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Communication failure in the intensive care unit--learning from a near miss.

A 51-year-old female inpatient was given three times the intended dose of intravenous human immunoglobulin. This mistake was not recognised for seven hours. At least 20 well-intentioned and capable staff members were involved in a series of 11 communication failures. How this can be prevented from recurring is discussed.

CASE HISTORY

The patient was admitted to the neurology service of a tertiary referral hospital with suspected Guillain-Barre syndrome. On day two she was transferred to the intensive care unit (ICU) for closer observation due to concerns regarding her respiratory function. The neurology service remained her primary bed-card unit. In the ICU the patient was commenced on intravenous human immunoglobulin at a dose of 30 g daily, for five days, by instruction of the neurology service to be prescribed by ICU medical staff. Review of her chart by the neurology service on the following morning indicated she had been given 150 g of immunoglobulin over a six-hour period - five times the intended daily dose. The neurology and ICU teams informed the patient, documented the incident in the medical record and completed an incident report, which was subsequently discussed at the weekly ICU morbidity and mortality meeting and at the hospital's quality and safety committee.

Immunoglobulin therapy was ceased and the haematology service was consulted regarding the risk of coagulopathy. The patient's condition did not deteriorate. She was discharged from the ICU to the ward on day five where she continued to improve. She was discharged home on day eight with the expectation of a full recovery. Having made a full recovery, the patient provided full verbal consent for her de-identified case to be discussed in a professional publication.

ANALYSIS

This case provides the opportunity to learn from a 'near miss' (1). The case demonstrates that, despite our best efforts, a patient can be overdosed on intravenous medication in the ICU of a major Australian teaching hospital. In this case, the error was not noticed for roughly seven hours. It is fortunate, albeit irrelevant, that an overdose of intravenous human immunoglobulin does not usually carry serious consequences.

There is clear evidence demonstrating the relationship between multiple system errors, breakdowns in communication and adverse patient events (2). This case highlights that relationship.

It is clear from the outset that this incident was not one person's fault. Based on discussion with the staff involved, it appears that from the time the patient was admitted to the neurology service until the time it was realised that she had been overdosed on immunoglobulin, there were at least 11 specific failures in communication. Table 1 documents these failures and classifies the communication errors (3).

DISCUSSION

The analysis in Table 1 indicates a diffusion of responsibility (5) by the treating teams, in that neither team took adequate responsibility for documenting and implementing the intended treatment plan. The key factors that led to the patient being overdosed were breakdowns in written and verbal communication and junior medical staff who did not fully understand their role.

The reasons why the neurology service did not document the entire plan in more detail before their patient was transferred to ICU, or why the ICU team did not question ambiguous notes is not clear. Perhaps the plan seemed 'too simple' to warrant detailed documentation? Perhaps junior staff did not feel that they could ask an obvious question? Perhaps no-one noticed that the plan had not been written down, due to the inevitably busy workload of staff in a tertiary hospital? There is no clear explanation.

What is clear, however, is that junior medical staff from both the neurology service and the ICU were charged with implementing a plan that they seemingly did not fully understand. That plan was, therefore, not clearly communicated to the ICU nursing staff. That successive breakdown in communication and subsequent propagation of error resulted in the patient being given at least three times the intended dose of intravenous immunoglobulin.

Situations like this are common in modern healthcare(6). Indeed, mistakes are an inevitable part of practising medicine in a dynamic and time-pressured environment (7). The important question now is, how can this be prevented from happening again?

In general, the medical profession is poor at ensuring that all members of a treating team know and understand not only the what of a plan but also the how to (8,9). One solution that might help in preventing an event such as this from occurring in the future is the adoption of a more uniform approach to note-taking and medical record keeping, in conjunction with a robust and formal orientation program for junior medical staff (10). Standardised frameworks for documentation of information are built into the daily routine of other industries, most notably the military, aviation industry and emergency services (11). However, the use of such frameworks is an uncommon practice in medicine. Historically, the rigour applied to medical note-taking and verbal handover has been left to the individual practitioner, rather than being embedded as a formalised process within the structures of the workplace (11).

The communication failures outlined in Table 1 can be summarised as follows: the management plan was not clearly documented. That initial lack of clarity was not questioned in the early phases of its implementation. As such, errors made in implementing the ambiguous plan were carried over by multiple personnel.

Communication failures such as these are more common when documentation and clinical handover is poor or when junior staff members do not understand their seniors' intent (12). There are several recognised formats designed to reduce communication breakdown.

SBAR is an acronym that originates in the US Navy submarine service. It stands for situation, background, assessment and recommendation. It was developed to allow easy, efficient and safe communication between junior crew and senior officers during extended day/night operations. It has since been adopted by several health services in the US as a way for junior nursing and medical staff to communicate clinical information to on-call consultants (13,14). In this case, an adapted acronym, SBAP (situation, background, assessment, plan), could be utilised by medical staff to convey clinical information and the medical plan in a written format. This may have resulted in a more clearly documented plan by specifically directing the assessing doctor to write one down.

However, while acronyms can assist trained staff members to minimise error and mitigate risk, they would not have solved this problem. The crux of this communication failure is that junior medical staff members were not adequately trained to make complex decisions or implement unusual plans in an intensive care environment. At the time of this incident, a formal orientation program for residents commencing terms in the ICU did not exist. The first day of a new term served as a form of ad hoc orientation and was, therefore, variable in its quality and comprehensiveness. ICUs are unlike other areas of medical practice. While residents from the medical or surgical ward can transport general principles of patient care into the ICU, the specifics of daily practice and the demands of the ICU patient are, by definition, more intense. As a result the consequences of error are more serious. The likelihood of error occurring is heightened when new staff members are not trained to perform their new job (13).

Since this incident, a formal orientation program is conducted for residents in the first week of a new term and an orientation pack with common information and tasks is provided to them during the orientation program. This orientation includes specific instruction on appropriate prescribing and fluid ordering in the ICU. The overarching theme of this orientation program is one of seeking help and clarification of instructions early.

In summary, this case highlights the need to remedy a significant failure in the lines of communication both within and between treating teams in order to avoid similar events of this nature occurring in the future. It provides a unique opportunity to revisit concepts of patient safety and explore new ways to further increase the quality of healthcare provided by tertiary ICUs. The solutions may be applicable to other clinical environments.

Furthermore, this case demonstrates the role of regular and open clinical audit in ICUs to highlight misunderstandings and communication deficits early. This case may demonstrate the need to adequately orient new clinical staff to the specifics of their new job, particularly in an intensive care environment.

CONCLUSION

Successive failures in communication both between and within treating teams led to the overdose of this patient. More research needs to be conducted into effective ways of improving written and verbal communication, within an intensive care or other clinical setting, if such failures are to be avoided in the future.

ACKNOWLEDGEMENT

This paper would not have been possible without the ongoing and insightful assistance of Dr Julia Harrison.

REFERENCES

(1.) Nashef S. What is a near miss? Lancet 2003; 361:180-181.

(2.) Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care 2005; 14:401-407.

(3.) Gibson WH, Megaw ED, Young MS, Lowe E. A taxonomy of human communication errors and application to railway track maintenance. Cogn Tech Work 2006; 8:57-66.

(4.) Medical record committee, Southern Health. Accepted abbreviations listing and policy. September 1995.

(5.) Lingard L, Espin S, Rubin B, Whyte S, Colmenares M, Baker GR et al. Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR. Qual Saf Health Care 2005; 14:340-346.

(6.) West E. Organisational sources of safety and danger: sociological contributions to the study of adverse events. Qual Health Care 2000; 9:120-126.

(7.) Tucker AL, Edmonson AC. Why hospitals don't learn from failures: organisational and psychological dynamics that inhibit system change. California Management Review 2003; 45:5572.

(8.) Witman AB, Park DM, Hardin SB. How do patients want physicians to handle mistakes? A survey of medicine patients in an academic setting. Arch Intern Med 1996; 156:2565-2569 .

(9.) Mukherjee S. A precarious exchange. N Engl J Med 2004; 351:1822-1824.

(10.) Lingard L, Espin S, Whyte S, Regehr G, Baker GR, Reznick R et al. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care 2004; 13:330-334.

(11.) Helmreich RL. On error management: lessons from aviation. BMJ 2000; 320:781-785.

(12.) Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care 2004; 13(Suppl 1):i85-90.

(13.) Spath PL, ed. Error Reduction in Health Care: A Systems Approach to Improving Patient Safety. Jossey-Bass, California, USA 2000.

(14.) US Medicine. DoD Medical Teamwork, Safety Stressed In New Rollout Effort. From http://www.usmedicine.com/article. cfm?articleID=1598&issueID=101 Accessed December 2007.

S. A. HENDEL *, B. T. FLANAGAN ([dagger])

Southern Health Simulation Centre, Melbourne, Victoria, Australia

* M.B., B.S. (Hons.), Anaesthetics Registrar, Alfred Hospital, Prahran.

([dagger]) M.B., B.S., F.A.N.Z.C.A., Associate Professor in Patient Safety Education,

Monash University and Director of the Southern Health Simulation Centre.

Address for reprints: Dr S. Hendel, Anaesthetics Registrar, Alfred Hospital, PO Box 315, Prahran, Vic. 3181.

Accepted for publication on April 6, 2009.
 Table 1
 Communication failures

Day/ Points of What is wrong with this External error
time failure in communication? mode/
 communication classification
 of error (3)

Day 1, By late 'IV to describe what was Too little
1500 afternoon on actually a specific 10 g in information/
hours day 1, a 200 ml formulation of content error.
 diagnosis of intravenous human
 Guillain-Barre immunoglobulin (marketed as
 syndrome was Octagam [TM]). Nowhere in
 made and the the medical record were
 decision was these unfamiliar and
 taken to treat non-standardised
 with "IV Ig" abbreviations explained.
 (verbatim, from
 the medical
 record).

Day 2, ICU staff At no stage do either the Too little
900 became involved medical or nursing notes information/
hours in the document the specifics of content error.
 patient's the the treatment plan. In this
 specifics of instance, the ICU notes are
 the assessment, ambiguous (i.e. does this
 the ICU mean 5 days of 'Intragam'
 registrar noted or 5 doses given over an
 "management--5 unspecified timeframe?).
 X Intragam".

Day 2, The nursing The nursing notes are Omission/too
1100 notes from the similarly ambiguous and little
hours neurology potentially misleading. By information/
 service on day documenting only partial content error.
 2 state "... information and omitting
 For transfer to key information (such as
 ICU ... To the frequency of
 commence administration and duration
 Intragam when of treatment), the medical
 arrives (for 5 record ceases to be a safe
 days--30 g)". means of
 inter-professional
 communication.

Day 2, When it was APP is not a widely Wrong action
1100 decided to accepted acronym on drug right little
hours start the charts (4). APP was most information/
 patient on likely intended to mean 'as content is
 intravenous per protocol', as is
 immunoglobulin sometimes the case in the
 (in the ICU), ICU, but could mean 'as per
 the neurology plan'. The use of acronyms
 resident is acceptable if it can be
 documented five assured (not assumed) that
 separate orders all involved in their use
 for "IVIG 30 g" have a shared understanding
 on the ward of their meaning.
 drug chart, all
 dated on the
 same date and
 charted that it
 be administered
 "APP".

Day 2, The ICU The neurology service was Repeated
1200 resident who the primary bed-card unit error/
hours admitted the but they did not document cognitive
 patient to the the treatment plan in the elements of
 ICU directly medical record. The ICU human error.
 transcribed the team began treatment of the
 IVIG order to patient according to a plan
 the ICU drug that was not clearly
 chart from the documented. The result is a
 neurology medical a treatment plan
 resident's that is ambiguous and open
 record and ward to order on the
 drug chart. The interpretation. While
 order was for ambiguity exists for all
 five separate staff, the purpose of
 30 g IVIG documenting a management
 doses, but all plan is to reduce ambiguity
 dated on the for those charged with
 same date. The implementation.
 administration
 schedule was
 documented as
 "APP".

Day 2, The ICU This entry and the Repeated
1200 admission notes following entry demonstrate error/
hours state in the the diffusion of cognitive
 plan "IV Ig as responsibility (5) between elements of
 per neurology the ICU and the neurology human error.
 service". service. The implication of
 these entries is that both
 teams thought that the
 other team was in control
 of implementing the plan.

Day 2, On the See above. See above.
1645 afternoon of
hours day 2, the
 neurologist and
 the neurology
 registrar saw
 the patient.
 Their
 documented plan
 states
 "ventilatory
 function
 stable. Observe
 for 24/24. If
 remains stable
 could return to
 ward. Continue
 IV Ig".

Day 2, The evening ICU This suggests that the ICU Wrong action
1800 round noted staff considered their role right object/
hours that the as one of monitoring a too little
 patient was neurology patient who would information/
 "stable" and be returned to the cognitive and
 that the plan neurology ward as soon as content error.
 was to they were able.
 "continue IV Ig
 and discharge
 to ward
 tomorrow if
 patient remains
 stable".

Day 2, The nursing This entry suggests that Wrong action
1930 notes, the nursing staff right object/
hours following the responsible for actually cognitive
 evening ICU administering the error.
 round state immunoglobulin did not
 that "all understand the treatment
 general care plan.
 attended.
 Intragam 30 g X
 2 given so
 far".

Day 3, The night ICU This entry suggests that Wrong action
400 round notes the night ICU medical team right object/
hours state that the did not understand the too little
 patient "is on treatment plan, though it information/
 IV Intragam". is unclear if the night the cognitive
 medical staff observed and content
 exactly how much error.
 immunoglobulin the patient
 had been given. There were
 seemingly no documented
 concerns with the progress
 of the patient's treatment,
 despite had been given at
 least twice the intended
 daily amount.

Day 3, The neurology When blood products are Wrong action
900 service administered in this right object/
hours recognised the institution, they must be too little
 dosing error. recorded on both the drug information/
 On closer chart and the fluid balance cognitive and
 scrutiny, the chart because they affect content error.
 ICU drug chart volume status. The amount
 shows 150 g of signed for, as being
 Intragam as administered on the drug
 being signed chart should equal the
 and given. The amount recorded on the
 fluid balance fluid balance chart. The
 chart documents disparity between the drug
 70 g of chart, the fluid balance
 Intragam as chart and the blood bank
 being record meant that it was
 administered not possible for the
 and the blood neurology service or the
 bank records ICU team to be sure of the
 state that 90 g exact amount of
 of Octagam [TM] immunoglobulin that had
 was released to actually been administered.
 the ICU on day There were no surplus
 2. bottles of Octagam [TM], so
 it is reasonable to assume
 that the patient received
 the 90 g released by the
 blood bank and that errors
 were made in documenting
 the dose administered on
 the ICU drug and fluid
 charts.
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Article Details
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Author:Hendel, S.A.; Flanagan, B.T.
Publication:Anaesthesia and Intensive Care
Article Type:Report
Geographic Code:8AUST
Date:Sep 1, 2009
Words:2896
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