Written by Judith Riess, MTM editor-in-chief

Patient Care

Healthcare is complex and has many silos and many different approaches but the greatest problem is the inability to communicate effectively and efficiently with all members of a healthcare team which is also diverse and siloed.  In a recent family experience the lack of communication and inefficiency of the system complicated a family member’s recovery, all due to five of the eight common root causes of medical errors which in a recent Johns Hopkins study noted the Agency for Healthcare Research and Quality’s (AHRQ) eight common root causes of medical errors which include: Communications Breakdowns, Inadequate Information Flow, Human Problems, Patient Related Issues, Organizational Transfer of Knowledge, Staffing Patterns and Workflow, Technical Failures and Inadequate Policies as the most common causes of medical errors.

During my family member’s experience five of the eight causes given by AHRQ hampered recovery.  As I have stated many times in MTM editorials providers never intend to harm patients but the system they live under is fraught with errors.  These issues can arise in a medical practice or a healthcare system and can occur between a physician, nurse, healthcare team member, or patient. Poor communication often results in medical errors or lack of care.

The five issues in my family member’s case began with a breakdown in communication. The patient was severely ill with pneumonia and a kidney infection and spent four days in ICU and four days in hospital. After being released from the hospital the family member was having difficulty breathing and contacted the infectious disease doctor’s office and explained the problem.  A member of the doctor’s staff had the patient go in for a chest X-Ray and recommended the patient see a pulmonologist since the patient had pneumonia, then the trouble continued.  The patient, being a well-educated healthcare provider, had asked for a copy of the X-Ray.  Upon seeing, the patient immediately called the doctor’s office and needed to speak with the doctor or NP about the x-ray.  Repeated calls to the infectious disease doctor’s office and to pulmonologist offices had no results.

A patient’s family member was describing the patient’s condition to a friend and described the family’s inability to have phone calls returned or reach a pulmonologist.  The family member’s friend was friends with a pulmonologist and sent x-ray to him; at which time he contacted the infectious disease doctor and told him his patient was in distress and needed to go to emergency room immediately. The patient was re-admitted to the hospital, had a chest tube inserted, fluid withdrawn from the lung, spent six additional days in the hospital with day after day of chest x-rays, CT’s and intravenous antibiotics.

The infectious disease doctor did not deliberately ignore the patient’s calls.  The patient was unable to reach the NP who ordered the chest x ray as she was off for two days and the doctor was in clinic.  The medical assistant to whom the patient repeatedly spoke said she would relay the message to the doctor but did not have the skills or knowledge necessary to understand the urgency of the request even though the patient told the assistant that the patient was NP.

So there was definitely Inadequate Information Flow which we all know is critical. Unfortunately, the critical information was not reaching the doctor or nurse practitioner.

There was also an issue of training or inadequate education on the part of the medical assistant to understand the seriousness and urgency of the situation and therefore highlights the lack of Organizational Transfer of Knowledge within the doctor’s office.

Staffing Patterns and Workflow played a key role in the patient’s inability to reach the necessary providers.  Since the NP was off and the doctor in clinic, someone with the expertise to understand the situation should have responded to the patient and made sure the doctor had the information about the x-ray which leads to the problem of when the x-ray was read. 

In this case, the x-ray is read by a radiologist at the hospital and then sent to the doctor’s office which can cause up to a 24-hour delay which leads to Inadequate Policies between the hospital and the doctor’s office.  As a thought, what would have happened if the patient had a broken leg? Is there a policy for immediate transfer of knowledge of x-ray?  A bit facetious but in this patient’s case far more sever complications than a broken leg! In this case inadequate procedures played a role.

Having highlighted failures, would be remiss if I did not state that the hospital provided excellent care and in two incidents saved the patient’s life.

 The Johns Hopkins study further stated, “Studying these mistakes, learning how to prevent, monitor, and respond to them is key to changing the standards of care. By working to eliminate common medical errors, healthcare systems and providers can protect patients, protect themselves, improve standards of care, and lower costs.”