mL/h). He was unsure of the proper infusion rate, so ™ he arbitrarily chose 0.5 mL/h. š He expected the pharmacist on duty to make adjustments to the order as needed. [Note: The correct infusion rate for this patient would have been 20 mL/h.] The eptifibatide order was electronically transferred to the pharmacy for processing. The › pharmacist processed the order as entered, and eptifibatide was sent to the floor for administration. The œ nurse on duty was harried because he was caring for six patients instead of the usual four. He correctly administered the loading dose and ran the maintenance infusion at 0.5 mL/h, under-dosing the patient by a factor of 40. The night shift nurse continued the infusion at this rate, as did the nurse on the following day shift. The day shift nurse  was curious about the low dose and queried the intern, but the nurse was distracted by her additional charge nurse duties.

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The patient was taken to the percutaneous cardiac intervention (PCI) lab at 2:00 PM on Monday, by which time his troponin values had peaked and were trending down. In the PCI lab, the eptifibatide infusion error was immediately noted. The patient subsequently underwent coronary angioplasty with stenting. It is impossible to say whether the underdose of the blood thinner led to more cardiac damage.

Communication Principles 1. Redundancy in content and richness in channel enhance accuracy The intern deliberately committed a ™ communication encoding error of accuracy (error of commission) by ordering the wrong infusion rate, hoping that it would serve as a placeholder and be corrected by the pharmacist. The intern and the pharmacist made a › transactional communication error of accuracy (error of omission) by not engaging in communication to validate and correct the infusion rate with each other. These two errors illustrate how redundancy (in this case, the missing repetition of the fact that the correct infusion rate was uncertain) and richness in channel (i.e. direct communication rather than electronic information transfer) could have facilitated a more accurate communication and, ultimately, the safety of the patient. 2. Preconceptions and perceptions vary among communicators The intern committed a š communication encoding error of interpersonal adaptation (error of underuse) by communicating insufficiently with the pharmacist via his medication order, accompanied by his unspoken assumption that the pharmacist would catch and fix it. To the contrary, the pharmacist assumed the ordered dose was what was intended. This error demonstrates the importance of recognizing that peoples’ individual perceptions vary and that interpersonally adaptive communication skills are needed to bridge this gap in order to establish a shared understanding. 3. Communication is contextual The nurse on duty and the night shift nurse committed a œ communication decoding error of contextualization (error of underuse) by not allotting sufficient time within their unusually busy schedules to correctly decode the infusion rate indicated by the pharmacist (chronological context), particularly with respect to the treatment objective (functional context). Instead, they ran the maintenance infusion as ordered and the patient received a subtherapeutic dose. The second day shift nurse also committed a  communication encoding error of contextualization (error of underuse) by not allotting enough time (chronological context) to establish a shared understanding (functional context) of the medication dosage with the intern. Instead, her communication with the intern remained at the level of a query rather than a more assertive interaction.

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These two errors illustrate the importance of framing one’s communication within the context of a given care scenario to optimize a shared understanding and promote patient safety.

Discussion The key patient safety theme highlighted in this case is the accuracy of communication. The case demonstrates how the involvement of multiple staff members in the care for one patient can complicate communication processes and thereby decrease the likelihood of communication accuracy, which in turn can compromise patient safety. At the same time, if staff members communicate well, their participation can perform a validative function. In this case, this kind of inter-staff communication could have led to recovery and averted the adverse event.

Alternative Strategies In this case, several behaviors could have prevented the adverse event or permitted recovery: – Because the intern did not know the correct calculation, he could have consulted others to learn the correct infusion rate. – The intern could have supported his communication to the pharmacy with a follow-up phone call to indicate that he did not know how to calculate the infusion rate and that the value he entered might be wrong. – The clinical staff members, particularly the nurses, could have relied on their instincts and experience, communicated with each other to validate the accuracy of the infusion rate, and then communicated this to the intern.

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provided in the answer key on page 252. Are there any discrepancies? Discuss how any alternative lessons that you may have chosen or disregarded apply to this case.

Discussion Questions 1.

How could the clinical staff have allocated time to ensure message receipt and a shared understanding?

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Describe three ways in which clinical staff members could have validated the accuracy of communication.

Exercises 1.

Script writing Write an alternate script of action and dialogue for the intern when he realized that he was unsure of the proper infusion rate (before Point 1).

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Recovery scenario Write two interactions, each of which would take less than 60 seconds, that could have interrupted the inaccurate communication from reaching the patient.

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Case 17: Code blue – Where to? Cross-professional interaction Inadvertent intubation and Near miss Clinical context: Acute inpatient admission (hallucinations and anxiety) Communication context: Interaction between a senior medical resident, a medical intern, an anesthesia resident, anesthesia attending, a critical care nurse, and inpatient psychiatry nurses Incident: Communication error leading to near intubation Patient safety outcome: Near miss Case reprinted with permission of AHRQ WebM&M. Adams BD. Code blue – Where to? AHRQ WebM&M [serial online]. October 2007. Available at: https://psnet.ahrq.gov/webmm/case/162.

An 80-year-old man with a history of coronary artery disease, hypertension, and schizophrenia was admitted to an inpatient psychiatry service for hallucinations and anxiety. On hospital day 2, he had sudden onset of confusion, bradycardia, and hypotension. He lost consciousness, and a “code blue” was called. The inpatient psychiatry facility was adjacent to a major academic medical center. The “code team” (comprised of a senior medical resident, medical intern, anesthesia resident, anesthesia attending, and critical care nurse) within the main hospital ™ was activated. The message blared through the overhead speaker system, “Code blue, fourth floor psychiatry. Code blue, fourth floor psychiatry.” The senior resident and intern had never been to the psychiatry facility. “How do we get to psych?” the senior resident asked a few other residents in a panic. “I don’t know how to get there except to go outside and through the front door,” a colleague answered. So the senior resident and intern ran down numerous flights of stairs, outside the front of the hospital, down the block, into the psychiatry facility, and up four flights of stairs (the two buildings are actually connected on the fourth floor). Upon arrival, the team found the patient apneic and pulseless. The nurses on the inpatient psychiatry ward had placed an oxygen mask on the patient, but the patient was not receiving ventilatory support or chest compressions. The resident and intern š began basic life support (CPR with chest compressions) with the bag valve mask. When the critical care nurse and the rest of the code team arrived, they attempted to hook the patient up to their portable monitor. Unfortunately, the leads on the monitor were incompatible with the stickers on the patient, which were from the psychiatry floor (the stickers were < 10 years old). The team did not have appropriate leads to connect the monitor and sent a nurse back to the main

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hospital to obtain compatible stickers. In the meantime, the patient remained pulseless with an uncertain rhythm. Moreover, despite ventilation with the bag valve mask, the patient’s saturations remained < 80%. After minutes of trying to determine the cause, it was discovered that the mask had been attached to the oxygen nozzle on the wall, but the oxygen had not initially been turned on by the nursing staff. The oxygen was turned on, the patient’s saturations started to rise, and the anesthesiologist š prepared to intubate the patient. Chest compressions continued. At this point, a staff nurse on the psychiatry floor came into the room, recognized the patient, and shouted, › “Stop! Stop! He’s a no code!” Confusion ensued – œ some team members stopped while others continued the resuscitation. A review of the chart showed  no documentation of a “Do Not Resuscitate” order, so the resuscitation continued. The intern on the team called the patient’s son, who confirmed the patient’s desire to not be resuscitated. The efforts were stopped, and the patient died moments later.

Communication Principles 1. Redundancy in content and directness in channel enhance accuracy The inpatient psychiatry ward staff committed a ™ communication encoding error of accuracy (error of commission) by inappropriately activating the code team. 2. Communication is contextual The resident, the intern, and the anesthesiologist committed a š transactional communication error of accuracy (error of omission) by not addressing the patient’s DNR/DNI preferences while getting ready to initiate life support. The staff nurse on the psychiatry floor committed a  communication encoding error of sufficiency (error of omission) by having neglected to add the DNR order to the patient’s records. The staff nurse also committed a › communication encoding error of sufficiency (error of underuse) by insufficiently justifying her sudden “stop” order. The code team clinicians committed a œ transactional communication error of clarity (error of misuse) by being ineffective in their communication with one another and the staff nurse to clarify the ambiguity of the contradictory DNR/no-DNR messages. The staff nurse on the psychiatry floor committed a › communication encoding error of contextualization (error of underuse) by not intervening with code team’s activation in a more timely manner (chronological context). The clinicians committed a  communication decoding error of contextualization (error of underuse) by reviewing the chart and facing the DNR-question only after preparing the patient for intubation (chronological context).

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Discussion This case demonstrates the importance of communication as a vehicle to attain coordinated care. In this incident, all clinicians relied on an initial call for a code and assumed that everything needed to be done to keep the patient alive. The cause of this inaccuracy was a lack of communication on several levels – for example, the patient’s DNR preference had not been documented in the records, the code was not interrupted by the staff nurse before the clinicians prepared to intubate, and the team was confused about the patient’s DNR preference until the intern finally called the patient’s son to confirm the DNR status. This inaccuracy was not only caused by poor communication, but it could have also been repaired through accuracy-promoting communication processes. Content redundancy could have clarified ambiguities, reduced uncertainty, and corrected accuracy with respect to the patient’s DNR status. For example, the inpatient psychiatry ward staff could have verified the patient’s DNR preference in various ways before activating the code team, the clinicians could have engaged in direct communication with one another to clarify their uncertainty regarding the patient’s DNR preference, and the staff nurse could have reinforced her sudden call to stop with a more detailed explanation. Of course, this case was framed within a tight timeline that did not allow much flexibility for ad-hoc discussions. It is important to recognize, however, that it was an initial communication error that induced this time constraint. Competent communication in the first place could have averted this communication-induced dilemma.

Alternative Strategies In this case, several behaviors could have prevented or intervened with the near miss: – The inpatient psychiatry ward staff should not have activated the code team without first making sure that the patient had not expressed a DNR preference, or could have checked immediately after activating the call. – The resident, the intern, and the anesthesiologist could have communicated with one another to validate the accuracy of the patient desiring CPR and intubation while preparing to initiate life support. – The staff nurse on the psychiatry floor could have added a DNR order to the patient’s records at the time of admission. – The staff nurse on the psychiatry floor could have accompanied her sudden call to “stop” with a succinct and clear explanation. – The code team clinicians could have communicated with one another and the staff nurse to clarify the ambiguity of the contradictory DNR/no-DNR messages.

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The staff nurse on the psychiatry floor could have either intervened with code team activation right away, or been present at the code team’s arrival to correct the errorin-the-making. The clinicians could have reviewed the chart and discussed the DNR question while preparing the patient for intubation.

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Discussion Questions 1.

What are two steps that hospitals could take to improve communication in order to reduce confusion among staff when a code is called?

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What are three diverse channels of communication that could have been better engaged in this case?

Exercises 1.

Identify failure points Re-read the case and identify points at which actors could have ensured message receipt and shared understanding. For each point, describe one action that could have helped to accomplish this goal.

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Policy making Describe an institution-wide policy or system that could help providers maintain clarity on the status of advanced directives and DNR/DNI orders for the duration of a patient’s care, across multiple care locations and staff.

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Case 18: Right? Left? Neither! Inter-institutional interaction Inadvertent surgery and Near miss Clinical context: Acute outpatient after-hours clinic visit with subsequent inpatient admission (signs of dehydration) Communication context: Interaction between after-hours clinic staff, an orthopedic surgeon, radiology staff, and staff at a prior ED Incident: Communication error nearly leading to inadvertent surgery Patient safety outcome: Near miss Case reprinted with permission of AHRQ WebM&M. Howell EA, Chassic MR. Right? Left? Neither! [Spotlight]. AHRQ WebM&M [serial online]. May 2006. Available at: https://psnet.ahrq.gov/webmm/case/ 127.

A 79-year-old woman presented to an after-hours clinic with a 1-week history of diarrhea and progressive weakness. Due to signs of dehydration, the patient was directly admitted to the hospital. Past medical history was notable for stroke with residual leftsided hemiparesis, hypertension, coronary artery disease with ischemic cardiomyopathy, peptic ulcer disease, asthma, and obesity. Two weeks prior to this admission, she had spontaneously developed right ankle and foot pain and had been evaluated in the ED of another hospital. The family was told of a possible fracture and a splint was applied. The patient was instructed to follow up with an orthopedist as soon as possible. Due to transportation difficulties, the patient was not seen in follow-up. On physical examination, the patient was afebrile and appeared weak. She had a left-sided hemiparesis. The right ankle and foot were in the same splint that had been applied 2 weeks earlier. When examined, the ankle had a normal range of motion with no localized tenderness. A stool specimen collected in the ED was subsequently positive for Clostridium difficile (C. difficile) toxin. At the time of admission, a release of information was signed and faxed to the other hospital to obtain records of the recent ED visit for the ankle and foot injury. The family requested an orthopedic consultation to expedite work-up. ™ Outside records from the previous ED visit did not arrive promptly, so another x-ray was taken of the right foot and ankle. This x-ray was read by the radiologist as showing a right ankle trimalleolar fracture and dislocation. The consulting orthopedist š reviewed the x-ray report, and then briefly examined the patient. › Surgery was recommended and discussed with the family, and consent was obtained.

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The next morning, the patient was taken to the OR, and spinal anesthesia was administered. The orthopedist was scrubbed and was preparing to operate. The ankle x-ray was on the view box in the OR. Prior to making an incision, the orthopedist reviewed the x-ray and œ was shocked to notice that it was a left ankle x-ray showing a trimalleolar fracture. A prompt examination of both ankles of the patient under anesthesia did not demonstrate any clinical evidence of fracture or dislocation. The x-ray was clearly labeled as belonging to the patient. STAT x-rays of both ankles were then done in the OR. The left ankle was intact and x-ray of the right ankle showed an intact ankle with a healing fracture of the fifth metatarsal bone. During the ensuing confusion,  one of the OR technicians recalled that another patient had undergone an operative reduction-internal fixation of a left ankle trimalleolar fracture 2 days prior. It was later confirmed that the x-ray showing the left ankle trimalleolar fracture was mislabeled by date and patient and belonged to this other patient who already had surgery. The spinal anesthesia was reversed, and the patient was returned to her room and fortunately did not have any consequences. Full disclosure and an apology were given to the family. The patient continued to recover from the dehydration and colitis and was able to be discharged from the hospital. Treatment for the metatarsal fracture consisted of a supportive boot. By the time of discharge, a faxed ™ copy of the ED records from the outside hospital had been received. Included in these records was an x-ray report describing a nondisplaced, fifth metatarsal fracture of the right foot.

Communication Principles 1. Communication is contextual The responsible staff at the previous ED and at the after-hours clinic committed a ™ transactional communication error of contextualization (error of underuse) by not sufficiently considering the chronological context within which their communication was framed (i.e. the communication needing to take place immediately due to an impending surgery). Instead of direct and prompt communication that could have corrected the incorrect impression of a fracture of the right ankle rather than the foot that critical communication was delayed until the records from the previous ED visit arrived. Because of this delay, the receiving hospital took another x-ray. This unnecessary test reduced the efficiency of care and nearly compromised the safety of the patient by unnecessary surgery. 2. Redundancy in content and richness in channel enhance accuracy Three communication errors contributed to the near miss in this case, which nearly ended in unnecessary surgery. First, the radiological technician who did the initial

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x-ray at the after-hours clinic committed a  communication encoding error of accuracy (error of misuse) by mislabeling the x-ray with the name of the wrong patient. Second, the orthopedist committed a š communication decoding error of accuracy (error of misuse) by misreading the x-ray (i.e. it showing a left rather than the right ankle of the patient). As a direct result of this error, he committed a › communication encoding error of accuracy (error of commission) by recommending an unindicated surgery. Luckily, the orthopedist œ caught and corrected his two errors on time to intervene with the surgical error-in-the-making.

Discussion This case illustrates the importance of communication accuracy to safe and highquality patient care. It also demonstrates how an initial inaccuracy in communication must be corrected through subsequent skillful communication. In this example, the initial encoding inaccuracy in the form of the radiological technician’s mislabeling error of the x-ray triggered a cascade of additional communication accuracy errors that nearly led to an unnecessary surgery. It was the communication redundancy in content (i.e. repeated exposures to the x-ray with the image reappearing on the view box of the OR) and the directness of the communication channel (i.e. the clinical staff communicating about the x-ray in a synchronous setting and face-to-face) that ultimately corrected the errors and averted an impending adverse event. This chain of events demonstrates that communication is much more than a mere channel for information transfer; instead, communication is an adaptive, dynamic process that clinicians interactively engage in to effectively co-construct a shared understanding as a foundation for safer, higher quality care. This case also demonstrates how multiple care participants contribute to and share in this joint meaning-making process. The case demonstrates particularly the role of the nonclinical participants in enabling safer care – it was the family of the patient who initiated the needed orthopedic consultation.

Alternative Strategies In this case, several behaviors could have prevented the near miss at an earlier point in time: – The staff of the previous ED and the staff of the after-hours clinic could have engaged in immediate communication – directly by phone – to establish a common ground and shared understanding of the patient’s health condition and recent fracture.

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The radiological technician at the after-hours clinic could have verified that he had assigned the x-ray to the right patient and labeled it correctly. Prior to recommending surgery, the orthopedist could have verified that he read the x-ray correctly.

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Discussion Questions 1.

What hospital-wide policy could reduce mislabeling of date and patient name?

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What system could clinical staff adopt to reduce mislabeling of date and patient name?

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Name the actors Describe the roles that nonclinical actors played in this case.

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Build resilience into the system List factors in this case that promoted recovery from the initial communication error. Describe how the system could be changed to increase this kind of resilience.

Stage 4: Storage Storage entails the processes that occur between the formulation and execution of a treatment plan for a patient’s medical condition. Such processes include interactions and information exchange between clinicians and patients, among different clinicians, and between care teams, both within and across hospitals, ambulatory care clinics, pharmacies, and other healthcare institutions. Storage is not a term that is generally used by clinicians to describe the care they deliver. However, the storage phase represents an error-prone period of time in which transitions, handoffs, timeliness, and many other issues can compromise the safety of patient care.

DOI 10.1515/9783110455014-010

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Case 19: Bad writing, wrong medication Provider-patient interaction Inadvertent medication and Adverse event Clinical context: Routine outpatient follow-up visit (cardiac arrhythmia) Communication context: Interaction between a physician and a patient Incident: Communication error leading to patient’s inadvertent medication use Patient safety outcome: Adverse event Case reprinted with permission of AHRQ WebM&M. Devine B. Bad writing, wrong medication [Spotlight]. AHRQ WebM&M [serial online]. April 2010. Available at: https://psnet.ahrq.gov/webmm/case/215.

A 73-year-old man with a long-standing cardiac arrhythmia came to the ambulatory clinic for a routine follow-up visit. After evaluation, he received a ™ handwritten prescription for Rythmol (propafenone), 150 mg, which had been his usual antiarrhythmic medication for the past 3 years. The patient delivered the prescription to the clinic pharmacy and it was filled. Shortly after starting to take the medication, the man began to feel “very, very bad,” with nausea, sweating, and an irregular heartbeat. These symptoms persisted › for 2 weeks, and the patient called his physician to schedule another appointment. The patient brought the medication to his physician, stating that the Rythmol tablets looked different from their usual appearance. Based upon the altered appearance of the tablets, both the patient and the physician suspected that this might not be the correct drug. Upon investigation, the physician identified the patient’s medication as Synthroid (levothyroxine), 150 mg, not the intended Rythmol (propafenone), 150 mg. When the physician spoke with the pharmacist who had filled the prescription, it became apparent that a medication dispensing error had occurred due to œ unclear handwriting on the original prescription. The patient’s symptoms of nausea, sweating, and irregular heartbeat were related to both inadvertent, abrupt discontinuation of Rythmol, and the unnecessary use of Synthroid at a relatively high initial dosage. Synthroid was immediately discontinued, and the patient restarted Rythmol as originally prescribed.

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Communication Principles 1. Preconceptions and perceptions vary among communicators The physician committed a ™ communication encoding error of clarity (error of misuse) by submitting the prescription with unclear handwriting. In addition, the physician and the pharmacist committed a œ transactional communication error of clarity (error of omission) by not communicating with each other to clarify the ambiguity of the handwriting and how to decipher prescription. 2. Redundancy in content and directness in channel enhance accuracy The pharmacist committed a œ communication decoding error of accuracy (error of misuse) by misreading the physician’s handwritten order. 3. Communication is contextual The patient committed a › communication encoding error of contextualization (error of underuse) by waiting 2 weeks (chronological context) to raise the issue regarding the medication refill looking different and causing side effects (functional context) to the physician.

Discussion This case demonstrates the importance of understanding communication as a shared meaning-making process. A successful establishment of shared understanding entails more than merely transferring information to the next informational “docking point” (i.e. to next person in the care process). Rather, it requires thinking the communication process through to the last person involved, with the objective of establishing a common ground among all care participants. In other words, communication is an interactive sense-making activity participants engage in to establish a shared “meaning,” which constitutes an intersubjective product that is larger than the sum of its parts. This sense-making process is complex, as demonstrated in this case, even at the most basic level of deciphering someone’s handwriting. The case also illustrates the importance of timely communication in promoting safe and high-quality care to patients. In this case, the patient’s more timely communication about his own symptoms could have prevented him from taking the wrong medication. Had the patient immediately raised his concerns to the pharmacist or physician about the medication looking different, the incident could have been prevented. When the patient began to experience adverse drug effects, he could have also communicated this sooner. This event underlines the importance that all involved actors, including patients and their families, need to be involved as active partners for safe and high-quality care.

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Alternative Strategies In this case, several behaviors could have prevented or intervened with what was fortunately a relatively mild adverse event with no long-term consequences: – The pharmacist could have contacted the physician to verify what was intended on the handwritten prescription. – The pharmacist should not have filled the prescription without being certain about the meaning of the physician’s handwriting. – The patient could have immediately raised attention to the pharmacist that the medication looks different than usual. – The patient could have immediately contacted his physician to inform him about the medication side effects. – Generally, replacing paper prescribing with electronic prescribing could reduce the problem of unclear handwriting on prescriptions.

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Discussion Questions 1.

How can providers activate patients and encourage them to participate sooner and with greater confidence to prevent medication errors like the incorrect prescription in this case?

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Exercises 1.

Roleplay Roleplay what the pharmacist might have said to the physician to clarify what was handwritten on the prescription.

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Case 20: Nothing-per-oral (NPO) for possible fracture Provider-family interaction Delayed treatment and Harmless hit Clinical context: Acute ED visit (rule out leg fracture) Communication context: Interaction between ED staff and the patient’s mother Incident: Communication error leading to delayed treatment Patient safety outcome: Harmless hit Case written by Annegret F. Hannawa, Ph.D. and Sandra W. Hwang, M.S.P.H.

A 6-year-old boy presented to the ED at 11:30 AM with sharp pain in his right leg and inability to walk after an accident on the playground. The patient appeared to be in shock, but the leg showed no swelling. ™ After a 2-hour wait, an x-ray was performed. While waiting for the results, the patient’s mother noticed that her son appeared faint. She stepped into the hallway to request that the nurse provide some water or juice, as her son had not eaten lunch or drunk water, and his blood sugar had dropped. š The nurse refused stating that if the patient’s leg were fractured, he would need to avoid food and drink prior to potential surgery. ™ About an hour later, the ED team returned with the x-ray results, which indicated a broken right lower tibia. The team decided against surgery and elected for a cast. As the › patient remained without water, the mother noticed his eyes drifting. She stepped into the hallway again to request water or juice. With an œ onslaught of new cases in the ED, the ED staff  dismissed her request and ž told her to remain in the room, stating that Ÿ someone would be with her son to put the cast on. About half an hour later, the patient fainted. The mother called out for help, and the medical team overseeing the case rushed to assist. The patient regained consciousness within several minutes and was given a fruit juice. The cast was applied and the patient was discharged with pain medications.

Communication Principles 1. Communication is contextual The ED staff committed a ™ communication decoding error of contextualization (error of underuse) by insufficiently decoding the patient’s appearance within the chronological and functional context of the care episode – with the patient present-

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ing to the ED at lunchtime (i.e. not having had anything to eat or drink in a while; chronological context/“timing”) and that extensive delays in his treatment (chronological context/“duration”) may cause his blood sugar to drop (functional context). The ED nurse committed a š communication decoding error of contextualization (error of underuse) by insufficiently decoding the mother’s alerting communication in the context of the mother being close to the patient (relational context) and thus being aware of his past history and a resource for detecting unusual signs or symptoms in the patient (functional context). The ED staff committed a œ communication decoding error of contextualization (error of underuse) by taking insufficient time within the context of a busy ED (chronological context) to attend to the mother’s alerting request (functional context). The ED staff committed a Ÿ communication encoding error of contextualization (error of underuse) by insufficiently stating within what anticipated timeframe (chronological context) the mother could expect to see a clinician for the cast, given her son’s faintness (functional context). 2. Communication entails factual and relational information The ED staff committed a ™› communication decoding error of interpersonal adaptation (error of underuse) by insufficiently embracing the patient’s need to be treated quickly, because further delays in his treatment (with added time implications of a potential surgery that may be needed to align his fracture) would cause him discomfort. The ED staff committed a › communication encoding error of interpersonal adaptation (error of underuse) by insufficiently adapting to the patient’s needs once the ED team had decided that surgery was not required. The ED staff committed a ž communication encoding error of interpersonal adaptation (error of underuse) by insufficiently communicating with the mother in a way that adapted to her need to draw attention to her child’s care condition. 3. Redundancy in content and directness in channel enhance accuracy The ED staff committed a  communication decoding error of accuracy (error of misuse) by misinterpreting the mother’s behavior as nagging rather than as an informed warning.

Discussion This case illustrates three principles of human communication and their importance to the provision of safe and high-quality patient care. First, the care episode demonstrates the importance of communication as a process that is contextual on multiple levels. Particularly, it shows that the chronological

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dimensions of any given healthcare interaction (i.e. timing, duration, timeliness, and allocating time) can compromise the effectiveness and appropriateness of any care episode. In addition, the case illustrates how relational compositions (e.g. hierarchical differences due to status or gender) among care participants can either facilitate or constrain communication and directly affect a patient’s care outcome. Second, this case highlights that communication includes factual and relationship-defining information, both of which may not necessarily be stated verbally. In fact, relational messages tend to be perceived more strongly from nonverbal than verbal communication. In this episode, relational messages were communicated, for example, by the care providers’ insufficient adaptation of their communication to the needs and expectations of the young patient and his mother. The episode demonstrates how such interpersonal adaptation is not only relevant to “soft” care outcomes (e.g. patient satisfaction), but how it can directly contribute to a better understanding of the well-being of the patient and – as shown in this case – even prevent an adverse event. In other words, the skill of flexibly adapting to the expressed needs and expectations of an other care participant can greatly contribute to successful communication and facilitate positive care outcomes. Third, this case illustrates the principle of redundancy facilitating accuracy, a recurring theme throughout this book. Different in this case, however, is the negative implication of redundancy if it is overused, evidencing that redundancy is a two-edged sword: if it is overused, it can severely constrain the potential of communication leading to a shared understanding. This case furthermore demonstrates how the negative effect of such over-redundancy on competency perceptions can be moderated by hierarchical status differences among care participants. Here, the “lay” mother’s redundancy was perceived as annoying by the “expert” ED staff who trusted in their own clinical competency rather than in the mother’s judgments of the patient’s condition.

Alternative Strategies In this case, several behaviors could have prevented or intervened with the harmless hit: – The ED staff could have recognized that the patient presented to the ED at lunchtime and treated him more promptly to avoid the extensive delays that caused him to faint. – The ED nurse could have recognized the value of the mother’s communication in facilitating timely pain management and treatment of the patient’s fracture. – The ED staff could have started intravenous fluid to avoid a decrease in fluid volume or hypoglycemia, while maintaining him NPO until the decision was made to not proceed with surgery.

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The ED staff could have provided pain medication and a snack/water to the patient shortly after the ED team decided that surgery was not required. The ED staff could have taken the time, despite the onslaught of new cases in the ED, to properly decode the mother’s alerting request. The ED staff could have appropriately adapted their communication with the mother to her needs and expectations regarding the care of her child. For example, by taking her concerns seriously and responding to (rather than dismissing) her request with verbal and nonverbal attentiveness to convey that they understood and will act upon her concern promptly to decrease the discomfort of her son. The ED staff could have been clearer in their communication with the patient’s mother about the anticipated timeframe within which the clinician would come to see her child for setting the cast.

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Discussion Questions 1.

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Exercises 1.

Script writing Write an alternate script for the interaction between the nurse and the mother between points 1 and 2.

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Case 21: A room without orders Team interaction Medication misuse and Adverse event Clinical context: Acute inpatient admission (chemotherapy) Communication context: Interaction between three nurses across shifts Incident: Communication error leading to patient’s medication misuse Patient safety outcome: Adverse event Case reprinted with permission of AHRQ WebM&M. Vogelsmeier A, Despins L. A room without orders [Spotlight]. AHRQ WebM&M [serial online]. January 2016. Available at: https://psnet.ahrq.gov/webmm/ case/365.

A 56-year-old man with acute lymphoblastic leukemia and diabetes mellitus was admitted to the hospital for a scheduled cycle of chemotherapy. He had no acute complaints. The patient arrived directly to the medical unit on a busy afternoon and waited in a nearby area for his assigned room. At shift change, the patient’s room was ready, but the nurse who had initially greeted him on arrival had been replaced by a new nurse who ™ escorted the patient to his room. The nurse completed the usual check-in process later in the evening, but š did not contact the admitting provider, making the assumption that this had occurred several hours earlier. Therefore, no admitting orders were written. The patient spent the night in the hospital and took his own insulin, which he had brought from home. No evening meal was delivered; › the patient thought that holding his food was part of his chemo regimen, so he œ did not question this. Because he was not complaining of any symptoms and took few medications at home, he  did not prompt the need for any orders overnight. The following morning, the new nurse (the third in his care so far) noted that the patient was difficult to arouse. She went to review the existing orders and discovered they were completely absent. She paged the on-call team, who immediately evaluated the patient and successfully treated him for symptomatic hypoglycemia, which had been caused by the patient’s insulin taking effect in the absence of food intake. The case prompted a formal review as, in addition to the preventable episode of hypoglycemia, the initiation of his scheduled chemotherapy was delayed.

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Communication Principle 1.

Preconceptions and perceptions vary among communicators; Communication is more than words The nurses and patient in this case committed five critical communication errors based on their discrepant perceptions and incorrect assumptions that communication constitutes a mere transfer of verbal information. First, the nurse committed a ™ transactional communication error of sufficiency (error of underuse) by missing the opportunity to validate the information exchanged with the previous nurse and with the patient while escorting him to his room. The nurse also committed a š communication encoding error of sufficiency (error of omission) by not getting in touch with the admitting provider during the check-in process. In his role as an active partner for safe and high-quality care, the patient committed a › communication decoding error of accuracy (error of misuse) by misinterpreting the fact that his dinner was not delivered as part of his chemo regimen. The patient also committed a œ transactional communication error of accuracy (error of omission) by not contacting the nurse to verify that he was in fact not supposed to be getting dinner. The patient committed another  transactional communication error of accuracy (error of omission) by not validating with the providers that he was not supposed to be getting any medication overnight.

Discussion Humans often hold differential preconceptions and perceptions of the same object they have in mind. This case illustrates the importance of establishing a common ground as a foundation for neutralizing such discrepant perspectives, en route to engaging in accurate communication and reaching a shared understanding. In this case, the opposite happened: the nurse omitted critical communication with the admitting physician based on her misperception that this communication had already taken place. As a result, admitting orders were never written. In addition, the nurse omitted critical communication with the patient while she was transferring him to his room. Instead, the nurse held firmly to her initial perception that the necessary communication had already taken place. Therefore, she did not make an effort to validate those perceptions. This case also demonstrates the importance of encouraging a communication culture that engages patients as active partners in their own care. The patient trusted in his perception that “not eating” was part of his chemo protocol, and thus misinterpreted and omitted critical communication with the medical team that could have prevented his hypoglycemic episode. He did not communicate with the providers because he trusted in his perception that he was doing fine with his home medication.

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A culture that encourages patients to speak up when they perceive something amiss could have prevented this adverse event. In summary, both the nurses and the patient in this care episode acted based upon incorrect assumptions. Their failure to communicate with each other resulted from their inaccurate belief that (1) communication equals words (i.e. underestimating the power of “missing” verbal communication, evident in a missing dinner, to convey meaning); (2) meaning lies within people rather than between people (i.e. underestimating the importance of interpersonal communication as an essential process for safe and high-quality care); (3) information passes from one person to the next (i.e. understanding communication as a linear information transfer rather than a complex interactive meaning-making process); and (4) others will figure out what is in their head (i.e. trapped in the common ground fallacy). Together, the care participants could have overcome these perceptual gaps and prevented an adverse event through direct and sufficient communication.

Alternative Strategies In this case, several behaviors could have prevented or intervened with the adverse event: – The care participants should not have assumed that communication has already taken place. – The nurse could have spoken in more detail to the nurse on the previous shift to understand what had already taken place during this care episode. – The nurse should have communicated with the admitting physician during the check-in process. – The patient could have contacted the nurse regarding his missing dinner and medications to validate his impression that they had been missed.

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Discussion Questions 1.

What were two points in this case at which actors made assumptions that should have been validated before moving forward?

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The providers taking care of a hospital patient change several times during the day. How can clinical staff work together around shift changes, hand-offs, and other care transitions to reduce insufficient and unsuccessful communication?

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Prepare patient instructions Write a set of instructions that could have helped the patient understand what to expect when being admitted to the hospital to receive chemotherapy.

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Case 22: Tacit handover, overt mishap Team interaction Incomplete handoff, Unsafe treatment, and Adverse event Clinical context: Acute inpatient admission (infected aortic stent) Communication context: Interactions between anesthesiologists Incident: Communication error leading to incomplete handoff and unsafe catheter removal Patient safety outcome: Adverse event Case reprinted with permission of AHRQ WebM&M. Cooper JB, Kamdar BB. Tacit handover, overt mishap. AHRQ WebM&M [serial online]. June 2010. Available at: https://psnet.ahrq.gov/webmm/case/219.

A 61-year-old man was admitted for management of an infected aortic stent, which had been placed 3 years ago to treat an abdominal aortic aneurysm. In preparation for surgical removal of the infected stent and graft repair of the abdominal aorta, a spinal drain was placed by an anesthesiologist. The spinal drain, a small soft catheter, was inserted into the lower spinal cord to remove cerebrospinal fluid – these drains lower pressure in the spinal cord and thereby reduce the risk for post-surgery paralysis. The patient underwent uncomplicated removal of the infected stent and graft repair of the aorta. As per protocol, the spinal drain remained in place for 48 hours after the procedure. At that time, the anesthesiologist attempted to remove the drain, but aggressive pulling resulted only in stretching of the catheter. Concerned about causing injury to the patient, he consulted a neurosurgeon, who recommended that further attempts to remove the catheter be done under general anesthesia in the OR, in hopes that anesthesia would relax the back muscles. The patient was placed on the OR schedule for the following day. The anesthesiologist and neurosurgeon both clearly documented the plan of care in the chart. The following morning, the five anesthesiologists on duty met to discuss all of the cases scheduled for the day, including the catheter removal, so all of them were aware of the plan. Unfortunately, because of prolonged surgeries, the case was pushed to the end of the day. By that point, ™ the anesthesiologist on call for the night had arrived, unaware of any of the treatment plans. š She noticed that this case was labeled “spinal drain removal” on the schedule. Confident that she knew how to manage these devices, she approached the head anesthesiologist for the day and asked if she could “take care of the spinal drain case.” The head anesthesiologist knew that she had experience in the area and › simply said “yes,” œ without conveying any

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further information. The on-call anesthesiologist  did not review the patient’s chart or obtain any further information. Unaware of the plan for general anesthesia, the on-call anesthesiologist proceeded to try to pull out the drain while the patient was awake in the preoperative area. Unfortunately, the catheter broke, leaving a portion inside the spinal canal. Consequently, the neurosurgeon had no choice but to surgically remove the catheter. Luckily, the patient suffered no major consequences, but was at risk for spinal cord injury and had to undergo a second surgical procedure.

Communication Principles 1. Communication is contextual The head anesthesiologist properly delegated the spinal drain removal to an experienced colelague who was qualified to perform it. However, he committed a › communication encoding error of contextualization (error of underuse) by not taking the necessary time to review the patient’s records (chronological context) prior to delegating the task to the on-call anesthesiologist. 2. Preconceptions and perceptions vary among communicators The on-call anesthesiologist committed a š communication decoding error of accuracy (error of misuse) by misinterpreting the label “spinal drain removal” as indicating a simple procedure rather than the more complicated catheter removal in this case. Similarly, the head anesthesiologist committed a › communication encoding error of clarity (error of misuse) by approving the anesthesiologist on call to perform the procedure without clarifying what the procedure actually entailed. 3. Communication is a non-summative process This case demonstrates a lack of information exchange that resulted from three critical communication errors: First, the initial team of anesthesiologists and the incoming anesthesiologist on call committed a ™ transactional communication error of sufficiency (error of underuse) by not engaging in enough communication to establish a common ground on the recent medical history and specific treatment plans for the patient. Second, the head anesthesiologist committed a œ communication encoding error of sufficiency (error of underuse) by insufficiently describing the complete details of the needed procedure with the anesthesiologist on call. He did not convey any further information beyond approving her to carry out “the task.” Third, the on-call anesthesiologist committed a  communication decoding error of sufficiency (error of omission) by not reviewing the patient’s chart or any

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other information (i.e. not establishing a shared understanding of the patient’s medical circumstances) before conducting the procedure.

Discussion This case illustrates the importance of contextualizing communication – in particular, the importance of allocating time for completing required transactional communication. This care episode also highlights the importance of clear, unambiguous encoding and decoding as a core prerequisite for communication accuracy that establishes a common ground based on which participants can engage in a mutual meaning-making process. Finally, the case demonstrates the importance of information sufficiency (i.e. review and discussion of the complete available information) and illustrates how communication does not merely entail “passing off” information to the next provider. Rather, the case exemplifies how communication is a complex interactive process that facilitates the establishment of a shared understanding between all care participants. This meaning-making activity is illustrated well by the labeling of the needed treatment as a “spinal drain case,” which evoked different associations among the different care providers. Competent communication would have been required to attain a shared understanding of this label and its implications for the patient’s treatment.

Alternative Strategies In this case, several behaviors could have prevented or intervened with the adverse event: – The previous team of anesthesiologists could have debriefed the incoming anesthesiologist on call and the head anesthesiologist about the patient’s care, including the recent complicating factors. – The anesthesiologist on call could have clarified what the previous team meant by “spinal drain case.” – The head anesthesiologist and the anesthesiologist on call could have established a shared meaning in review of the records with respect to the label “spinal drain case,” and discussed the most appropriate path of action. – Both the head anesthesiologist and the anesthesiologist on call could have allocated time to review the patient’s records prior to delegating/executing the treatment.

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Communication Lessons for Safer, Higher Quality Care

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Discussion Questions 1.

How did an initial error in this case contribute to the incomplete handoff and subsequent treatment error?

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In this case, it initially appeared that all providers had full information, given that all five anesthesiologists on duty met and were aware of the plan. In the event of delays and handoffs that ensue, how can teams ensure accurate and sufficient communication?

Exercises 1.

Identify opportunities for recovery Describe three opportunities in which various clinical staff could have validated the sufficiency of communication in this case.

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Script writing Write an alternate script for the interaction between the head anesthesiologist and the on-call anesthesiologist, beginning at Point 2.

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Case 23: Empty handoff Interprofessional interaction Medication misuse and Harmless hit Clinical context: Acute-on-chronic inpatient admission to general surgery (brittle diabetes) Communication context: Interactions between a nurse, transportation assistant, surgical nurse, and anesthesiologist Incident: Communication error leading to clinician’s medication misuse Patient safety outcome: Harmless hit Case reprinted with permission of AHRQ WebM&M. Goldman A, Catchpole K. Empty handoff. AHRQ WebM&M [serial online]. September 2012. Available at: https://psnet.ahrq.gov/webmm/case/279.

A 29-year-old man with “brittle diabetes” was admitted to the surgery service for incision and drainage of a leg wound. The patient’s medical history included chronic renal failure, hypertension, and prior stroke after a hypoglycemia event. Prior to surgery, while still on the hospital floor, the patient’s blood glucose level fell precipitously after receiving insulin, requiring glucose several times. Due to workload, the nurse did not accompany the patient during transport to the OR. ™ Instead, the nurse informed the transportation assistant about the patient’s extreme sensitivity to insulin. š The transportation assistant neglected to pass this information on to the surgical nurse or the anesthesiologist in OR. The EHR did not reflect the glucose levels because the bedside glucose-monitoring device was not docked, so › the information did not upload to the EHR for physician or nurse review. The patient spent 90 minutes in surgery and went to the recovery room where the blood sugar level was found to be 15 mg/dL, confirmed on repeat testing. Fortunately, the patient recovered quickly once he received intravenous glucose.

Communication Principles 1. Communication is a non-summative process The nurse committed a ™ communication encoding error of sufficiency (error of underuse) by merely informing the transportation assistant about the patient’s extreme sensitivity to insulin, but failing to instruct the assistant to pass on that information to the surgical nurse and anesthesiologist in the OR.

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2. Redundancy in content and directness in channel enhance accuracy The nurse committed a ™ transactional communication error of sufficiency (error of omission) by not following up with the surgical nurse and anesthesiologist in the OR to verify their receipt of this important message and their understanding of its implications. The anesthesiologist and the nurse committed a › transactional communication error of sufficiency (error of omission) by relying on the EHR but failing to verify the completeness of the patient’s electronic records with the floor clinicians or staff. 3. Communication is contextual The transportation assistant committed a š communication decoding error of contextualization (error of underuse) by insufficiently decoding the nurse’s request to pass on the information about the patient’s insulin intolerance in the context of the patient’s impending surgery (functional context). The transportation assistant committed a š communication encoding error of contextualization (error of underuse) by not including the nurse’s information about the patient’s insulin intolerance when handing off the patient to the surgical nurse and anesthesiologist in the context of the patient’s imminent surgery (functional context).

Discussion This case demonstrates how a simple piece of information that passes through a mediator to another care provider can easily get lost in transition and, as a result, create risk for harm. In other words, the case illustrates how communication involves more than a mere transfer of information. Three principles of human communication convey the safety lessons that can be learned from this relatively harmless hit: The first lesson regards the nurse’s assumption that the transportation assistant will deliver her message to the surgical nurse or anesthesiologist, without her needing to explicitly tell him to do so. The nurse also assumed that her communication would arrive at its intended “destination,” that the receivers would fully understand and interpret her message as intended, and that they would perform the indicated clinical adjustments for the impending surgical procedure. In other words, the nurse assumed – by mere encoding – that a mutual understanding would be established with the transportation assistant, and that the OR clinicians would figure out what to do with that information in practical terms. The nurse did not understand communication as a complex interpersonal meaning-making process that is error-prone and thus requires skilled contributions from all involved care participants. The second lesson from this event regards the principle that “communication is contextual.” Clinical communication is nested within a highly complex healthcare setting that involves many people from diverse professional backgrounds who work un-

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der intense pressures and time constraints. Substantial information passes through these care providers on a daily basis, making it impossible for them to retain all information. Inevitably, clinicians and staff have to judge which pieces of information to keep in their minds for each healthcare encounter. The transportation assistant, in this case, had to make that decision when the nurse informed him about the patient’s severe insulin sensitivity. He did not retain that this information was crucially important for the patient’s imminent surgery and thus did not convey it in his upcoming conversation with the surgical team. The third lesson from this case relates to the principle of redundancy and directness enhancing accuracy. The providers in the surgical team relied on the patient’s EHRs without questioning the records’ completeness. From past experience, they could have known that not all information is updated in real time. This assumption constitutes a common safety threat in healthcare, because it rests on the incorrect perception that the digitization of communication constitutes a safer exchange of information. Healthcare systems across the globe are increasingly relying on this myth. Their unquestioned reliance on EHRs as a solution to an endemic lack of information exchange is a problem, however, because it is not the lack of information as much as the lack of shared understanding that commonly causes patient safety events. EHRs merely contain information. The digitization of information does not facilitate the establishment of a shared understanding among care participants. In fact, they may often hinder rather than aid the establishment of shared understanding, as shown in this case, due to added structural challenges (e.g. awkward layout causing decoding errors) and process elements (e.g. records not always being as updated as what is in the providers’ minds). Thus, EHRs may actually provide added opportunities for information to fall through the cracks, and as long as communication is seen as lying within rather than between people, this problem will continue to pose a severe threat to the safety of patient care.

Alternative Strategies In this case, several behaviors could have prevented or intervened with the harmless hit: – The nurse could have informed the transportation assistant that the patient’s extreme sensitivity to insulin is critical information to pass on, given to the patient’s upcoming surgery. – The nurse could have explicitly instructed the transportation assistant to pass on that critical information to the colleagues in the OR when handing off the patient. – The nurse should not have assumed that the surgical nurse and the anesthesiologist had received and understood that information – she could have followed up with them to verify their message receipt and understanding of the implications of the patient’s insulin intolerance for his upcoming surgery.

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The anesthesiologist and the nurse should not have relied on EHRs – they should have verified the completeness of the patient’s EHRs with the sending clinicians and/or staff.

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Discussion Questions 1.

In the context of heavy workload and limited time, what highly reliable systems can providers adopt to ensure that the relevant medical history is communicated and acted upon down the line and across various levels of clinical training?

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With advances in health information technology, how can teams ensure that the EHR serves as a facilitating tool, rather than as an ineffective substitute for faceto-face communication?

Exercises 1.

Script writing Write a script between the nurse and the transportation assistant, beginning at Point 1, in which both actors share an understanding at the end of the interaction that the patient’s sensitivity to insulin must be conveyed to the surgical team.

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Script writing Write a new script between the transportation assistant and the surgical nurse, beginning at Point 2. Assume that the transportation assistant does not convey any information about the patient’s insulin sensitivity.

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Case 24: A triple handoff Cross-professional interaction Incomplete handoff, Delayed treatment, and Harmless hit Clinical context: Acute-on-chronic inpatient admission to cardiac surgery (pacemaker) Communication context: Interactions between a cardiologist, cardiothoracic surgeon, nurses, on-call intern, night float resident, and radiologist Incident: Communication error leading to incomplete handoff and delayed treatment Patient safety outcome: Harmless hit Case reprinted with permission of AHRQ WebM&M. Vidyarthi A. Triple handoff [Spotlight]. AHRQ WebM&M [serial online]. September 2006. Available at: https://psnet.ahrq.gov/webmm/case/134.

An 83-year-old man with a history of chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease (GERD), and paroxysmal atrial fibrillation with sick sinus syndrome was admitted to the cardiology service of a teaching hospital for initiation of dofetilide (an antiarrhythmic medication) and placement of a permanent pacemaker. The patient underwent the pacemaker placement via the left subclavian vein at 2:30 PM. A routine postoperative single view radiograph was taken and showed no pneumothorax. The patient was sent to the recovery unit for overnight monitoring. At 5:00 PM, the patient stated that he was short of breath and requested his COPD inhaler. He also complained of new left-sided back pain. The nurse found that his pulse oxygenation had dropped from 95% to 88%. Supplemental oxygen was started and the nurse asked the covering physician to see the patient. The patient was on the nurse practitioner (NP) nonhouse staff service; however, the on-call intern provides coverage for patients after the NPs leave for the day. The intern, who ™ had never met the patient before, examined him and found him already feeling better and with improved oxygenation with the supplemental oxygen. The nurse suggested a STAT x-ray to be done in light of the recent surgery. The intern concurred, and the portable x-ray was done within 30 minutes. About an hour later, the nurse wondered about the x-ray and asked the covering intern if he had seen it. The covering intern stated that he was š signing out the x-ray to the night float resident, who was coming on duty at 8:00 PM.

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Meanwhile, the patient continued to feel well except for mild back pain. The nurse gave the patient acetaminophen as prescribed and continued to monitor his heart rate and respirations. At 10:00 PM, the nurse still had not heard anything about the x-ray, so he met with the night float resident. The night float resident had been busy with an emergency but › promised to look at the x-ray and advise the nurse if there was any problem. Finally, at midnight, the nurse signed out to night shift, œ mentioning the patient’s symptoms and noting that the night float had not called with any bad news.  The next morning, the radiologist read the x-ray and notified the NP that it showed a large left pneumothorax. Cardiothoracic surgery service was consulted and a chest tube was placed at 2:30 PM, nearly 23 hours after the x-ray was performed. Luckily, the patient suffered no long-lasting harm from the delay. The team subsequently learned that the night float resident had mistakenly examined the radiograph done immediately postoperatively rather than the chest x-ray done at 4:00 PM, and therefore did not see the film with the large pneumothorax.

Communication Principles 1. Communication is contextual The intern nearly committed a ™ communication decoding error of contextualization (error of misuse) by assessing that the patient was “feeling better” in disregard of the context that he had never met the patient before (relational context). The nurse intervened with his error-in-the-making by contextualizing the intern’s assessment in light of the patient’s recent surgery and recommending an x-ray (functional context). The nurse and the night shift nurse committed a › transactional communication error of contextualization (error of omission) by not communicating with the night float resident to make sure that he had viewed the x-ray, given his busy night shift (i.e. an emergency case, environmental context), the impending implications of a potentially negative result for the patient’s health (chronological context), and the fact that there were two chest x-rays of the patient taken on the same day (functional context). 2. Communication is a non-summative process The intern committed a š transactional communication error of sufficiency (error of underuse) by not engaging in enough communication with the incoming night float resident to ensure that he had fully understood the patient’s recent course, including the fact that both the chest x-ray and the second STAT x-ray had been taken only a few hours apart, with the latter still needing to be read. The nurse committed a › communication encoding error of sufficiency (error of underuse) by merely noting to the night shift nurse that the night float resident had not called with “any bad news,” leaving the night shift nurse uninformed about other

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important information, such as the fact that there had been two x-rays taken, what the anticipated bad news might be, and that there might be a need to follow-up again with the night float resident. 3. Redundancy in content and richness in channel enhance accuracy Both the nurse and the night float nurse committed a › transactional communication error of accuracy (error of omission) by not following up with the night float resident to make sure that he had viewed the latest x-ray.

Discussion This case illustrates the challenge of conducting sufficient communication in the context of a healthcare episode that is complicated by time pressures and interprofessional hierarchies among participants who bring varying perspectives to the patient’s care. However, sufficiency is a foundation for successful communication. Therefore, it is crucial that clinicians and staff find a way to establish sufficient communicative exchange with their colleagues, despite and because of the challenging contextual layers that frame their interactions. In this case, the day nurse and the night shift nurse faced the challenge of having to engage in sufficient communication with each other and with the night float resident to optimize accuracy through redundant communication. Given the status differential between the nurses and the resident, however, repeated interactions may have caused interpersonal conflict, because the resident may have perceived the nurses’ message redundancy as inappropriate – regardless of the fact that it would have facilitated the objective of the resident viewing and assessing the correct chest image in a timely manner. This example illustrates how the “redundancy enhances accuracy” principle of communication becomes a challenge when hierarchical status differentials are involved. People run the risk of patronizing others if they overuse redundancy. Paradoxically, the solution to this contextual barrier lies in the contextualization itself: Care participants can use the exact contextual layers that constrain a healthcare interaction – in this case, the relational context of the hierarchical communication, the functional context of the two x-rays taken on the same afternoon, the chronological context of the pressing timeliness, and the environmental context of the resident’s busy schedule due to a parallel emergency case – as framing tools to facilitate the co-creation of a shared understanding. In other words, it is through the contextual framing of their messages that the nurses could have established a shared understanding with the resident in this case without triggering interpersonal conflict. In summary, this case conveys the lesson that any contextual layer that threatens to compromise the effectiveness and appropriateness of a given interaction can

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be used to facilitate the establishment of a shared understanding during that interaction. In other words, the context within which an interaction is framed both constrains and facilitates communication – on the one hand, by challenging the establishment of a shared understanding, but on the other hand, by providing explicit contextual framing tools that can be used by participants to overcome these constraints. So it is the use of context as a framing tool that dissolves the constraining function of context and facilitates a shared understanding.

Alternative Strategies In this case, several behaviors could have prevented or intervened with the harmless hit: – The intern could have evaluated the patient’s well-being in light of the limiting fact that he had never seen the patient before. – The nurse and the night shift nurse could have followed up with the night float resident anticipating that, given the busy night schedule, he may have forgotten to look at the x-ray or examined the wrong one. – The night shift nurse could have framed this additional follow-up with the night float resident within the context of her being new on the shift, the fact that two chest images were taken on the same day, and the need to make sure that the resident views the correct one. – The intern and the nurse could have communicated more with the incoming night shift resident and nurse to establish a common ground and shared understanding of the care episode.

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Discussion Questions 1.

What factors contributed to the reviewing of the incorrect x-ray? What changes could be made to prevent this error from reoccurring in the future?

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What is “environmental context”? Why is it essential to provider communication?

Exercises 1.

Identify opportunities for recovery Re-read the case and identify points where actors could have ensured message receipt and shared understanding. For each point, describe one action that could have helped to accomplish this goal.

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Script writing Write a new script in which one provider of your choice circles back upstream to validate shared understanding.

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Case 25: Transfer troubles Inter-institutional interaction Unsafe surgery, Sentinel event Clinical context: Acute inpatient admission to orthopedic surgery (hip fracture) Communication context: Interactions between interprofessional clinicians across institutions Incident: Communication error leading to unsafe surgery Patient safety outcome: Sentinel event Case reprinted with permission of AHRQ WebM&M. Hains IM. Transfer troubles [Spotlight]. AHRQ WebM&M [serial online]. June 2012. Available at: https://psnet.ahrq.gov/webmm/case/269.

An orthopedic surgeon at a small community hospital contacted an ED physician at a large academic medical center about a patient transfer. At this hospital, standard procedure called for all transfers from outside hospitals to be seen and evaluated in the ED. The orthopedic surgeon ™ briefly described a 92-year-old woman with a history of dementia and a left hip fracture. They had taken her to the OR, but she developed low BP, and the anesthesiologists were not comfortable managing her care at the community hospital. The referring orthopedic surgeon š also spoke with the on-call orthopedic surgery resident at the tertiary care center and conveyed the same brief history. › Minimal other clinical details were discussed. The patient was transferred to the tertiary care center and was clinically stable on arrival to the ED. œ None of the notes or clinical documentation from the referring hospital arrived with the patient other than her demographic data.  She was quickly admitted by the orthopedic surgery resident and ž prepared for surgery the following morning. Early the next day, the patient was taken to the OR for surgical repair of her hip fracture. During induction of anesthesia, the patient rapidly became hypotensive and required vasopressors. The surgical team proceeded, but the case was complicated by significant hemodynamic instability. The patient survived the surgery, but experienced persistent postoperative hypotension (shock) of unclear cause and could not be weaned from the ventilator. Ultimately, care was withdrawn and she died a few days after surgery.

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Notably, Ÿ following her operation on hospital day 2, medical records arrived from the referring hospital, and the anesthesia notes were reviewed. They were handwritten and   difficult to read, but described “profound hypotension” at the start of the case and that the patient had actually suffered a full cardiac arrest (written as “unable to obtain BP . . . no palpable pulse . . . arterial access . . . case cancelled, to PACU.”). There were only few other details in the notes about the cardiac arrest.

Communication Principles 1. Communication is a non-summative process The sentinel event in this care episode was caused by an evident lack of interactive communication. The referring orthopedic surgeon committed a ™ communication encoding error of sufficiency (error of underuse) by briefly describing the patient’s history and not mentioning the cardiac arrest to the ED physician and on-call orthopedic surgery resident. In addition, both receiving clinicians committed a › transactional communication error of sufficiency (error of underuse) by insufficiently establishing a shared understanding of the clinical details with the referring surgeon. The referring hospital committed a œ communication encoding error of sufficiency (error of underuse) by sending the receiving hospital insufficient documentation about the patient’s health condition (i.e. only the patient’s demographic data). As a result of this chain of communication errors, the orthopedic surgeon committed a ž communication encoding error of accuracy (error of commission) by ordering to prepare the patient for surgery, which led to a sentinel event. 2. Communication is contextual This case illustrates a common failure to contextualize communication during handoffs. The referring hospital staff committed a œŸ communication encoding error of contextualization (error of underuse) by taking too much time to send the needed documentation (chronological context). In the same vein, the clinical staff at both the referring and receiving care institutions committed a Ÿ transactional communication error of contextualization (error of underuse) by waiting too long to communicate with one another (chronological context), given the medical urgency of the care episode. The records, which contained critical information for the anesthesiologist in preparation for the surgical procedure, arrived only after the operation. 3. Preconceptions and perceptions vary among communicators The referring hospital committed a   communication encoding error of clarity (error of misuse) by sending the receiving staff handwritten records that were difficult to decipher. The sending hospital staff acted based on the “common ground fallacy,”

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assuming that the receiving hospital staff will figure out the handwritten notes and make sense of what they mean.

Discussion This case illustrates how the communication principles are at times related. For example, one of the principles states that “redundancy in content and directness in channel enhance accuracy.” The referring orthopedic surgeon in this case skillfully engaged in message redundancy by informing both the ED physician and the on-call orthopedic surgery resident about the patient in transfer. However, the information he provided was limited in scope, defeating the function of redundancy. This case demonstrates how the redundancy principle for accuracy only works if the informational content that is being communicated is complete, and that redundancy does not aid accuracy if insufficient information is being repeated. Another example that illustrates how the communication principles connect is shown by the contextual communication errors in this case. The staff at the two clinical institutions failed to communicate promptly and thus did not frame their communication within the chronological context (i.e., urgency) of the care episode. Another principle of communication, however, states that “directness in channel enhances accuracy.” Thus, communicating directly (i.e. face-to-face or over the phone rather than through written records) would have enabled the staff members to engage in timely (i.e. chronologically framed) interaction about the patient’s health. In other words, “directness in channel” enhances the function of contextualized communication. Finally, this case scenario demonstrates how communication is an interactive meaning-making process that entails more than mere information transfer. The sufficiency errors in this case show how clinicians were trapped in a “common ground fallacy” on multiple occasions. Each of them assumed that the receiver will “figure out” the content and meaning of what they were saying (e.g. the surgeon’s telegraphic debriefing and the anesthesiologist’s handwritten notes). The providers did not recognize communication as a (1) complex and interpersonally adaptive process that facilitates (2) an interactive co-creation of shared meaning that (3) is different from the sum of its parts and (4) lies between rather than within people or handwritten notes.

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Alternative Strategies In this case, several behaviors could have prevented or intervened with the sentinel event: – Despite the time constraints imposed by the medical urgency, the referring orthopedic surgeon should have allocated time to engage in more sufficient communication with the receiving clinicians. – The community hospital staff could have sent the medical records along with the patient, ideally accompanied by a direct communicative exchange (either face-toface of by phone), or even faxed them. – The receiving clinicians should not have concluded their debriefing with the referring surgeon until they received and fully understood all needed information. This was difficult, as they did not understand the severity of the incident that had occurred. – The receiving orthopedic surgeon should not have recommended surgery without a comprehensive assessment and understanding of the patient’s condition. – All participants in this case scenario should have approached their communication with each other under the assumption of no common ground and utilized their communication skills to co-create a shared understanding.

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Discussion Questions 1.

What highly reliable systems can hospitals employ to ensure that records essential for subsequent treatment arrive in a timely manner?

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Why did the principle “redundancy enhances accuracy,” applied successfully in this case, fail to prevent the communication error?

Exercises 1.

Script writing Write a script for a new interaction between the referring orthopedic surgeon and the on-call orthopedic surgery resident at the tertiary care center, beginning at Point 2.

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Channel surfing Describe how “directness in channel” could have enhanced accuracy in this case and potentially prevented the sentinel event.

Stage 5: Treatment execution Treatment execution is the stage of care that involves the application of the treatment plan in attempted remediation of a patient’s medical condition. Treatment execution can proceed as planned or not-as-planned. Barriers to successful treatment execution can be located at multiple levels of the healthcare system, including but not restricted to failures of actions by both patients and clinicians.

DOI 10.1515/9783110455014-011

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Case 26: Totally wrong knee replacement Provider-patient interaction Wrong-site surgery and Sentinel event Clinical context: Acute inpatient admission to orthopedic surgery (knee replacement) Communication context: Interaction between two physicians and a patient Incident: Communication error leading to wrong-site surgery (treatment misuse) Patient safety outcome: Sentinel event Case written by Annegret F. Hannawa, Ph.D. and Sandra W. Hwang, M.S.P.H.

A 44-year-old female was scheduled for knee replacement surgery of her left knee. Under the pressure of a heavy workload that day and upset by an earlier case, the attending anesthesiologist and resident entered the room quickly, taking a brief skim of her x-rays to confirm the joint disease. The clinicians ™ did not greet the patient and š briefly discussed the procedures, › talking to each other more so than with the patient. The anesthesiologist œ referred to the patient as “the subject” as he began  preparing her right leg for surgery. Confused, but wary of the attending’s dismissive tone as he spoke to the resident, the patient hesitated to question aloud why her right leg was being prepared. Considering that she had no clinical background, she rationalized that it could be standard for both legs to be prepared. She attributed her concerns to her overall anxiety about the procedure and ž elected to remain quiet. The patient was put under general anesthesia supplemented by use of an epidural catheter, and her right leg was prepared and draped before she met the orthopedic surgeon, Ÿ who entered shortly after. The knee replacement surgery was uneventful. When the patient came out of anesthesia, she was horrified to learn that total knee replacement surgery had been completed on the wrong knee.

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Communication Principles 1. Communication entails factual and relational information The surgeon committed a ™ communication encoding error of interpersonal adaptation (error of underuse) by insufficiently adapting the way he greeted the patient to the patient’s needs and expectations. The attending anesthesiologist committed a œ communication encoding error of interpersonal adaptation (error of misuse) by referring to the patient as “the subject” in his conversation with the resident. 2. Redundancy in content and directness in channel enhance accuracy The clinicians committed a š transactional communication error of sufficiency (error of underuse) by engaging in insufficient communication to establish a shared understanding of the impending surgical procedure. The clinicians committed a š transactional communication error of accuracy (error of underuse) by engaging in insufficient communication to validate the accuracy of the planned surgical procedure with one another and the patient. The orthopedic surgeon committed a Ÿ transactional communication error of sufficiency (error of omission) by engaging in insufficient communication with his colleagues and the patient about the surgical procedure. The orthopedic surgeon committed a Ÿ transactional communication error of accuracy (error of omission) by not validating the accuracy of the planned surgical procedure with his colleagues and the patient. The patient committed a ž communication encoding error of sufficiency (error of omission) by remaining quiet instead of expressing her concern about her wrong leg getting prepared for surgery.

Discussion This case demonstrates how appropriateness can be an important element of safetypromoting communication. Appropriate communication not only contributes to patient satisfaction. As illustrated in this case, it can also trigger preventable patient harm. The clinicians’ inappropriate behavior in front of (and implicitly toward) the patient discouraged the patient from speaking up to prevent a severe patient safety event. The trigger was not only what the clinicians said, but how they said it – their nonverbal communication generated an unsafe environment for the patient to raise her concerns. This case also demonstrates the importance of patients becoming involved as active partners for safe and high-quality care. In this care episode, the patient could have been brought in as an important resource to validate the accuracy of the planned surgical procedure. Her contribution would have likely prevented the wrong-site surgery.

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The clinicians failed to recognize the patient as an active care participant and missed the opportunity to utilize their communication to establish a shared understanding of what needed to be done. Finally, this case illustrates the importance of context, both as a facilitator and constraint to esablish shared understanding. The patient perceived the relational context of the care episode (i.e. the nonverbally implied status and gender differences between the providers and the patient) as a constraint that prevented her from speaking up.

Alternative Communication Strategies In this case, several behaviors could have prevented the sentinel event: – The clinicians could have greeted the patient more appropriately to establish a trusting communication environment in which the patient would have felt safe to speak up. – The clinicians could have involved the patient as an active care participant rather than talking about her as the “subject” of the care episode. – The clinicians could have communicated with one another and with the patient to jointly establish a shared understanding of the surgical procedure. – The patient could have used the relational context of the encounter as a facilitator rather than a constraint to expressing her concern about the wrong leg getting prepared for surgery.

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Discussion Questions 1.

What methods could providers use in a case like this to engage patients and encourage them to be active partners for safe and high-quality care?

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What highly reliable systems can hospitals employ to reduce communication errors that contribute to wrong-site surgery?

Exercises 1.

Script writing Write a script for a new interaction between the patient and the attending anesthesiologist and resident, beginning at Point 1. Focus on establishing a safe space that encourages the patient to be an active care participant and to speak up.

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Patient script writing Assuming the original script of this case, write a new interaction in which the patient acts upon her concerns by contextualizing her communication (begin at Point 6).

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Case 27: Mismanagement of delirium Provider-family interaction Delayed revised diagnosis and Adverse event Clinical context: Acute inpatient admission to geriatric-psychiatry ward (delirium, agitation) Communication context: Interaction between geriatric-psychiatry ward clinicians and the patient’s family Incident: Communication error leading to delayed revised diagnosis Patient safety outcome: Adverse event Case reprinted with permission of AHRQ WebM&M. Merrilees J, Lee K. Mismanagement of delirium. AHRQ WebM&M [serial online]. May 2016. Available at: https://psnet.ahrq.gov/webmm/case/375.

An 85-year-old man with early stage vascular dementia fell on the sidewalk and fractured his leg. Although fitted with a cast at a regional hospital, the patient was not able to walk independently. He was given crutches and instructions for no weight bearing on the injured leg. He was admitted to a skilled nursing facility (SNF) for physical therapy to establish mobility and for assistance with bathing and dressing. His wife stayed with him most of the time during the first 2 days. Prior to this event, the patient lived at home and was independent in activities of daily living. He used distance and reading glasses, eye drops three times daily, and had hearing aids. Over the previous year, he experienced nondisturbing visual hallucinations (e.g. bird in the tree, squirrel on the lawn, and bug on the floor). He had disturbed nighttime sleep and occasionally got up at night, showered, and dressed, before asking his wife the time. He experienced frequent daytime sleepiness with varying levels of concentration. He had a shuffling and sometimes propulsive gait, and he fell easily. On day 3 in the SNF, prior to arrival of his wife, the patient became delirious and agitated. He waved his crutch to keep staff at a distance, threatened to kill them if they approached, and knocked over furniture. The sheriff was called. The patient was taken to the hospital ED. The patient spent his first night in the ED hallway with his wife and daughter alternately by his side. On day 2 of hospitalization, he was transferred to a hospital room and was visited by a psychiatrist. That night, the patient became delirious and threw a cup of water at a sitter. On day 3, the patient was lucid and explained he thought he been captured and was trying to escape. He expressed remorse. The psychiatrist ™ recommended transfer to the geriatric-psychiatry ward for better patient management, and the patient’s wife š accepted the recommendation without under-

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standing the implications. At the time of the transfer, the patient had been immobile for 3 days, and he had constipation, mild dehydration, and pain. Over the next 2 days, the wife and daughter became concerned about their loved one’s care and › requested alternate ward placement that allowed a 24-hour family caregiver at the bedside. They further œ requested that the staff address the patient’s mobility needs and work to eliminate some of the delirium triggers. The psychiatric intern was called and  explained to the patient’s family that the patient had been involuntarily admitted, and no change in placement or treatment would be considered. The intern further explained that ž the primary medical concern was the patient’s behavior, not his mobility. The family Ÿ requested to see the intern’s supervisor, who spoke to the family by telephone and   confirmed the intern’s statement. The family then Ÿ called the patient’s primary care physician, who   deferred to the specialists on the overall plan, but requested that the patient’s daughter be allowed to stay with the patient overnight. The   ward nurse refused the request and the   wife and daughter were escorted from the locked ward at 9:30 PM. The patient continued to experience nighttime agitation and was aggressive toward staff during nights 3–5, which led to the use of restraints. Ward staff extended the daytime visiting hours for the family, 8 AM–10 PM, but continued to   refuse the family’s requests to stay at night to provide comfort and reassurance. Medical students rounded on days 5 and 6 and administered mini-mental status exams, but no in-depth medical history or dementia evaluation was administered. The patient continued to have constipation, mild dehydration, increased leg pain, and ingrown toenail pain. Risperidone was administered to control agitation and hallucinations on day 5. On day 6, the patient became aphasic, exhibited slurred speech, moaned with discomfort, occasionally cried “spinning,” and exhibited breakdown on the skin of his heels and buttocks. On day 8, the patient’s wife called the hospital legal department to file a complaint. At that point, the hospital allowed the patient’s daughter to spend the night. The patient continued to act out dreams, but having a family caregiver at the bedside prevented escalation to aggression. The patient was released back to the SNF on day 9, with a revised diagnosis of Lewy body dementia. The risperidone was discontinued several months later by a new geriatrician in the SNF. Since the precipitating incident, the patient has lost 40 lbs. He now has limited speech, limited mobility, and tardive dyskinesia, and he is dependent for all activities of daily living.

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Communication Principles 1. Communication includes factual and relational information The psychiatric intern committed a  communication encoding error of interpersonal adaptation (error of underuse) by insufficiently adapting his explanation that the patient had been involuntarily admitted and no ward change would be considered to the ad-hoc needs of the patient’s wife and daughter to accommodate their emotional involvement and expectancies regarding the patient’s care. The intern’s supervisor, the primary care physician, and the ward nurse committed a   communication encoding error of interpersonal adaptation (error of underuse) by insufficiently adapting the way in which they responded to the family’s request and to their ad-hoc needs and expectations. 2. Communication is contextual The psychiatrist committed a ™ communication encoding error of contextualization (error of underuse) by insufficiently framing his recommendation to transfer the patient to the geriatric-psychiatry ward “for better patient management” in the context of the patient’s immobility, acute constipation, mild dehydration, and pain (functional context). The psychiatry ward staff committed a œ communication decoding error of contextualization (error of underuse) by insufficiently decoding the family’s requests in light of their potential to become active facilitators of the care episode (functional context). The psychiatry ward staff committed a › communication decoding error of contextualization (error of underuse) by insufficiently framing his interpretation of the patient’s wife and daughter’s request for alternate ward placement within the context of their close relationship with the patient (relational context). The psychiatry intern committed a ž communication encoding error of contextualization (error of underuse) by insufficiently framing his explanation that the primary concern was the patient’s behavior (not his mobility) within the context of the wife and daughter’s relational closeness to the patient (relational context) and the potential facilitating function of their knowledge of the patient (functional context) for a safer, higher quality care episode. The intern’s supervisor, the primary care physician, and the ward nurse committed a Ÿ communication decoding error of contextualization (error of underuse) by insufficiently decoding the family’s request within the context of them being close to the patient (relational context) and disregarding the potentially facilitating function of them knowing the patient well (functional context).

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3. Preconceptions and perceptions vary among communicators The psychiatrist and the patient’s wife committed a š transactional communication error of sufficiency (error of underuse) by insufficiently discussing and establishing a shared understanding of the implications of the patient’s transfer to the geriatricpsychiatry ward.

Discussion This case exemplifies how a chain of communication errors can contribute to an adverse event. Two lessons can be learned from applying the principles of human communication to this case. First, the case illustrates the importance of communication as a contextually embedded interpersonal meaning-making process. All care providers in this episode failed to recognize the functional context within which their communication with the patient’s wife and daughter took place. They did not recognize that the family’s knowledge of the patient and their relational closeness could be a potential facilitating resource for a safer and higher quality care episode. For example, the wife and the daughter were able to prevent escalation to aggression, provide comfort and reassurance, and validate the clinician’s assessments of the patient’s condition in comparison to what behavior has been “normal” in the patient’s everyday life outside of the ward. Second, the clinicians and staff in this case understood communication as a mere message transfer. They disregarded the fact that interpersonal communication conveys both informational and relational meaning. For example, rejecting the family’s requests without adapting that communication to the needs of the family, escorting them from the locked ward, and disregarding their concerns conveyed important relational messages that upset the family and caused them to contact the hospital’s legal department to file a complaint. It was not the informational content of what they were saying, as much as the way in which they disregarded the family members that triggered the complaint.

Alternative Communication Strategies In this case, several behaviors could have prevented or intervened with the adverse event: – The psychiatrist and the patient’s wife could have fully discussed and established a shared understanding of the implications of the patient’s transfer to the geriatric-psychiatry ward.

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The psychiatrist could have decoded the patient’s behaviors within the context of the patient’s physiological symptoms before administering risperidone to control the patient’s agitation and hallucinations. The clinicians and staff could have interpreted the patient’s wife and daughter’s requests in the context of their potentially facilitating role as active care participants. The clinicians and staff could have adapted their interpersonal communication with the patient’s wife and daughter to their ad-hoc needs (e.g. their emotional involvement and expectancies regarding the patient’s care), conscious of the fact that their communication conveys both factual and relationship-defining information to the patient’s family.

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Discussion Questions 1.

In what ways did the providers in this case commit a communication error of contextualization?

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Caregivers and family members can be valuable participants in a patient’s care and, when activated, play a critical role in improving the patient’s health outcomes. However, caregivers and family members are often left out of the process. How can providers engage family members and care companions as a valuable resource for safer, higher quality care?

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Exercises 1.

Script writing Write a script for a new interaction between the wife, daughter and staff, beginning at Point 3.

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Identify opportunities for recovery Re-read the case and identify points at which the providers could have engaged the patient’s wife and daughter as active members of the care team. For each point, describe one action that could have helped to accomplish this goal.

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Case 28: Raise the bar Team interaction Patient fall and Adverse event Clinical context: Acute outpatient surgery (lipoma) Communication context: Interaction between an anesthesiologist and a nurse Incident: Communication error leading to a preventable patient fall Patient safety outcome: Adverse event Case reprinted with permission of AHRQ WebM&M. Stotts J, Lyndon A. Raise the bar. AHRQ WebM&M [serial online]. May 2014. Available at: https://psnet.ahrq.gov/webmm/case/324.

A 57-year-old man presented to an ambulatory surgery center for excision of a right groin lipoma. The patient was seen and evaluated by an anesthesiologist who was new to the center. After discussing anesthetic options with the patient, the ™ physician proceeded with regional anesthesia and performed a right iliac block in the preoperative holding area. The patient was then taken to the OR, where he awaited the arrival of the surgeon. › Without alerting the nurse, the patient tried to get up to use the restroom, but – because his leg was now numb – fell and hit his head on the ground. After hearing the fall, the nurse came quickly to evaluate and, given complaints of acute neck pain, the patient was transferred to the local emergency room. A heated interaction ensued between the anesthesiologist and nurse around why certain safety measures had not been taken to protect the patient. Ultimately, the patient did not experience any significant injury and he had his lipoma removed the following week. The quality review committee at the ambulatory surgery center investigated the events. It was noted that the rails of the patient’s bed were not raised after the block was placed, largely because the ™ nurses were unaware that the procedure had been performed by the anesthesiologist. Because of this poor communication, the š nurse assumed that the block would be placed in the OR (as done by other anesthesiologists on staff).

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Communication Principles 1. Communication is contextual The anesthesiologist and the nurses committed a š transactional communication error of contextualization (error of underuse) by insufficiently establishing a shared understanding of the surgical procedure within the context of the anesthesiologist being new to the team (relational context) and requiring information about the hospital’s standard procedures such as blocks normally being placed in the OR (cultural context). 2. Communication is a non-summative process The anesthesiologist committed two ™ communication encoding errors of sufficiency (errors of omission) by not informing the nurses about the fact that he had performed the block, and by failing to make sure that the patient understood that he would need to call a nurse if he wanted to get up because his leg would be numb. Because of this lack of communication, the patient committed a › communication encoding error of sufficiency (error of omission) by not calling the nurse when he needed to get up.

Discussion This case demonstrates the importance of understanding communication as a vehicle for enculturating clinicians to a new institution. Clinicians need to become accustomed to an institution’s unique processes and procedures before they begin their clinical work in that new setting. This training is also important in a relational context, because it gives newcomers an opportunity to get to know their new colleagues, build a relational history, and establish a shared understanding with their team, all of which are prerequisites for safe and high-quality care. This case also highlights the importance of sufficient communication. The case demonstrates that it is safer to communicate some than none – with both colleagues and patients – to make sure that a shared understanding can be attained. The anesthesiologist inthis case would have acted more safely if he had informed the nurses about the block. Although this message would have been redundant, it would have fulfilled a reinforcing safety function. In the same vein, the anesthesiologist would have acted more safely if he had told the patient about the danger of getting out of bed without calling the nurse for help. Such communication sufficiency would have been the only vehicle for establishing a shared understanding that could have prevented the adverse event.

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Alternative Strategies In this case, several behaviors could have prevented the adverse event: – The anesthesiologist and the nurses could have established a shared understanding of the procedures that are routinely performed in the OR (e.g., blocks typically being placed in the OR). The hospital could maintain a list of these procedures to be included in materials used to orient new staff. – The anesthesiologist could have immediately informed the nurses that he placed the block. – The anesthesiologist could have informed the patient about him needing to call the nurse for assistance in case he would like to use the bathroom prior to surgery.

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Discussion Questions 1.

How could the anesthesiologist and the nurse have interacted more competently at Point 3 and avoided blaming individual participants for the fall?

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Based on the results of the quality review committee’s investigation, what are two steps that the institution could take to avoid this type of error from recurring in the future?

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Exercises 1.

Policy making A core tenet of patient safety and quality is eliminating blame culture. Heated interactions such as the one seen in this case may naturally ensue after an error. What policies could the institution adopt to support providers and help them learn postevent?

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Putting yourself in others’ shoes Explain how this case demonstrates the principle that “preconceptions and perceptions vary among communicators.”

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Prepare patient instructions Write a set of instructions that could have informed the patient what to expect around the experience of surgery and anesthesia.

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Case 29: Acute care admission of the behavioral health patient Interprofessional interaction Inadvertent discontinued medication and Sentinel event Clinical context: Acute-on-chronic ED visit with subsequent inpatient admission (Crohn’s disease with acute pancreatitis) Communication context: Interaction between a gastroenterology consultant and the patient’s medical team Incident: Communication error leading to inadvertent medication discontinuation Patient safety outcome: Sentinel event Case reprinted with permission of AHRQ WebM&M. Weiss AP, Rosenbaum JF. Acute care admission of the behavioral health patient. AHRQ WebM&M [serial online]. April 2013. Available at: https: //psnet.ahrq.gov/webmm/case/298.

A 25-year-old man presented to the ED with a 3-week history of abdominal pain, nausea and vomiting, and weakness. His medical history included Crohn’s disease with ileocolectomy and ileostomy, chronic pain, schizophrenia and major depression with prior suicide attempts, and narcotic abuse with hydrocodone. Medications included mesalamine, clonidine, tramadol, haloperidol, olanzapine, venlafaxine, potassium chloride, and magnesium oxide. The patient was disabled, participated in an intensive case management program (ICM), and lived in supportive housing. The ED work-up was consistent with acute pancreatitis, and the patient was admitted to the hospital. A gastroenterology (GI) consult noted that olanzapine could cause pancreatitis. In addition, the GI consult described how the patient requested a reduction in the haloperidol dose, because he felt overmedicated. The GI consult ™ declined the patient’s request and suggested that changes in the haloperidol dose, as well as the decision to discontinue olanzapine, could be made by the patient’s psychiatrist. š Despite this advice, the medical team discontinued the olanzapine without consulting the patient’s psychiatrist. The patient’s condition improved and he was discharged to home. The discharge summary documented that › the patient was instructed to follow up with his PCP, his gastroenterologist, and his psychiatrist in 1 week, and to inform his psychiatrist that olanzapine had been discontinued. Tragically, 2 weeks after discharge, the patient committed suicide.

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Communication Principles 1. Communication is a non-summative process The GI consult committed a ™ transactional communication error of sufficiency (error of underuse) by establishing insufficient common ground and shared understanding with the medical team about the potential safety threat of discontinuing medications without involving the patient’s psychiatrist. The medical team committed a š communication encoding error of sufficiency (error of underuse) by engaging in communication that was insufficient for establishing a shared understanding of the situation and for assuring that a discontinuation of the medication was safe. 2. Communication is contextual The medical team committed a › communication encoding error of contextualization (error of misuse) by insufficiently framing the discharge communication within its functional context. The team should not have delegated these follow-up tasks to an incapacitated patient who, given his prior suicide attempts and sudden medication withdrawal, would likely not be in the condition to comprehend and follow through within the requested timeframe. In other words, the patient was the wrong receiver (functional context) for the medical team’s follow-up instructions. 3. Redundancy in content and directness in channel enhance accuracy The medical team committed a › communication encoding error of sufficiency (error of omission) by not communicating directly and immediately with the patient’s other providers about the discharge information.

Discussion This case demonstrates how effective communication among care providers is essential for establishing coordinated and consistent care. The case shows how coordination is the outcome of sufficient communication that establishes a shared understanding among the involved care participants. In this case, this objective was not attained because the care participants failed to achieve the most essential level of sufficient information exchange. In other words, there was insufficient communication (in terms of quantity) between the GI consult, the medical team, and the psychiatrist to achieve a shared understanding. The medical team also committed a critical error by failing to contextualize its communication with the patient. Given the patient’s prior suicide attempts and history of chemical dependency, the medical team could have anticipated that the patient would not be able to follow through with the discharge follow-up instructions.

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Even if the patient had been capable of following up with his care providers as instructed, much of the information of this complex, contextually nested care scenario would have likely gotten “lost in transition” as a result of a game of telephone effect that commonly compromises both the quantity and quality of informational content as it passes through multiple receivers. The medical team would have needed to engage in direct communication with the patient’s other care providers to ensure a shared understanding for continued safety of the patient after discharge.

Alternative Communication Strategies In this case, several behaviors could have prevented the sentinel event: – The GI consult could have engaged in direct communication with the medical team to establish a shared understanding about the risks of discontinuing the patient’s medication without the involvement of his psychiatrist. – Given the context of the patient’s medications and prior suicide attempts, the medical team could have directly communicated with the patient’s psychiatrist prior to discontinuing any medications. – The medical team could have directly communicated with the patient’s PCP, gastroenterologist, and psychiatrist rather than delegating that follow-up task to the patient, to secure the patient’s safety after discharge.

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Discussion Questions 1.

How could contextualizing communication with the patient have avoided this event?

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How can providers balance their knowledge of a patient’s mental health history with the goal of engaging patients and acting on their preferences?

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Script writing Write a script for a new interaction starting before Point 1, in which the patient voiced that he felt overmedicated.

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Identifying opportunities for recovery Re-read the case and identify points where direct communication between the care participants could have prevented the sentinel event.

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Trouble shooting One of the recommendations in this case state that the GI consult could have engaged in direct communication with the medical team. Such redundancy requires additional time, which may not be available in all cases. How could this issue be addressed?

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Case 30: The results stopped here Interprofessional interaction Medication misuse, Delayed treatment, and Adverse event Clinical context: Acute inpatient admission to a skilled nursing unit (wound care and methicillin-resistant Staphylococcus aureus (MRSA) treatment) Communication context: Interaction between an attending physician, laboratory staff, and nurses Incident: Communication error leading to incorrect medication and delayed treatment Patient safety outcome: Adverse event Case reprinted with permission of AHRQ WebM&M. Astion M. The result stopped here. AHRQ WebM&M [serial online]. June 2004. Available at: https://psnet.ahrq.gov/webmm/case/65.

A 91-year-old female was transferred to a hospital-based skilled nursing unit from the acute care hospital for continued wound care and intravenous (IV) antibiotics for MRSA osteomyelitis of the heel. She was on IV vancomycin and began to have frequent, large stools. The attending physician ordered a test for Clostridium difficile on Friday, and was then off for the weekend. That night, the test result came back positive. The lab called infection control, who in turn notified the float nurse caring for the patient. ™ The nurse did not notify the physician on call or the regular nursing staff. Isolation signs were posted on the patient’s door and chart, and the result was noted in the patient’s nursing record. Each nurse who subsequently cared for this patient š assumed that the physician had been notified, in large part because the patient was receiving vancomycin. However, it was IV vancomycin (for the MRSA osteomyelitis), not oral vancomycin, which is required to treat C. difficile. On Monday, the physician who originally ordered the C. difficile test returned to assess the patient and found the isolation signs on her door. He asked why he was never notified and why the patient was not being treated. The nurse on duty at that time told him that the patient was on IV vancomycin. The float nurse, who had received the original notification from infection control, stated that she had › assumed that the physician would check the results of the test he had ordered. Due to the œ lack of follow-up, the patient went 3 days without treatment for C. difficile, and continued to have >10 loose stools daily. Given her advanced age, this degree of gastrointestinal loss undoubtedly played a role in her decline in functional status and extended hospital stay.

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Communication Principles 1. Communication is a non-summative process The float nurse committed a ™ communication encoding error of sufficiency (error of omission) by not notifying the physician on call and the regular nursing staff about the infection control alert. The nurse also committed a › transactional communication error of sufficiency (error of omission) by assuming but not verifying that the physician had checked the results of the test he had ordered. 2. Preconceptions and perceptions vary among communicators The nurses who subsequently cared for the patient committed a š communication decoding error of accuracy (error of misuse) by misinterpreting the fact that the patient was receiving vancomycin as an indication that the physician had been notified. The inaccuracy of their decoding was evident in the fact that the medication was IV vancomycin rather than oral vancomycin, which would have been required to treat C. difficile. However, they failed to recognize this. The nurses also committed a š transactional communication error of sufficiency (error of omission) by assuming but not verifying with the physician and the other nurses that the physician knew about the infection alert. 3. Communication is contextual The physician committed a œ communication decoding error of contextualization (error of underuse) by taking too long to follow up with the test results (chronological context).

Discussion This case demonstrates three important communication challenges that could have prevented the adverse event: First, the case illustrates how the common misperception of communication as simplistic message transfer that largely “takes care of itself” (e.g. by posting isolation signs or noting it into the patient’s record) can cause severe patient harm. In this case, the care providers engaged in insufficient interaction with one another. As a result, they failed to establish a common ground and shared understanding of the patient’s infection, which imposed a safety threat to other patients in the hospital. Second, the care providers misperceived “information” as resting within rather than between people. As a result, they did not understand accuracy as a product that is co-established among care participants by jointly engaging in successful communication.

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Third, the physician failed to contextualize his decoding of the laboratory test results as a time-sensitive matter (i.e. chronological context). Instead, he implicitly (instead of explicitly) delegated the responsibility for this task to others, assuming they would act on the lab results if the test were positive. In summary, all clinicians in this case underestimated, underused, and misperceived the role of communication as a necessary interpersonal process for facilitating accuracy and establishing a common ground as a foundation for safe and high-quality patient care.

Alternative Strategies In this case, several behaviors could have prevented the adverse event: – The float nurse could have been mindful of the tendency for information to “fall through the cracks” (common ground fallacy) and notified both the physician on call and the regular nursing staff about the infection alert. – The physician could have been mindful of the chronological context within which he ordered the lab test and followed up despite the fact that he was off for the weekend, or ensured that the covering physician was aware of the need to look for the result. – The float nurse could have verified with the physician that he checked and received the test results he had ordered. – At sign-out, the nurses who subsequently cared for the patient could have debriefed the float nurse and verified whether the physician knew about the alert.

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Discussion Questions 1.

How does this case relate to the myth that “communication can be accessed, deposited, and delegated” (see Chapter 2)?

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What changes could be made at the system level to make it easier for providers to communicate more effectively in cases like this?

Exercises 1.

Flowcharting Draw an assumptions flowchart, outlining each interaction in this case and the underlying assumptions that informed each actor’s behavior. What could have been done to promote more effective communication?

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Script writing Write a script for one interaction between providers of your choice that could have prevented the treatment delay.

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Case 31: Medication overdose Cross-professional interaction Medication overuse and Harmless hit Clinical context: Acute inpatient admission to a pediatric ICU (mental status changes) Communication context: Interaction between a pediatric resident, pediatric ICU, and pharmacist Incident: Communication error leading to medication overuse Patient safety outcome: Harmless hit Case reprinted with permission of AHRQ WebM&M. Kaushal R. Medication overdose. AHRQ WebM&M [serial online]. April 2003. Available at: https://psnet.ahrq.gov/webmm/case/9.

A 15-year-old boy with end-stage AIDS was admitted to the pediatric ICU with mental status changes. He was diagnosed with status epilepticus and started on a loading dose of IV phenytoin. In the step-down unit, the resident wrote an order for a maintenance dose of phenytoin. The order was written as mg/kg/d ™ without specification that “d” meant day versus dose. As a result, the š patient received approximately three times the indicated dose. › Later that day, a pharmacist called to alert the resident to his mistake. The subsequent phenytoin level was 98 (therapeutic range, 10–20). Administration of phenytoin was held until the level was therapeutic, and the patient’s mental status gradually improved. He had no further seizure activity and, ultimately, his mental status returned to baseline. He was discharged back to a chronic care facility.

Communication Principles 1.

Communication varies between thought, symbol, and referent; Preconceptions and perceptions vary among communicators The resident committed a ™ communication encoding error of clarity (error of misuse) by writing an ambiguous “d” on the prescription order. He assumed that his perception of what the “d” means (i.e. the thought-symbol-reference chain) would be shared by the pharmacist (i.e., common ground fallacy).

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2. Redundancy in content and directness in channel enhance accuracy The pharmacist, the resident, and the medical team committed a š transactional communication error of accuracy (error of omission) by not following up with one another to validate the accuracy of the indicated prescription dose, which resulted in the patient receiving three times the indicated dose. At the very latest, the need for accuracy-promoting redundancy could have been recognized by the staff administering the medication, given that the drug was indicated as a “maintenance dose,” yet contained a dose three times higher than that. As a result of this transactional communication error, the pharmacist committed a š communication encoding error of accuracy (error of commission) by filling the order for the excessive dose of medication. 3. Communication is contextual The pharmacist committed a š communication decoding error of contextualization (error of underuse) by insufficiently decoding the “d” within the context of the medication being intended to be a “maintenance dose” (functional context). If the other pharmacist could have caught the error sooner, he committed a › communication encoding error of contextualization (error of underuse) by not communicating the alert in a timely manner, given the medical urgency (chronological context). The call only happened later that day.

Discussion This case illustrates how a single letter, representing the most basic element of communication, can risk the safety of a patient. In this case, the resident had a thought (“day” as a reference) in mind and used a symbol (“d” as a sign) for the referent (the signified “day”). This thought-symbol-referent chain was attributed differently by the pharmacist, who associated the same symbol (“d”) with a different referent (i.e. “dose”). This communication event demonstrates a fundamental type of misinterpretation. If misinterpretation remains uncorrected, it eventually leads to misunderstandings and, finally, miscommunication. In this case, the clinicians’ failures to validate the accuracy of the ordered dosage in the context of the medication being ordered for the function of “maintenance” caused a patient safety threat that luckily was caught and corrected, thus only resulting in a harmless hit. Regardless, the chain of communication errors in this case conveys two important lessons: First, it demonstrates that communication is safe as long as it is framed within the context of a given care episode. Second, communication is safe if it is used as an interactive meaning-making process and not relied upon as a mere information transfer mechanism. In other words, all care participants – including patients – need to be mindful of the impor-

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tance of co-establishing a shared understanding based on a pre-established common ground, rather than assuming that information simply passes from one person to the next.

Alternative Communication Strategies In this case, several behaviors could have prevented the harmless hit: – The resident could have written out the “d” as “day” to be clearer in his communication to the pharmacy. Electronic prescribing software could automatically prompt the prescriber to specify what “d” is intended to signify. – The pharmacist could have decoded the “d” within the functional context of this communication (i.e. the dose representing a “maintenance dose”) and followed up with the resident to validate the accuracy of his interpretation of the dosage. – The medical team and the pharmacist could have engaged in direct communication to validate the accuracy of the ordered medication dose in the context of its function as a maintenance dose.

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Discussion Questions 1.

What type of transactional communication error took place in this case? Discuss the error.

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As this case demonstrates, an ambiguity as seemingly trivial as the meaning of a single letter can cause an error. (a) How could the medication review process by clinicians and pharmacists be improved to ensure that a noted dose “makes sense”? (b) What policy can institutions employ to ensure that small ambiguities in units and labeling are avoided in the future?

Exercises 1.

Channel surfing Describe how “directness in channel” could have enhanced accuracy in this case.

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Design an intervention Several factors contributed to this medication error. Describe one intervention that could prevent this kind of overdose in the future.

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Case 32: The case of mistaken intubation Inter-institutional interaction Inadvertent intubation and Adverse event Clinical context: Acute ED visit with subsequent inpatient admission (hypoxia) Communication context: Interaction between a SNF physician, ED staff, and an internal medicine team Incident: Communication error leading to inadvertent intubation Patient safety outcome: Adverse event Case reprinted with permission of AHRQ WebM&M. Silveira M. The case of mistaken intubation [Spotlight]. AHRQ WebM&M [serial online]. June 2016. Available at: https://psnet.ahrq.gov/webmm/case/ 377.

A 65-year-old man with a history of end-stage renal disease, injection drug use, and multiple prior infections was living at a SNF. He had recently been discharged from the hospital after a prolonged and complicated hospitalization for severe sepsis secondary to osteomyelitis. During a routine morning vital signs check at the SNF, he was found confused and tachypneic, complaining of severe shortness of breath. Paramedics were immediately called, and they found him hypoxic, hypotensive, and tachycardic. He was taken to the hospital. A packet with the ™ appropriate documentation from the nursing facility was transported with the patient. The physician at the SNF who knew him well š called the ED to provide clinical details. When the patient arrived in the ED, he had persistent hypoxia despite maximal oxygenation. The ED providers attempted to determine the patient’s wishes for intubation and life-sustaining care, but no family members were present, and › they could not find clear documentation in the records from the SNF. The patient was intubated and placed on a mechanical ventilator, and a central line was inserted. He was treated for severe pneumonia with antibiotics and intravenous fluids. The ED providers œ contacted the inpatient internal medicine team for admission. The inpatient team happened to be the same team that had recently discharged him. When hearing about the case, the resident asked why the patient had been intubated as the patient had made it clear during the last admission that “he did not want to be intubated or resuscitated under any circumstances.” The resident stated that the patient had  completed a “physician orders for life-sustaining therapy”

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(POLST) form, and the team ž had clearly documented his wishes in the discharge summary. They had also Ÿ spoken directly with the provider at the SNF. The admitting team evaluated the patient in the ED. When the patient’s family arrived, the team explained to them that the patient had been intubated because his wishes were not clear when he arrived to the ED in acute respiratory distress. In discussions with the family, all agreed the patient would not want ongoing aggressive therapy. The endotracheal tube was removed and he was taken off life support. He died peacefully later that day with his family at the bedside.

Communication Principles 1. Preconceptions and perceptions vary among communicators The SNF staff committed a ™ communication encoding error of contextualization (error of underuse) by not framing their written transfer communication with the receiving hospital in the context of the patient’s critical condition (functional context, i.e. to include information about the patient’s wishes for intubation and life-sustaining care). 2. Communication is contextual The SNF physician who called the ED committed a š transactional communication error of contextualization (error of underuse) by not establishing a shared understanding with the ED staff that the patient did not desire intubation or life-sustaining care (functional context). The ED providers committed a œ communication encoding error of contextualization (error of underuse) by not framing their admission communication with the inpatient internal medicine team within the context of not knowing the patient’s desire for intubation and life-sustaining care (functional context). 3.

Communication is a non-summative process; Redundancy in content and directness in channel enhance accuracy The SNF staff committed a ™ communication encoding error of sufficiency (error of underuse) by not including the patient’s wishes for intubation and life-sustaining care in the records they sent along with the patient. The ED providers committed a ›ž communication decoding error of sufficiency (error of underuse) by not gathering enough information from the records (including the POLST form and the patient’s previous discharge summary) to fully understand the patient’s desire for intubation and life-sustaining care. The ED providers committed a ›Ÿ transactional communication error of sufficiency (error of underuse) by not gathering enough information – by directly con-

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tacting the family members or the SNF providers – to determine the patient’s desire for intubation and life-sustaining care. The ED providers committed a œ communication encoding error of accuracy (error of commission) by admitting the patient to inpatient internal medicine.

Discussion This case demonstrates why information does not equal communication. In this case, all relevant information regarding the patient’s desire for intubation and life-sustaining care had been accurately and properly documented in medical records (e.g. POLST form and discharge summary) and persons (e.g. the SNF provider, internal medicine hospital providers, and patient’s family). Thus, the meaning of this critical information was resting within people and their written words. However, a shared understanding of this information was never established between the care participants. In other words, despite the fact that the ED providers were trying to access this information, the required common ground between people that would have been necessary for them to establish a shared understanding of this information was never attained. The written documentation had been in place to attempt such communication, but that communication was never decoded and thus never took place. The reasons for the insufficient establishment of necessary communication processes to advance the documented knowledge in the records to a shared understanding at the front line of care can be explained by three communication principles: First, there was an assumption on behalf of the SNF staff that the ED providers, given the patient’s recent discharge, would already have such knowledge based on their records. This common ground fallacy is illustrated by the principle that “preconceptions and perceptions vary among communicators,” which often leads to insufficient communication. Second, the providers’ insufficient contextualization of their communication given the patient’s life-critical condition (functional context) caused them not to consider talking about the patient’s wishes for intubation and life-sustaining care. Third, this case illustrates how “redundancy in content” and “richness in channel” enhance accuracy and facilitate the objective of attaining a common ground and shared understanding. An appropriately redundant reinforcement of the patient’s documented wishes regarding intubation and life-sustaining care through multiple channels – such as in direct conversations with the SNF provider and the patient’s family members, and in consulting the patient’s past summary and POLST form – could have prevented the inadvertent intubation and intervened with the harmlesshit-in-the-making.

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Alternative Communication Strategies In this case, several behaviors could have prevented the adverse event: – The SNF staff could have framed their written transfer communication within the context of the patient’s critical condition; they could have included information regarding the patient’s desire in respect to intubation or life-sustaining care. – The SNF physician who called the ED could have established a shared understanding with the ED staff, given the patient’s life-critical condition, that the patient does not desire intubation or life-sustaining care. – The ED providers could have gathered sufficient information from the records (e.g. the POLST form and the patient’s past discharge summary) to fully understand and determine the patient’s desire for intubation and life-sustaining care. – The ED providers could have gathered sufficient information, in direct communication with the family members and the SNF providers, to fully understand and determine the patient’s desire for intubation and life-sustaining care. – The ED providers should not have admitted the patient for inpatient care.

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Discussion Questions 1.

What was the functional context in this case? How could more adequately contextualized communication have changed the outcome of this case?

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What are two communication principles that, if applied, could have altered the outcome in this case?

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Exercises 1.

Policy making Describe one institution-wide system or policy that could help providers maintain clarity on advanced directives and DNR/DNI orders for the duration of a patient’s care, across multiple staff and points of care.

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Flowcharting Draw an assumptions flowchart, outlining each interaction in this case and the underlying assumptions that informed each actor’s behavior.

Stage 6: Post-treatment care Post-treatment care is a process that entails follow-up and monitoring of a patient after treatment execution. It encompasses medical, administrative, and interpersonal components. For instance, it may include in-person follow-up visits or may be performed with repeated medical tests or by measuring certain parameters (e.g. blood glucose). It also involves transitions of patients in different healthcare settings (e.g. between different locations within one facility, between hospitals or ambulatory healthcare settings, and to the patient’s residence).

DOI 10.1515/9783110455014-012

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Case 33: Discharging our responsibility Provider-patient interaction Ineffective discharge and Adverse event Clinical context: Acute ED visit (shortness of breath, fatigue) Communication context: Interaction between an ED physician and a patient Incident: Communication error leading to ineffective discharge and preventable patient readmission Patient safety outcome: Adverse event Case reprinted with permission of AHRQ WebM&M. Fonarow G. Discharging our responsibility. AHRQ WebM&M [serial online]. September 2007. Available at: https://psnet.ahrq.gov/webmm/case/159.

A 75-year-old man with a history of hypertension, coronary artery disease, and congestive heart failure (CHF) presented to the ED with shortness of breath and fatigue. He had a long history of CHF exacerbations requiring hospitalization and was known to the ED as a “frequent flyer.” In fact, he had been discharged from the hospital just 3 days prior. On physical examination, the patient had a low oxygen saturation level with elevated neck veins and crackles on chest auscultation, all consistent with an exacerbation of his CHF. When asked by the admitting physician what happened, the patient replied, “You know, I was feeling pretty good when I left here, but my breathing just got worse and worse.” Upon further questioning, it became clear that the patient had been eating bags of potato chips, not restricting his fluid intake, and only intermittently taking his diuretics. Since discharge, he had gained 6 pounds. The admitting physician realized that the patient had a poor understanding of his disease and how to care for himself outside of the hospital. In reviewing prior admissions, the physician discovered that ™ the patient had never been given explicit discharge instructions about CHF and had received only a š generic medicalsurgical discharge instructions handout. In the hospital, the patient was treated with diuretics, an angiotensin-converting enzyme (ACE) inhibitor, and a beta-blocker, and he improved clinically. At the time of discharge, he was counseled on appropriate activity, diet, medications, his follow-up appointment, and weight monitoring. Subsequently, he did well and was not readmitted to the hospital for at least 2 months.

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Communication Principles 1. Communication is a non-summative process The previous medical team committed a ™ communication encoding error of sufficiency (error of underuse) by not giving the patient explicit discharge instructions about his CHF. 2. Preconceptions and perceptions vary among communicators The previous medical team committed a š communication encoding error of interpersonal adaptation (error of underuse) by merely handing the patient a generic medical-surgical discharge instructions handout, but not adapting the discharge instructions (both their content and delivery) to the needs of the patient (e.g. his health literary, cognitive processing speed, and living and eating habits).

Discussion This case highlights three insights from communication science that contribute to an improved understanding of interpersonal processes that affect patient safety and quality of care. First, questioning of the patient made it clearer that the patient had not been following his discharge instructions. It also required another ED visit for the clinicians to realize that the patient had not understood (or in any event not followed) what he needed to do after returning home. This phenomenon is informed by the communication principle, “redundancy in content and directness in channel enhances accuracy.” It took a repeated ED visit for a clinician to catch the discharge error, and it took repeated questioning for the clinician to accurately understand what the patient had been doing at home. Along the same vein, communication redundancy during discharge with the use of combined channels (e.g. accompanying the handout with face-to-face conversations) could have facilitated an accurate understanding of the discharge instructions. The second insight relates to the principle that “communication is contextual.” Although the patient was known to the ED staff as a “frequent flyer,” the ED physician discovered a lack of discharge instructions only after reviewing the patient’s prior admissions. This issue highlights the importance of framing any communication within its context. Here, the clinician’s decoding of the patient’s visit communication could have been framed within the relational context of the patient being well-known to the ED staff based on many prior visits. It would have been important for clinical staff to realize that any contextual dimension has the potential to work either as a facilitator or as a constraint to effective communication. In other words, it could have been used as a contributing resource to facilitate enhanced understanding. In this case, it

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became a judgmental bias that narrowed perspectives and constrained the meaningmaking process. The third insight regards the importance of communication being an adaptive interactive process that establishes a common ground between people to neutralize discrepant perspectives. This phenomenon is addressed by the principles “communication is a non-summative process” and “preconceptions and perceptions vary among communicators.” In this case, the clinical staff’s misperception that the handout will deliver the needed information to the patient constituted a linear (rather than a process-oriented) understanding of communication. However, the patient’s literacy and dieting habits required adaptive communication on behalf of the clinical staff – such as messages that were flexibly adapted to the needs of the patient both in content and delivery – to neutralize perceptual discrepancies and optimize the likelihood of the patient understanding and following the discharge instructions. In other words, the quality of the discharge instructions cannot solely be measured based on their “explicitness,” but also based on their appropriateness in terms of the extent to which they are adapted to the unique sense-making processes that will occur within this particular patient.

Alternative Communication Strategies In this case, several behaviors could have prevented the adverse event: – The previous medical team could have discussed explicit discharge instructions with the patient face-to-face. – The previous medical team could have recognized communication as a complex interactive meaning-making process through which they needed to establish a common ground with the patient. They could have adapted their discharge communication (both in content and delivery style) to the patient’s sense-making processes to optimize the accuracy of the patient’s understanding. – The ED clinician could have approached his communication with the patient within a relational context (i.e. the patient being an ED “frequent flyer”).

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Select the communication lessons from Chapter 6 that best apply to this case and mark the respective circle(s) in this graph. Explain your choices and discuss how the lessons you selected inform this particular case. Compare your choices with the responses provided in the answer key on page 252. Are there any discrepancies? Discuss how any alternative lessons that you may have chosen or disregarded apply to this case.

Discussion Questions 1.

How does the patient’s “frequent flyer” status constitute a relational context in this case?

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How does this patient’s health outcome, after receiving a generic medical-surgical discharge instructions handout, demonstrate the importance of interpersonal adaptation?

Exercises 1.

Script writing Write a script for a new interaction between the provider and the patient at the initial point of discharge, before his hospitalization.

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Policy making A frequent concern of providers is the time constraint under which they provide care. Describe an institution-wide system or policy that could help providers successfully communicate with their patients at point of discharge to reduce rehospitalizations while balancing time constraints.

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Case 34: Discharged blindly Provider-patient interaction Ineffective discharge and Near miss Clinical context: Acute inpatient admission (thrombosis) Communication context: Interactions between several providers and a patient Incident: Communication error leading to ineffective discharge and preventable patient readmission Patient safety outcome: Near miss Case reprinted with permission of AHRQ WebM&M. Iezzoni LI. Discharged blindly. AHRQ WebM&M [serial online]. December 2005. Available at: https://psnet.ahrq.gov/webmm/case/111.

An elderly blind man developed a deep vein thrombosis during his hospital stay. At discharge, he was to receive enoxaparin (Lovenox) for self-administration at home in addition to other medications. Before leaving the hospital, he was given ™ written information sheets regarding his medications and received counseling from a nurse and a pharmacist. š They did not notice that the patient was blind. › Several days after discharge, the patient called the primary care triage nurse and stated that he had been discharged with a bag of medications and some injections, but that he could not administer them because œ he could not read the instructions. After retrieving his chart, the triage nurse noted that the patient was blind and, upon questioning, also learned that he lived alone. The patient was subsequently readmitted to the hospital for continuation of anticoagulation therapy.

Communication Principles 1. Communication is more than words Both the nurse and the pharmacist committed a š communication decoding error of sufficiency (error of underuse) by not noticing during their interaction with the patient that the patient was blind. 2. Communication is a non-summative process The nurse and pharmacist committed a š communication decoding error of sufficiency (error of underuse) by not retrieving the fact that the patient was blind and lived alone from the medical chart.

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The nurse and the pharmacist committed a ™ transactional communication error of interpersonal adaptation (error of underuse) by not flexibly adapting the content and delivery of their medication instructions to the patient’s displayed adhoc needs during the conversation, to optimize the likelihood that the patient would fully understand the instructions and know how to apply them in the context of his daily life routine. As an active partner of safe and high-quality care, the patient committed a œ transactional communication error of sufficiency (error of omission) by not reinforcing the fact that he was unable to read the instructions during his discharge conversation with the pharmacist and nurse. 3. Communication is contextual As an active partner of safe and high-quality care, the patient committed a › communication encoding error of contextualization (error of underuse) by waiting several days until he called the primary care triage nurse for clarification (chronological context). 4. Communication entails factual and relational information Both the nurse and the pharmacist committed a ™ communication encoding error of interpersonal adaptation (error of misuse) by not adapting their communication with the patient to the fact that the patient was blind and lived alone.

Discussion This case illustrates three key insights that can be derived from communication science to facilitate safer and higher quality care: First, the case demonstrates the importance of nonverbal communication. More often than not, nonverbal behaviors carry more reliable and accurate information than verbal communication. Despite that fact, clinicians often focus on computer screens or verbal information, neglecting this crucial source of information. In this particular case, their lack of decoding effort caused two care providers (i.e. both the pharmacist and the nurse) to independently miss the crucial nonverbal cue of the patient being blind during two separate face-to-face conversations with the patient. Second, this case shows how interpersonal communication is a complex, adaptive process that entails multiple components and requires interpersonal skills that reach far beyond mere information sufficiency. It demonstrates that communication is an interactive meaning-making process that occurs between people. Through this complex process, humans pursue the objective to establish a common ground based on which they can co-create a shared understanding. This case scenario illustrates several different layers that contribute to the complexity of this process: communication

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needs to be not only sufficient in quantity, but also optimal in quality – in this case, interpersonally adaptive and clear in the decoding and encoding of both messages and behaviors. Third, this case shows how any given interaction is nested within a larger context (e.g. functional, relational, chronological, environmental, and/or cultural context) that needs to be taken into account when encoding and decoding information. In other words, communication needs to be adapted to be most effective and appropriate in the given context within which it is taking place. In this case, the participants’ insufficient adaptation of their communication to the chronological context (i.e. the timing and timeliness) and to the functional context (i.e. the alignment of objectives pursued by the communication) compromised both the safety and the quality of the care episode.

Alternative Communication Strategies In this case, several behaviors could have prevented the near miss: – The nurse and the pharmacist could have read the patient’s medical chart prior to consulting him on the medication use, so that they could have contextualized and adapted their communication with the patient. – The nurse and the pharmacist could have paid closer attention to and accurately decoded the nonverbal behaviors of the patient during their discharge conversations. – The patient could have actively contributed to the establishment of a shared understanding during his discharge conversations with the nurse and the pharmacist. – The patient could have immediately clarified his lack of understanding of the medication use with the care providers, rather than waiting several days.

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you selected inform this particular case. Compare your choices with the responses provided in the answer key on page 252. Are there any discrepancies? Discuss how any alternative lessons that you may have chosen or disregarded apply to this case.

Discussion Questions 1.

How could contextualizing communication with this patient have avoided this critical incident?

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What are three examples of nonverbal communication that the primary care triage nurse and the pharmacist may have missed?

Exercises 1.

Script writing Write a script for an initial interaction between the nurse and the patient that would have created an open, comfortable space for the patient to disclose that he is blind and lives alone.

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Cue finding Choose a health condition that is not physically obvious, such as a traumatic brain injury with deficits in sequencing, information processing, calculation, and shortterm memory. Write a list of nonverbal cues that providers can look out for to ensure that the patient is discharged in a manner that is well-adapted to his/her personal situation.

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Case 35: Discharge instructions in the post-anesthesia care unit (PACU): Who remembers? Provider-family interaction Ineffective discharge and Adverse event Clinical context: Acute outpatient orthopedic surgery (torn ligament) Communication context: Interactions between a surgeon, a patient, and the patient’s family Incident: Communication error leading to ineffective post-surgery discharge and unsafe postoperative behavior Patient safety outcome: Adverse event Case reprinted with permission of AHRQ WebM&M. Engel K. Discharge instructions in the PACU: who remembers? AHRQ WebM&M [serial online]. July/August 2013. Available at: https://psnet.ahrq.gov/ webmm/case/303.

A 42-year-old woman was diagnosed with a torn anterior cruciate ligament (ACL) in her left knee after a skiing accident. ™ Before arthroscopic surgery, she had been given postoperative instructions for ACL repair, which included 50% weight bearing starting immediately. Upon examination of the knee under anesthesia and with visualization from the arthroscope, the surgeon determined that the ACL was only partially torn and that the joint had sufficient stability. Rather than ACL repair, the surgeon performed microfracture to address damage to the intra-articular cartilage as well as meniscus repair. After the surgery, the surgeon briefed the patient in the PACU on his findings and the revised postoperative instructions. Because of the microfracture procedure, she was to be completely nonweight bearing for 6 weeks – a significant change from what had been originally anticipated. However, š the patient was still groggy from the anesthesia and asked the physician to give this information to her husband. The physician called the number in the chart and › made contact with the patient’s mother-in-law, who œ understood the surgeon to say that a second surgery would be required (rather than that a different type of surgery had been performed) and the patient could abide by the postoperative instructions he had given her. It was not understood by the mother-in-law that these instructions had in fact changed.  None of this was in writing. When the ž husband picked up the patient, the written discharge instructions from the surgeon were Ÿ generic and personalized only

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with the   handwritten phrase “do as instructed.” ¡ Confused, the patient followed the original, now incorrect, postoperative instructions. ¢ The confusion was never discovered at two subsequent postoperative visits, in part because the surgeon never explained specifically how the rehabilitation guidelines had changed based on the new findings and change in plan during the surgery. The patient pushed herself to bear weight several weeks after the surgery. When she experienced significant pain, she called the surgeon, who then chastised her for not following the postoperative plan. Needless to say, the patient was upset and concerned that she may have harmed her chances for a full recovery.

Communication Principles 1. Communication is contextual The surgeon in this case did not recognize that his communication with the patient and her family was embedded within important chronological and functional contexts. First, the surgeon committed a ™ communication encoding error of contextualization (error of underuse) by giving the patient postoperative instructions prior to the surgery. He neglected to frame his preoperative communication with the patient in a chronological (the time of the conversation being before the surgery, not knowing if they will be the same at a later point in time) and functional context (qualifying that some of the information may need to be adjusted due to possible changes in treatment objectives as a result of the surgery). Second, the surgeon committed a š communication encoding error of contextualization (error of misuse) by talking to the patient at a time when she was still groggy from the anesthesia, neglecting both the functional context (i.e. their discrepant objectives, with the patient’s focus being preoccupied with physical postsurgical discomfort rather than discharge information) and the chronological context (i.e. inappropriate timing in terms of the patient’s ability to fully comprehend the information) of that conversation. Third, the surgeon made contact with the patient’s mother-in-law instead of the patient’s husband, committing a › communication encoding error of contextualization (error of misuse) by encoding the instructions to the wrong receiver (functional context). 2. Communication is a non-summative process The surgeon committed a › communication encoding error of sufficiency (error of underuse) by not explicitly asking the mother-in-law to pass on the discharge information to the patient’s husband.

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The surgeon committed another ž communication encoding error of sufficiency (error of underuse) by not conveying the complete discharge information directly to the husband, given that the husband had never been debriefed before. 3. Redundancy in contents and directness in channel enhance accuracy The mother-in-law committed a œ communication decoding error of accuracy (error of misuse) by misinterpreting the surgeon’s discharge instructions. The surgeon and the mother-in-law committed a œ transactional communication error of accuracy (error of underuse) by not verifying with each other that the surgeon’s intended instructions were understood as intended. The surgeon and the patient committed a ¢ transactional communication error of accuracy (error of underuse) by not identifying and correcting their discrepant understandings of the message contents with each other (i.e. their accuracy of understanding) over two more postoperative visits, leading to miscommunication that ultimately compromised the safety of the patient. Finally, the surgeon committed a  communication encoding error of sufficiency (error of underuse) by not providing the patient with written discharge instructions along with his verbal communication. This lack of redundancy compromised the accuracy of the patient’s understanding. 4. Preconceptions and perceptions vary among communicators A chain of communication errors in this case contributed to the care participants’ failure to overcome their perceptual differences. First, the surgeon committed a   communication encoding error of clarity (error of misuse) by handwriting a vague “do as instructed” note onto the generic discharge handout. The patient, in turn, committed a ¡ communication decoding error of accuracy (error of misuse) by misinterpreting the surgeon’s handwritten note as referring to the original, now incorrect, postoperative instructions. The patient also committed a ¡ transactional communication error of clarity (error of omission) by not correcting her perceived ambiguity of the handwritten message in direct conversation with the surgeon. The surgeon committed a Ÿ communication encoding error of interpersonal adaptation (error of underuse) by merely handing generic discharge information to the patient’s husband (assuming it will be “understood”) instead of adapting his communication with the husband to his particular needs to optimize a shared understanding of the message contents.

Case 35: Discharge instructions in the post-anesthesia care unit (PACU): Who remembers? | 219

Discussion Three principles of human communication inform how the adverse event in the patient’s post-surgical care could have been prevented. First, communication is a contextually embedded process. In this case, both the timing (chronological context) and the care participants’ goal alignment (functional context) could have been strategically considered and interpersonally negotiated during the care interactions. Second, successful communication requires sufficient information exchange. In this case, the surgeon incorrectly assumed that the mother-in-law would pass on the discharge information to the patient’s husband. As a result, the surgeon did not sufficiently repeat that information to the husband. The surgeon’s assumption was flawed because accuracy is often compromised by a game of telephone effect (i.e. information getting lost in transition when passing through multiple receivers). Thus, even if the mother-in-law had passed on the discharge instructions to the patient’s husband, its accuracy might have been compromised. More redundant and direct communication would have facilitated a more accurate, shared understanding. Finally, this case illustrates the importance of clear communication to facilitate a shared understanding. There was a lack of accuracy due to unclear and insufficiently adaptive communication that was encoded taking for granted that the other will understand the intended meaning. This common ground assumption rests on an inaccurate understanding of communication as a linear information transfer rather than a complex meaning-making activity that requires active contributions from all care participants. The complexity of this activity is evident in the fact that meanings and shared understandings lie between people, not within people. Perceptual biases and preconceptions, on the other hand, rest within people and often inhibit rather than facilitate the co-establishment of a shared understanding.

Alternative Communication Strategies In this case, several behaviors could have prevented the adverse event: – The surgeon should not have given the patient postoperative instructions prior to the surgery, or at least qualified them as provisional, pending follow-up conversations after the procedure. – The surgeon could have waited to talk to the patient after she had fully recovered from the anesthesia, when she was capable to process his discharge information. – The surgeon could have spoken with the patient’s husband rather than her mother-in-law as instructed by the patient. – The surgeon could have conveyed the full amount of information to the patient’s husband, verifying and validating (both verbally and nonverbally) that he had completely and accurately understood the discharge information.

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The surgeon could have followed up with the patient at a later point in time to make sure that she had received and accurately understood the discharge information. The surgeon could have accompanied and supported his verbal discharge information with a precise typewritten document. The surgeon could have adapted his discharge communication to the ad-hoc needs of the patient’s husband, assuming no common ground.

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Discussion Questions 1.

What communication errors did the surgeon commit in this case?

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What other factors in the case contributed to those errors and to the adverse event?

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At what points could the initial error have been corrected? How?

Exercises 1.

Finding opportunities for recovery Re-read the case and identify points where actors could have ensured message receipt and validated a shared understanding. For each point, describe one action that could have helped to accomplish this goal.

Case 35: Discharge instructions in the post-anesthesia care unit (PACU): Who remembers? | 221

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Writing patient instructions Write a new example of written discharge instructions to be given to the husband at Point 6.

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Case 36: Communication failure – Who’s in charge? Team interaction Insufficient postoperative monitoring and Sentinel event Clinical context: Acute inpatient admission to cardiac surgery (hypoplastic heart syndrome) Communication context: Interactions between patient’s postoperative medical team members (i.e. resident physician, nurse, on-call ICU attending, surgeon, and cardiology fellow) Incident: Communication error leading to insufficient monitoring of a postoperative patient Patient safety outcome: Sentinel event Case reprinted with permission of AHRQ WebM&M. Fackler J, Schwartz JM. Communication failure – who’s in charge? AHRQ WebM&M [serial online]. October 2011. Available at: https://psnet.ahrq.gov/ webmm/case/253.

A 20-month-old boy was admitted to the ICU following a Fontan surgical procedure for hypoplastic left heart syndrome. The child initially made good progress. He was weaned from inotropic support and tolerated enteral liquids on the first postoperative day. That evening the child developed respiratory distress with acidosis and fever. The resident physician ™ notified the on-call ICU attending, who came in from home to manage the child’s respiratory status. The surgeon called from home to check on the child at midnight and spoke with the resident, who indicated that the š child had suffered respiratory deterioration and that the ICU attending was at the bedside managing the patient. The surgeon requested an echocardiogram, but › did not speak directly to the ICU attending, and the cardiology fellow who performed the echocardiogram communicated results to the surgeon, the child’s attending of record for this admission. After stabilizing and monitoring the child’s respiratory status, the œ ICU attending returned home. The resident communicated with the ICU attending by phone and pager through the rest of the night, as the child’s status was not improving as expected. The resident assumed that the ICU attending was communicating with the surgeon, and thus  did not contact the surgeon or cardiologist. The child suffered a cardiac arrest at 7:00 AM from low cardiac output. Despite aggressive resuscitation efforts, the child suffered massive brain injury and subsequently died.

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In post-event debriefings, staff identified several issues in the care of this patient. The attending surgeon and cardiologist were only briefed on the initial respiratory distress and did not have a complete picture of the child’s condition; similarly, the ICU attending focused on stabilizing the child’s respiratory status and missed his low cardiac output. There was confusion among the resident physicians and nursing staff about who was coordinating the child’s care, and a lack of awareness of how to ensure effective team communication when multiple attending physicians are involved in caring for a child. ž The nurse observed the resident on the phone frequently discussing the case, and did not realize that no one was communicating with the other physicians involved. Ÿ The residents and nurses noted that having the ICU attending physician at the bedside left them with the impression that the surgeon and cardiologist were being updated about the child’s continuing deterioration.

Communication Principles 1. Communication is contextual The resident physician committed a ™ communication encoding error of contextualization (error of underuse) by insufficiently framing his communication with the on-call ICU attending within the context of the child just having had heart surgery (functional context). The ICU attending committed a œ communication decoding error of contextualization (error of overuse) by assessing the patient only in the context of his respiratory distress (functional context). The resident physician and the surgeon committed a š transactional communication error of contextualization (error of underuse) by insufficiently discussing the patient’s respiratory distress within the context of the child’s recent heart surgery (chronological context), and the fact that the ICU attending was only managing the respiratory distress (no potential cardiac issues) at the bedside of the patient (functional context). 2. Communication is more than words The nurse committed a ž communication decoding error of accuracy (error of misuse) by misinterpreting the resident being on the phone as an indication of the surgeon and the cardiologist being informed. 3. Redundancy in content and directness in channel enhance accuracy The resident physician committed a  communication encoding error of sufficiency (error of omission) by not contacting the surgeon or cardiologist, under the incorrect assumption that the ICU attending was communicating with the surgeon.

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The surgeon and the ICU attending committed a › transactional communication error of sufficiency (error of omission) by not speaking with each other directly. The resident physician and the surgeon committed a š transactional communication error of sufficiency (error of underuse) by establishing an insufficient shared understanding of who will communicate with whom in attending to the patient’s acute post-operative condition. 4. Preconceptions and perceptions vary among communicators The surgeon and the cardiologist committed a Ÿ communication decoding error of accuracy (error of misuse) by misinterpreting the resident physician’s communication of the ICU physician being at the bedside as indicative of the ICU physician remaining with the patient all night.

Discussion This case illustrates the importance of the context within which a care episode is embedded, and the constraining and facilitating functions such context can have for the safety and quality of care. In this case, the context constrained rather than facilitated the clinicians’ communication. The resident physician’s initial communication with the ICU on-call physician narrowed the issue to “respiratory deterioration.” The omitted content of the patient just having undergone heart surgery from thereon contextually constrained the clinicians’ perceptions of the child’s condition. In other words, the resident physician overused his communicative contextualization of the care episode, which turned the context into a constraint that narrowed the clinicians’ perspectives onto a “respiratory issue.” This constraining contextualization left the patient’s cardiac problems undiagnosed and ended up contributing to the patient’s death. This case also demonstrates how communication contains more than words. The nurse’s interpretation of the resident physician being on the phone as indicative of the surgeon and the cardiologist “being informed” demonstrates that communication, both in encoding and decoding, entails more than words – with nonverbal behavior being perceived as more accurate than verbal information. The events in this case also draw attention to the communication principle “redundancy in content and directness in channel enhance accuracy.” The care episode demonstrates that care participants should never assume that communication has taken place. Follow-ups are generally the safer way to establish shared understanding, because even if information has been exchanged, it does not mean that the information was understood accurately, and that this understanding was being shared by all participants. In fact, the odds predict the contrary.

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Finally, this case demonstrates that successful interpersonal communication is the only process through which care coordination and consistency can be fully attained. The clinicians in this case did not achieve this outcome as a direct result of the prevalent lack of clarity, accuracy, and sufficiency in their communication.

Alternative Communication Strategies In this case, several behaviors may have prevented the sentinel event: – The resident physician could have framed his notification of the on-call ICU attending within the context of the child just having undergone heart surgery. – The resident physician and the surgeon could have discussed the patient’s respiratory distress within the context of the child’s recent heart surgery and clarified the fact that the ICU attending was focusing on the patient’s respiratory distress at the bedside. – The nurse should not have assumed that the resident talking on the phone indicated that the surgeon and the cardiologist had been informed. – The resident physician could have remained in direct contact with the surgeon, and the surgeon and the ICU attending could have communicated with each other directly. Ideally, all of them could have had a direct conversation (e.g., conference call) to establish a common ground and coordinate the patient’s postoperative care. – The resident physician and the surgeon could have established a shared understanding of who will communicate with whom in attending to the patient’s postoperative care. – The surgeon and the cardiologist should not have decoded the resident physician’s communication of the ICU physician being “at the bedside of the patient” as indicative of the ICU physician remaining with the patient all night.

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you selected inform this particular case. Compare your choices with the responses provided in the answer key on page 252. Are there any discrepancies? Discuss how any alternative lessons that you may have chosen or disregarded apply to this case.

Discussion Questions 1.

What constitutes a “transactional communication error of sufficiency”? What was “insufficient” about the communication in this case?

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In what way was nonverbal communication given greater weight than verbal communication in this case?

Exercises 1.

Recoding errors There were several decoding errors in this case. Choose one decoding error and describe how it could have been avoided or corrected.

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Flowcharting Draw an assumptions flowchart, outlining each interaction in this case and the underlying assumptions that informed each actor’s behavior.

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Case 37: Treatment challenges after discharge Interprofessional interaction Medication misuse and Adverse event Clinical context: Acute-on-chronic ED visit with subsequent inpatient admission and post-discharge ED readmission (mental status change) Communication context: Interactions between hospital clinicians and ED staff Incident: Communication error leading to clinician’s medication misuse Patient safety outcome: Adverse event Case reprinted with permission of AHRQ WebM&M. Coffey C. Treatment challenges after discharge [Spotlight]. AHRQ WebM&M [serial online]. November 2010. Available at: https://psnet.ahrq.gov/webmm/ case/227.

Family members brought a 66-year-old man to the ED with acute-on-chronic altered mental status. Several years earlier, the patient had a craniotomy for a brain tumor, which had resulted in mental retardation. The ED obtained routine laboratory tests (including urinalysis and CBC) that indicated a UTI. After a urine culture was obtained in the ED, the patient was started on vancomycin and ™ admitted to the hospital. By day 3, he showed marked improvement and, according to his family, was returning to his “usual self.” š He was switched to trimethoprim-sulfamethoxazole, an antibiotic he could take by mouth, and discharged home. The plan was for the patient to follow up with his primary care physician in 2 weeks. Eleven days later, the patient’s family brought him back to the ED after he had become increasingly disoriented and confused. His white blood cell count, which had been normal previously, was now very high (31,000), and his BP was lower than usual. He was admitted to the hospital with the diagnosis of severe sepsis. The › admitting nurse noticed that the urine culture results from his prior hospital admission indicated that the patient’s infection was not sensitive to trimethoprimsulfamethoxazole. These test results œ had become available 2 days after the patient’s discharge but  had not been reviewed by any of the hospital clinicians responsible for his care ž or forwarded to his primary care physician. As a result, the patient had continued to take the trimethoprim-sulfamethoxazole. His second hospitalization lasted 7 days. With the correct antibiotic, he made a full recovery.

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Communication Principles 1. Communication is contextual The ED staff committed a ™ communication encoding error of contextualization (error of underuse) by not framing the patient’s admission to the hospital within the context of a pending urine culture test (functional context). The hospital clinicians committed a š› communication encoding error of contextualization (error of overuse) by ordering to switch the patient to trimethoprimsulfamethoxazole too soon (chronological context); they could have awaited the urine culture results from the ED to make sure that the patient’s infection is sensitive to this antibiotic. 2. Redundancy in content and directness in channel enhance accuracy The ED staff committed a ™ transactional communication error of sufficiency (error of underuse) by insufficiently establishing a common understanding in conversation with the hospital staff that the patient had a pending urine culture test at the ED that was relevant for the choice of prescriptions to treat his UTI. The ED staff committed a œ communication decoding error of sufficiency (error of omission) by not analyzing the patient’s urine culture test results. The ED staff committed a  communication encoding error of sufficiency (error of omission) by not communicating the patient’s urine culture test results to the hospital clinicians and the patient’s primary care physician.

Discussion This case demonstrates how information that is “lost-in-transition” between two hospital departments can lead to inaccurate decision-making that has the potential to cause patient harm. Critical information was “lost” because the ED staff and the hospital staff insufficiently contextualized their transfer communication. For example, the ED staff did not inform the hospital staff that there was a pending urine culture test that would be relevant for the patient’s medication (functional context), and the approximate time it would take for test results to become available (chronological context). Similarly, the hospital staff did not inquire about any contextual information within which the transfer of the patient was taking place. Such a co-created contextual understanding of the patient’s care episode could have prevented the patient suffering sepsis and needing to be readmitted to the hospital 11 days later. In other words, the staff’s insufficient communication within the context of the patient’s care needs evoked a care episode that was poor in quality (i.e. lack of efficiency, effectiveness, and patient-centeredness) and compromised the safety of the patient.

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Alternative Strategies In this case, several behaviors could have prevented the adverse event: – The ED staff could have framed their initial transfer communication with the hospital staff within the context of the pending urine culture test. They could have established a common understanding that the patient had a urinary culture test pending at the ED that would be relevant for the hospital clinicians’ choice of prescriptions to treat his UTI. – The ED staff could have decoded the patient’s urine culture test results and immediately communicated them to the hospital clinicians and the patient’s primary care physician.

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Discussion Questions 1.

How could communicating within the functional context of this case scenario have prevented the adverse event?

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Amidst a team of multiple providers, how can care teams ensure that communication is chronologically contextualized?

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Exercises 1.

Script writing Write an alternate script for a new interaction between the ED staff and the hospital staff during their initial transfer communication.

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Policy making Describe an institution-wide system or policy that could help providers ensure that in a team of multiple providers, pending test results are reviewed and communicated in a timely manner.

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Case 38: July syndrome Cross-professional interaction Delayed postoperative treatment and Near miss Clinical context: Acute outpatient and then inpatient visit for thoracic surgery (lung cancer) Communication context: Interactions between an attending surgeon, two surgery fellows, a surgical intern, a nurse, an attending ICU physician, and a pharmacist on the ICU team Incident: Communication error leading to delayed postoperative treatment (prophylaxis) Patient safety outcome: Near miss Case reprinted with permission of AHRQ WebM&M. Young JQ. July syndrome. AHRQ WebM&M [serial online]. June 2016. Available at: https://psnet.ahrq.gov/webmm/case/378.

A 64-year-old man was seen in the thoracic surgery clinic in June after being diagnosed with a right lower lobe lung cancer. The attending surgeon saw the patient along with his fellow, who was completing his 1-year surgery fellowship. By that point in the year, the attending had supervised the fellow’s operative and postoperative care of nearly 100 patients, and he trusted him completely. The patient was a good candidate for surgery, so the surgeon ™ discussed the operative plan (a right lower lobe lobectomy) briefly with the fellow and had the procedure scheduled for a few weeks later. The procedure was scheduled for the first week of July. However, by this time, the fellow who had seen the patient in clinic had graduated and š left the institution. The procedure itself was uneventful, and the patient was transferred to the ICU postoperatively. The initial postoperative orders were written by the new thoracic surgery fellow, who had just started his fellowship and was new to the organization. He › wrote brief orders for postoperative care, œ assuming, as had been the case at the hospital where he did his residency, that the ICU team would write more comprehensive orders. The patient was received in the ICU  by a surgical intern, who was in her ž first rotation and had also graduated from medical school elsewhere. The patient’s nurse noticed that there were no orders for venous thromboembolism (VTE) prophylaxis, despite the patient being at high risk for VTE. She brought this to the intern’s attention. The intern Ÿ assumed that VTE prophylaxis was contraindicated, because the fel-

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low had not ordered VTE prophylaxis; she also recalled an incident during medical school where a surgery intern had been chastised for starting VTE prophylaxis inappropriately. Although the standard postoperative order set in the electronic medical record included a prompt for a VTE prophylaxis order, the intern   found that she could easily skip this order and complete the rest of the order set without difficulty. Therefore, ¡ the patient was not prescribed VTE prophylaxis. Two days later, the pharmacist on the ICU team was reviewing orders for the patient and realized that the patient was not receiving VTE prophylaxis. She brought this to the attention of the intern, who replied that she thought it was contraindicated, so she had not ordered it. The pharmacist conferred with the ICU attending, who agreed that VTE prophylaxis could have been started postoperatively and made sure it was started that day. Fortunately, the patient experienced no adverse consequences as a result, but the pharmacist and ICU attending wondered what could have been done to limit the risk of such an event in the future.

Communication Principles 1. Communication is contextual The surgeon committed a ™ communication encoding error of contextualization (error of misuse) by discussing the operative plan with the wrong person (functional context). The surgeon neglected that the fellow would have left the institution by the time of the surgery which was booked after July 1(chronological context). The initial surgery fellow committed a ™ transactional communication error of contextualization (error of underuse) by communicating insufficiently with the surgeon within the context that he would no longer be at the institution at the time of the planned surgery (chronological context). 2. Communication is a non-summative process The initial surgery fellow committed a š transactional communication error of sufficiency (error of omission) by not communicating with the incoming fellow (e.g. via appropriate notation in the medical record) to make sure that he had a shared understanding of the operative plan for this patient’s upcoming surgery. The new thoracic surgery fellow committed a › communication encoding error of sufficiency (error of underuse) by merely writing brief orders for postoperative care. The surgical intern and the surgery fellow committed a  transactional communication error of sufficiency (error of omission) by not establishing a shared understanding of the complete postoperative order contents.

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3. Preconceptions and perceptions vary among communicators The new thoracic surgery fellow committed a œ communication encoding error of contextualization (error of underuse) by insufficiently framing his postoperative care orders within the context of being new to the institution and needing to adjust his communication to the institution’s protocols and standards (cultural context). The surgical intern committed a ž communication decoding error of contextualization (error of underuse) by insufficiently decoding the surgery fellow’s order in light of her coming from a different institution with different communication standards and protocols (cultural context). 4. Redundancy in content and directness in channel enhance accuracy The surgical intern committed a Ÿ transactional communication error of accuracy (error of omission) by failing to confirm with the surgical fellow that no VTE prophylaxis was indicated for the patient. The intern committed a   communication decoding error of clarity (error of misuse) by ignoring her uncertainty about the patient needing a VTE prophylaxis and simply skipping over the prompt in the electronic medical record. The intern committed a ¡ communication encoding error of sufficiency (error of omission) by not prescribing the patient the VTE prophylaxis.

Discussion This case demonstrates the relevance of four principles of human communication to safe and high-quality patient care: First, the near miss resulted from the care participants’ insufficient chronological and functional contextualization of their communication. The surgeon and the initial surgery fellow failed to talk about the patient’s operative plan in anticipation of the fellow departing the institution at the end of the academic year, and the new fellow was never debriefed on the operative plan. Second, the clinicians did not recognize communication as an interactive meaning-making process. Several omitted conversations led to the insufficient establishment of a common ground and, as a direct result, inhibited a shared understanding. In fact, the participants did not even conduct the bare minimum of communication (e.g. evident in a brief rather than detailed information exchange on postoperative orders) that would have been required for safe patient care. Instead, the providers acted based on a common ground fallacy that could have severely harmed the patient. Third, the clinicians did not utilize communication as a process to overcome differential perceptions that they had formed based on previous experiences during medical school and at other institutions. The initial fellow underused this cultural context by resorting to a bare minimum of communication instead of actively adapting his

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postoperative ordering to the new organization’s standards. The new incoming fellow also underused this cultural context by drawing inferences from her recall of a similar medical school incident, and over-generalized that approach to her communication at this new institution. In other words, both fellows’ preconceptions caused them to think and act within their own experiential frames. As a direct result, they did not establish a common ground that could have bridged their perspectives. Fourth, this case shows the importance of appropriate redundancy in facilitating accuracy and, as a result, safer patient care. The clinicians failed to engage in direct communication with one another (e.g. by phone or face-to-face) to engage in accuracypromoting follow-up (i.e., redundancy). Instead, they remained vague and ambiguous in their encoding and decoding, which led to a degree of inaccuracy that nearly caused severe patient harm. Interestingly, a core issue in this case was the intern’s lack of response to the EHR prompt, which evidences that EHRs can work well as tools to facilitate a certain coverage of information (i.e. quantity). However, such digitization does not function well to facilitate a shared understanding as a foundation for safe and high-quality patient care. In other words, digitization tools provide structure, but they do not facilitate the communication process (i.e., an interpersonal meaning-making process that pursues a shard understanding).

Alternative Communication Strategies In this case, several behaviors could have prevented the near miss: – The initial surgery fellow could have contextualized that he will no longer be at the institution at the time of the planned surgery. – The surgeon could have discussed the operative plan with the new incoming fellow (either in person or, if the new fellow was unknown at that point in time, via appropriate notation in the medical record). – The initial surgery fellow could have made sure that the new fellow had a shared understanding of the operative plan he had discussed with the surgeon before leaving the institution. – The new thoracic surgery fellow and the surgical intern could have made an effort to adjust their communication to the new institution’s standards. – The new thoracic surgery fellow could have written more detailed orders for the patient’s postoperative care. – The surgical intern and the surgery fellow could have followed up with one another to make sure that they had a shared understanding of the written postoperative order contents. – The surgical intern should not have skipped over the prompt in the EHRs, but instead verified in direct conversation with the surgical fellow that no VTE prophylaxis was indicated for the patient.

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Discussion Questions 1.

What role did the “common ground fallacy” play in this near miss event?

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What are two principles of communication demonstrated by this case?

Exercises 1.

Policy making Institutions must regularly handle turnover of clinicians in various stages of training. Describe one institution-wide system or policy that could ensure that incoming staff have an adequate understanding of treatment plans before proceeding with treatment execution.

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Script writing Write a script for a new interaction between the new surgery fellow and the surgical intern in which both actors provide sufficient context to account for potential differences in policy and culture between the fellow’s current and previous institutions.

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Case 39: Discontinued medications: Are they really discontinued? Inter-institutional interaction Medication overuse and Adverse event Clinical context: Acute ED visit with subsequent inpatient admission to the ICU (bilateral subdural hematomas) Communication context: Interaction between ED clinicians and an outpatient pharmacy Incident: Communication error leading to patient’s medication overuse Patient safety outcome: Adverse event Case reprinted with permission of AHRQ WebM&M. Mankey CG, Varkey P. Discontinued medications: are they really discontinued? AHRQ WebM&M [serial online]. May 2014. Available at: https: //psnet.ahrq.gov/webmm/case/325.

A 69-year-old man with a history of chronic atrial fibrillation and associated cerebrovascular accident (CVA) treated with warfarin and aspirin presented to the ED with a severe headache. A STAT CT scan revealed bilateral subdural hematomas. His international normalized ratio (INR) was determined to be supratherapeutic at 4.9. He was admitted to the ICU for monitoring of his neurologic status. After resolution of the severe headache, warfarin was restarted because of the high risk associated with his previous CVA (CHADS2 score 3). One day after re-initiation of his warfarin, he experienced a recurrence of his subdural hematoma. ™ The warfarin was discontinued, the patient stabilized clinically, and he was later discharged home. Although warfarin was not included on his discharge medication list, a few days after returning home, the patient š received warfarin via mail order from his outpatient pharmacy. While confused by the receipt of the warfarin, the › patient restarted the medication. At his follow-up appointment, he was noted to have an elevated INR. Recognizing the elevated INR was a result of the patient’s re-initiation of warfarin, a repeat head CT was performed which fortunately was negative for recurrent hemorrhage. In response to these events, œ warfarin was added to his allergy list with the comment “Never to be resumed.” Regardless, when the PCP contacted the pharmacy weeks later,  warfarin remained on the active medication list, with available refills. The PCP had it removed from this list.

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Communication Principles 1. Redundancy in content and directness in channel enhance accuracy The ED staff committed a ™ communication encoding error of sufficiency (error of omission) by not contacting the pharmacy to inform them of the patient’s medication contraindication when they discontinued the warfarin at the ED. The outpatient pharmacist committed a š communication encoding error of accuracy (error of commission) by sending the patient the discontinued warfarin order. The patient committed a › communication decoding error of accuracy (error of misuse) by misinterpreting the fact that the pharmacy mailed him the warfarin as an indication that he should take the medication. The patient committed a › transactional communication error of clarity (error of omission) by not clarifying in direct conversation with his provider and the pharmacist why he received the warfarin via mail order, and how (if at all) he was supposed to take it. 2. Communication is contextual The clinicians committed a œ communication encoding error of contextualization (error of underuse) by adding warfarin to the patient’s allergy list too late (chronological context). The clinicians committed a  transactional communication error of contextualization (error of underuse) by failing to establish a shared understanding with the outpatient pharmacist on time (chronological context) that the patient had a contraindication to warfarin (functional context).

Discussion This case demonstrates the importance of all care participants needing to contribute to establish a common ground and shared understanding. Both the quantity and quality of communication that occurred in this case were insufficient for this purpose. For the most part, the insufficiency resulted from the providers’ mistaken assumption that others will access the information they deposited into records or discussed with another person. In other words, they abdicated their responsibility for communication at a point where they had “sent off” a message, instead of thinking it through to the “end” (i.e. where all care participants share an understanding). This linear perception of communication is flawed because the quality of communication could not be assessed without knowing whether and to what extent a person’s message was received and comprehended by the receiver. For example, the ED staff in this case should not have assumed that the pharmacy received and understood their note about the warfarin discontinuation. The staff could have communicated this ad-

238 | Stage 6: Post-treatment care

justment directly to the pharmacist to make sure that their records had been corrected. In summary, all providers in this care episode did not comprehend communication as a complex interactive meaning-making process that is required for establishing a shared understanding. This case also highlights the importance of patients getting involved as active partners for safe and high-quality care. The patient could have prevented the adverse event if he had expressed his uncertainty about having received the medication in the mail. He could have actively established a shared understanding of the meaning inherent in this mail order through direct communication with the pharmacist and/or his provider. This direct follow-up could have intervened with the adverse event-inthe-making. This incident also illustrates how communication entails more than words. The pharmacist’s mere act of sending the medication conveyed a nonverbal message to the patient, which the patient ended up trusting more than the ED provider’s verbal discharge instructions. This evidences the importance of understanding that not only verbal statements convey messages – even a perceived “lack” of behavior can convey important messages with both informational and relational meaning.

Alternative Communication Strategies In this case, several behaviors could have prevented the adverse event: – The ED staff could have added warfarin to the patient’s allergy list right away. – The ED staff could have contacted the outpatient pharmacy directly to inform them about the patient’s contraindication to taking warfarin. – The outpatient pharmacist should not have sent the patient warfarin via mail order without ruling out any potential allergies with the ED staff. – The patient could have clarified in direct conversation with the ED provider why the warfarin was sent to his home, and how he was supposed to use it.

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Case 39: Discontinued medications: Are they really discontinued? | 239

Select the communication lessons from Chapter 6 that best apply to this case and mark the respective circle(s) in this graph. Explain your choices and discuss how the lessons you selected inform this particular case. Compare your choices with the responses provided in the answer key on page 252. Are there any discrepancies? Discuss how any alternative lessons that you may have chosen or disregarded apply to this case.

Discussion Questions 1.

Patient activation can improve patient safety and care outcomes. Could this error have been avoided if the patient had been better engaged as an active care participant?

2.

If yes, what methods could the providers have used to engage the patient and encourage him to be an active partner for safe and high-quality care?

Exercises 1.

Flowcharting Draw an assumptions flowchart, outlining each interaction in this case and the underlying assumptions that informed each actor’s behavior. For each assumption, make note of how the actor(s) could have verified this assumption through direct communication.

2.

Draw a timeline Draw a timeline of the events for this case. For each action or interaction, note how the actor(s) could have changed their behavior by thinking their communication through to “the end,” as a complete and holistic process.

Concluding thoughts The primary goal of healthcare is to improve or sustain the health of a population. The goal of clinicians is to improve or sustain the health of individual patients. The goal of education in health professions is to train and prepare individual providers to deliver high-quality care to patients. Unfortunately, we often fall short in achieving these objectives. A core problem is that we have paid insufficient attention to communication between providers and patients as an essential process through which safe and high-quality care can take place. As laid out in the IOM (2001) report Crossing the Quality Chasm, high-quality healthcare is safe, effective, patient-centered, timely, efficient, and equitable. Thus, patient safety constitutes a core element of healthcare quality. Safe care is care that avoids harm to patients. Safety must be a property of the system in which care is delivered in order to effectively minimize errors, mitigate adverse effects, and prevent patient harm. In other words, patient safety requires a conscientious and competent collaborative effort by individual providers and the healthcare system in which they work. Paradoxically, one of the greatest shortcomings in the delivery of care lies in the element most familiar to all practitioners – interpersonal communication. In nearly all healthcare processes, communication is the vehicle through which care takes place. At the same time, communication is one of the least studied and least well-understood processes by providers and patients. Therefore, to enhance healthcare quality and patient safety, it is crucial to understand and adopt core principles from communication science that underpin the practice of effective and appropriate communication in healthcare delivery. Part I of our book presented core principles and lessons from communication science that apply to the safe practice of healthcare. The 39 cases in Part II of our book demonstrated these principles in practice. Following each case, we showed how the principles sometimes interact with one another in the context of actual medical encounters. Furthermore, we explicated the communication processes and their role in causing and preventing patient harm. Following each case presentation, we provided discussion questions, applied exercises, and a “communication lessons” activity as a pedagogical resource for educators, students, and practitioners to integrate the learned communication lessons into daily workflow. To improve the accessibility of the 39 cases, we organized them within 6 stages of the care delivery continuum (i.e. medical history taking, diagnosis, treatment planning, storage, treatment execution, and post-treatment care) across the most common levels of communication (i.e. provider-patient, provider-family, team, interprofessional, cross-professional, and inter-institutional communication). We cross-referenced the cases by type of event, type of care, and care setting. We chose cases that DOI 10.1515/9783110455014-013

242 | 6 Concluding thoughts

are reflective of critical challenges in the provision of safe and high-quality care to patients: medication events, diagnostic errors, handoffs, timeliness, postoperative monitoring, resuscitation events, discharge events, surgery events, and patient falls. Communication constitutes a fundamental activity in human life. However, the process of communication is often not understood very well by providers and patients. Communication is not as simple as it looks. It fails more often than it succeeds in attaining a mutual understanding. Communication is more than words, even carefully chosen words, and it entails much more than a mere transfer of information. Once initiated, it cannot be left alone and relied upon to be understood by the others. Communication does not rest within individuals; it is a complex and sometimes laborious interpersonal meaning-making process. Thus, more communication does not necessarily imply better communication, and communication does not simply “break down.” This notion relies on the incorrect assumption that communication is a linear process that runs on its own, and that participants make it fail. In fact, things generally go wrong in healthcare because communication was never sufficiently established, it was not accurately or clearly expressed, and it was not appropriately contextualized or interpersonally adapted (see Chapter 2). Humans communicate a lot, but too often not “well.” Insufficient, unclear, inaccurate, maladapted, and out-of-context communication can detract from everyday life, and in high-risk industries like healthcare, it can severely threaten safety. Unfortunately, most people view communication problems as aberrant, representing failure on the part of individuals. This focus on the individual is not an accurate description of the problem. In fact, miscommunication is a part of daily life, because of the “common ground fallacy” – we generally assume in our communication with others that other people are more similar to us than they actually are. As a result, we assume that our conversational counterparts will naturally understand the intentions, thoughts, feelings, and meanings that we express in our communication. In reality, however, it is essentially impossible to establish a complete shared understanding between two or more people, particularly if they come from different sociocultural and/or professional backgrounds (see Chapter 2). In theory, the simplest process of an interpersonal communication encounter between two parties can be diagrammed as including three components: individual encoding, individual decoding, and transactional (mutually negotiated) sense-making. However, it is more true-to-life to think of this communication as an ongoing, interactive negotiation between two or more people to minimize or take into account their individual differences en route to reaching a shared understanding. This process of “coming to an understanding” is complicated by the fact that any message is only an approximation of the notion the person initiating the communication originally had in mind. In addition, that communication is complicated by motivations and functions of that communication, some of which may not prioritize a shared understanding and the encoder may not be consciously aware of.

6 Concluding thoughts | 243

Viewed more technically, our book introduced nine core principles of interpersonal communication that can be viewed as essential take-home messages for the practice of safe and high-quality healthcare (see Chapter 2): 1. Communication varies between thought, symbol, and referent – humans make meaning through the creation and use of symbols, which include words, gestures, images, sounds, and artifacts. Communication is the vehicle that people use to create a shared reality. 2. Communication is a non-summative process – it is instead an interactive process that, in order to be effective, needs to continue until it reaches the goal of shared understanding. 3. Communication is functional – and those functions include more than information exchange. Other functions include making an impression, maintaining a relationship, reducing uncertainty, persuading others to take some form of action, managing one’s own privacy, avoiding or resolving conflict, and many more. 4. Communication is more than words – verbal messages are always accompanied by nonverbal expressions or behaviors, and communication typically occurs via multiple channels in addition to words. 5. Communication entails factual and relational information – factual messages often convey relational messages too. 6. Communication is contextual – the meaning of a message depends largely on the context in which it is encoded, received, and interpreted. Context includes goals, past history of relationships, hierarchical status differences, timing and timeliness of the communication, environmental setting, and sociocultural norms. 7. Preconceptions and perceptions vary among communicators – this leads to differences in expectations and interpretation, and the common but mistaken notion that “they will understand.” 8. Message redundancy and directness in communication channel enhance accuracy – repeated messages and direct face-to-face communication enhance the likelihood of a shared understanding. 9. Communication is equifinal and multifinal – that is to say, there are many possible communication paths to achieving the same outcome. One or more of these messages may be more effective than others. Analogously, the same communication path can lead to different actions and outcomes. In addition, our book introduced five core issues related to the quantity and quality of interpersonal communication (see Chapters 4 and 5): 1. Communication sufficiency – the extent to which interpersonal communication is complete in terms of the covered quantity of content to establish sufficient common ground upon which participants can co-construct a shared understanding. 2. Communication clarity – the extent to which interpersonal communication is either strategically or inadvertently vague, ambiguous or unclear, or clear enough

244 | 6 Concluding thoughts

to establish a common ground and shared understanding of the original intent, thoughts, feelings, and meanings. 3. Communication accuracy – the extent to which participants encode and decode message contents correctly. 4. Communication contextualization – to be effective and appropriate, communication must be sufficiently contextualized in terms of the applicable contextual layers in which the given communication episode is framed. This applies to encoding, decoding, and the transactional communication process. 5. Interpersonal adaptation – the extent to which communication is flexibly adapted to the needs and expectations that are expressed spontaneously and ad hoc (both verbally and nonverbally) during an interaction with another care participant. We conceptualized safe and high-quality communication in healthcare as that which contains all behaviors that are most appropriate to optimize the likelihood of achieving the most effective and preferable care outcomes (see Chapter 5). It is the task of clinicians to optimize effective healthcare by making sure that a common ground and shared understanding are established among the care participants to prevent and minimize the impact of inevitable misunderstandings. The cases in Part II of our book include examples of errors made by care participants in encoding, decoding, and transactional sense-making. Across the 39 cases, participants’ transactional communication errors mostly involved the verification of the receipt, completeness and accuracy of information. A number of safety-relevant communication themes emerged from the cases: 1. Time – this theme related to timeliness, time spent, timing, and duration of communication. 2. Patient-centered care – communication that is spontaneously responsive to explicitly and implicitly expressed needs and expectations of individual patients or care providers, which contributes to care that is both patient-centered and facilitates shared understanding among all care participants. 3. Sound-alikes – and look-alikes – refers to instances in which uncorrected misunderstandings among people, facilitated by similar sounding, looking, or naming of different medications, leads to misuse and harm. 4. Safety culture – which includes competent communication that occurs among healthcare providers who are preoccupied with the potential for insufficient, inaccurate, unclear, maladapted, and out-of-context verbal and nonverbal messages and errors in their care. 5. Digitization of healthcare – despite its promises, health information technology often fails to facilitate successful communication (i.e. a shared understanding), because it cannot convey important nonverbal messages, commonly generates information that may be incomplete and indirect, often fails to reliably establish a common ground, and frequently is not accessed by intended receivers. In addi-

6 Concluding thoughts |

6.

7.

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tion, it can distract providers from direct reception of encoded messages from the patient. Patient and family engagement – both patients and families need to contribute to safety-relevant transactional communication processes with and among clinicians. Handoffs – communication accuracy is commonly compromised during handoffs due to a loss of information that occurs through latent communication (i.e., “game of telephone” effect) involving too many individuals.

In summary, this book demonstrates that interpersonal communication is the essential vehicle through which safe and high-quality healthcare is attained. If that vehicle is operated competently, it facilitates favorable outcomes. Insufficient, unclear, inaccurate, maladapted, and out-of-context communication, on the other hand, leads to misunderstandings that can severely compromise the quality and safety of patient care. For that reason, we hope that our book will be a valuable resource to facilitate and inform widespread training interventions that introduce evidence-based communication skills rooted in communication science into healthcare education and practice.

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Answer Key 1.

3, 4, 5, 6, 7, 8, 10, 11, 12, 13, 15, 16, 17

2.

4, 6, 7, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19, 27, 29

3.

7, 9, 10, 11, 13, 16, 17, 18, 19, 27

4.

6, 7, 8, 10, 11, 12, 13, 15, 16, 20, 24, 27

5.

7, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19, 20, 28

6.

4, 6, 7, 8, 9, 10, 11, 12, 13, 16, 17, 18, 20, 27, 29

7.

1, 4, 7, 9, 11, 12, 13, 17, 18, 24, 26

8.

2, 4, 7, 11, 12, 13, 17, 18, 26, 27, 29

9.

3, 4, 5, 7, 8, 10, 11, 12, 13, 15, 16, 17, 18, 24, 27

10. 3, 5, 6, 8, 10, 11, 12, 13, 15, 16, 17, 18, 20, 24, 27 11. 3, 4, 5, 7, 8, 9, 10, 11, 13, 15, 16, 17, 18, 20, 27 12. 4, 7, 8, 10, 11, 12, 13, 16, 17, 18, 24, 25, 27 13. 1, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 15, 16, 17, 18, 19, 20, 24, 27, 28, 29 14. 8, 11, 12, 13, 17, 18, 19, 20, 22, 26, 27, 28 15. 1, 4, 5, 7, 8, 11, 12, 13, 15, 16, 17, 18, 22, 24, 25, 27 16. 4, 6, 7, 8, 9, 10, 11, 12, 13, 15, 16, 127, 18, 19, 24, 25, 27, 28 17. 7, 8, 11, 12, 13, 15, 16, 17, 18, 19, 20, 21, 22, 24, 28 18. 7, 11, 13, 15, 16, 17, 18, 19, 20, 22, 24, 27, 28, 30 19. 6, 7, 8, 9, 10, 11, 12, 13, 16, 17, 18, 19, 22, 27 20. 1, 2, 4, 11, 12, 13, 17, 18, 26, 27, 29 21. 1, 3, 5, 7, 9, 10, 11, 13, 15, 17, 18, 26, 28 22. 4, 5, 6, 7, 8, 9, 11, 12, 13, 16, 17, 18, 20, 27, 28 23. 1, 3, 6, 7, 8, 10, 11, 12, 13, 15, 16, 17, 18, 20, 21, 24, 27 24. 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 20, 21, 27, 28 25. 4, 8, 10, 11, 12, 13, 15, 16, 17, 18, 20, 21, 24, 25, 27 26. 1, 2, 4, 11, 13, 16, 17, 26, 27, 28, 29 27. 1, 2, 4, 7, 8, 9, 10, 11, 13, 14, 16, 18, 23, 26, 27, 29 28. 3, 4, 5, 7, 9, 10, 11, 13, 15, 16, 18, 27, 29 29. 4, 10, 11, 12, 13, 15, 16, 17, 18, 20, 27, 29 30. 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 27 31. 4, 6, 7, 8, 9, 11, 12, 13, 15, 16, 17, 18, 19, 24, 25, 27 32. 4, 7, 9, 11, 12, 13, 15, 16, 17, 18, 20, 27 33. 4, 6, 7, 8, 9, 10, 11, 13, 16, 17, 27, 28, 29, 30 34. 1, 4, 5, 7, 8, 11, 12, 13, 15, 16, 27, 29 35. 4, 7, 8, 11, 12, 13, 15, 16, 17, 18, 20, 23, 27, 28, 29 36. 1, 3, 4, 5, 7, 11, 12, 13, 15, 16, 17, 18, 27 37. 5, 10, 11, 12, 16, 18, 24, 27 38. 5, 8, 11, 17, 18, 22, 27 39. 1, 3, 5, 7, 9, 10, 11, 12, 13, 15, 16, 17, 18, 24, 27

Index A act of commission 5 act of omission 5 adverse event 4, 6, 7, 39 B bad outcome 6 C close call 6, 38 code blue 135 common ground 19 communication 11, 13 – accuracy 38, 244 – asymmetric 120 – attempted 75 – chronological context 34 – clarity 39, 243 – competence 33, 45 – contextual 18 – contextualization 40, 244 – error 34 – failure 13 – inadequate 27 – ineffective XIII – interpersonal 26, 32, 242 – latent 11, 30 – lesson 55 – nonverbal 12, 17, 21 – safe and high quality 244 – sufficiency 37, 243 – transactional 29 – understanding 145 communication skills, interpersonal 30 communicative competence 40 context – chronological 18 – cultural 18 – environmental 18 – functional 18 – relational 18 culture of safety 5 D decoding 34 diagnosis, medical 89

digitization of care 28, 29 discharge instructions 208 DNR – do-not-resuscitate status 118 E electronic health records (EHR) 28 encoding 34 error – active 5 – commission 47 – communication contextualization 40 – decoding 34 – encoding 34 – interpersonal adaptation 42 – latent 5 – misuse 47 – omission 46 – overuse 46 – transactional communication 34, 35 – underuse 46 F follow-up 207 follow-up task 191 H handoff 30, 101 Hannawa SACCIA Typology 47 harmless hit 6 hazardous circumstance 6 healthcare quality 7 I incident, critical XV interpersonal adaptation 41, 244 L Lake Wobegon Effect XIV M message redundancy 19, 243 miscommunication 31, 33, 34 model of human communication 34

254 | Index

N negligence 6 no harm event 6 nonbehavior 12 P patient factors 9 patient fall 186 patient safety 5, 9, 10, 241 patient safety incident 6 patient-centered care 26 patient-centeredness 8 post-treatment care 207 principles of interpersonal communication 243 Q quality of care 10, XIV

R read back strategy 65 S safety culture 6, 27 sentinel event 6, 39 shared understanding 11–13, 19, 29, 32 Swiss cheese model 9 T task factors 9 team factors 9 time allotment 24 timeliness 8, 24, 105 treatment execution 175 treatment plan 143