complex diseases demands an increase
in the number of specialists involved,
each with his or her own focus and
expectations about what should be
addressed and communicated among
health care professionals.
Even uncomplicated patient care
is subject to multiple lines of communication, continual interruption from
around-the-clock admissions and
discharges, multitasking responsibilities, changing priorities, and frequent
patient transfers. These events do not
relieve doctors and nurses of their
duty to ensure complete and accurate
exchange of patient information. In
evaluating a potential claim involving
a miscommunication, you will need
to know what authorities doctors and
nurses rely on and what potential pitfalls exist in the information exchange
between them.
Three types of authority dictate communications protocol among doctors
and nurses in hospitals: governmental,
professional, and institutional. Government guides include federal regulations,
state medical practice acts, and licensing
boards. Professional authorities include
ethics codes—the American Medical
Association (AMA) Code of Medical
Ethics,5 the refined Hippocratic Oath
for doctors6 and the Code of Ethics for
Nurses with Interpretive Statements for
nurses7—treatment guidelines, medical
or nursing specialty position statements,
and ethics board opinions.8
Hospitals also govern how doctors
and nurses should communicate with
each other through their policies and
procedures. Most hospitals use the
National Patient Safety Goals (NPSG),
published by the Joint Commission
(formerly the Joint Commission on
Accreditation of Healthcare Organizations), as a framework when drafting
their policies and procedures.9
Continually evolving, the goals focus
in part on reducing medical mistakes
caused by inadequate communication
between health care providers. The following goals may be relevant to a case
involving miscommunication in the
hospital setting.
Verbal and telephone orders
(NPSG 02.01.01). This guideline states
that a doctor (or his or her authorized
agent) who gives a verbal order should
confirm that the person who receives
and records the order has heard it correctly by having the recipient read it
back. The doctor then either acknowledges that the order has been understood or corrects it if it has not.
To date, the Joint Commission has
remained silent on any recommendation
for charting or documenting the read-back requirement. However, a hospital’s
policy may require documentation of the
“repeated and verified” process. You’ll
need to know whether such a policy
exists at the hospital involved in your
case and whether it was followed.
Abbreviations to avoid (NPSG
02.02.01). Each facility must devise
and disseminate a list of “do not use”
abbreviations—which is a combination
of the facility’s unapproved abbrevia-
tions and those that the Joint Com-
mission has identified as likely to be
misinterpreted.10 For example, MSO
4
(morphine sulfate) can be confused with
MgSO (magnesium sulfate), resulting in
4
patient harm. The restriction applies to
all documentation and entries, whether
handwritten or electronic.
In discovery, ask the hospital to
produce its list of unacceptable abbreviations. The abbreviation list is not
relevant to medication errors alone. If
the order involved a frequency, such as
every day or every other day, then the
misunderstanding could affect the timing of lab work, testing, or procedures.
Patient “hand-offs” (NPSG
02.05.01). Broadly defined, the transfer of a patient’s care occurs when test
results are reported to the nurse or
doctor, there’s a change of personnel
at the conclusion of the shift, or the
patient is transferred from one location
to another. This recommendation speci-fies that a standardized process should
be used for the transfer of patient care
and that the process should allow care-givers an opportunity to question and
clarify information and review the
patient’s chart.
The verbal report of the patient’s
condition should include any recent
treatment provided, and it should occur
under conditions that limit interruptions. When miscommunication occurs
in the transfer of the patient’s care, the
continuity of care is affected. The transfer of care often involves changes in the
patient’s condition and a change in the
doctor’s orders. Mistakes commonly
associated with the transfer of care are
failure to initiate or discontinue medications and failure to schedule further
diagnostic testing or notify the receiving
unit of lab results that were called to
the transferring unit during the transfer
process.
Critical test results (NPSG
02.05.01). This recommendation directs
that critical test results be given to the
responsible licensed health care provider—for example, the patient’s nurse
or doctor. The receiving professional is
expected to verify receipt of the results,
and the laboratory or diagnostic department that delivered the results should
document their receipt.
When receipt is verified via an electronic medium like a personal digital
assistant, a doctor’s response should
include an electronic signature to confirm the recipient’s identity. The proof
of the receipt of the electronically conveyed information would be found in
the protocols and tracking documents
and logs in the department notifying
the health care provider of the results.
Entries should reflect the name and
title of the person initiating the contact,
