An excerpt from The Mumbo Jumbo Fix: A Survival Guide for Effective Doctor-Patient-Nurse Communication.
Team building is a popular trend in health care. It promotes cooperation, trust and respect, improves communication, and enhances patient outcomes. Most of the time.
But the camaraderie and familiarity of working with the same group of people can carry unappreciated risk to patient safety—a breakdown of standardized communication protocols based on a misplaced trust in one another. Working daily with the same team of highly trained colleagues both impresses and lulls us into letting down our guard and skipping steps in defined processes. In the world of risk assessment and mitigation, this phenomenon is known as a human risk factor.
Standardized health care procedures took their inspiration from the disciplined field of aeronautics. Cockpit protocols are step-specific behaviors written in checklist form and audibly confirmed by another team member. No matter how many flight hours a pilot and co-pilot have logged together, each and every time they prepare to take-off or land they methodically perform the required drill. Without exception. Who among us would feel safe flying on a plane if we were told the cockpit opted to skip the checklist that day?
The “time-out” universal protocols in operating rooms are a good example of the use of required checklist behaviors. No surgery should commence without first taking the time to confirm out loud in the presence of the entire OR team the identity of the patient, the nature of the surgery, and the specific surgical site. And it works almost all the time—unless the OR is running behind schedule and the surgeon tries to skip the “time-out.” It takes a strong and confident nurse to speak up and challenge a time-pressed surgeon. After all, the surgeon is probably very experienced, and the correct patient and procedure were probably already confirmed in the pre-op area by another nurse—unless he was also pressed for time.
Pre-operative sponge counts by two nurses (or a nurse and a scrub tech) are required to ensure a correct baseline count before surgery begins. During surgery, each sponge brought into the operative field is logged on a board, and a tally of used sponges is reconciled at the end of the procedure before closing the patient. Of course, the entire process breaks down if the initial count was inaccurate. The first experienced nurse had been through the drill hundreds of times without an error, so there was probably minimal risk when the second required person slipped off to perform some other necessary pre-surgical task. No one has ever miscounted, right?
Administration of potentially dangerous medication requires the presence of two health care providers for a read-back to confirm the correct patient is receiving the prescribed medication in the proper dose. Occasionally busy providers trusting each other to do the job properly dispense with the read-back. What could possibly go wrong if a newborn baby in the neonatal ICU receives an adult dose or another baby’s potent medication?
As a risk manager who investigated multiple examples of each of these scenarios, the common thread was a skilled team member trusted a known experienced colleague to do the job correctly. Usually because the team member felt time pressure to do other tasks. In the rush of the moment, the communication protocol was rationalized as unnecessary and “probably safe this time.” What the field of risk assessment and mitigation reminds us is communication protocols exist for a reason. We are all human; all human beings make mistakes.
Michael J. Grace is an attorney and author of The Mumbo Jumbo Fix: A Survival Guide for Effective Doctor-Patient-Nurse Communication.
