Communication errors in patient care

Discuss about the Special Commission of Inquiry Acute Care Services.

Vanessa Anderson was a sixteen year old who was admitted at Hornsby Hospital in Sydney following an accident at the charity golf day that she had participated in. She had been hit behind the right ear with a golf ball and a CT scan had showed a depressed skull and confusions. She also presented vomiting and disorientation. A series of events that followed her admission at the hospital eventually led to the death of the young girl. Vanessa’s death was a result of human error and negligence by the care givers. It brought to light the importance good hospital systems that would promote good communication in an effort to promote top quality care. Any breakdown in communication can lead to serious complications and death as evidenced by the case of Vanessa Anderson.

According to a report by CRICO, who are patient safety experts, communication errors are a result of unrecorded information, misdirection, case of where information was never received, never retrieved or simply ignored (White, 2016, para 3). They pointed out the fact that miscommunication does not only happen when patients do not fully understand their doctors. It can also happen between the careers themselves if at any given point the aforementioned errors occur. The nurse bears a huge chunk or responsibility when it comes to ensuring that proper communication takes place. This is due to the fact that they are the primary caregivers and are often in direct contact with the patient. They RN facilitate communication between the patient and physician showing how important their involvement is (Lyndon et al, 2011, para 13).

Nurses have the responsibility of creating a favorable environment for the patients in order to ensure that there is open communication between them (Stone et al, 2008, para 18). They ought to take their time given that some patients could be incapacitated, nervous or upset and thus unwelcoming or rushed conversations. Choosing a private area free of distractions may also do the patient good since they will be assured of the confidentiality and protection of their personal information (TUNM, 2018, para 13).  There are many benefits that follow a direct and open communication between nurses and patients. First, it provides an opportunity for individualized care. This is because a nurse who is aware of the challenges and concerns that are unique to their patients will be in a good position to act as their advocate so as to ensure they receive the correct attention and treatment is given (Kuokota, 2014, p. 7). Nurses must advocate equal time to hands on care and documentation. This is because the two are components of patient care.

Role of nurses in communication

The fact that Vanessa Anderson lacked personalized treatment is quite evident.  Upon her admission to the hospital, she was transferred to Royal North Shore Hospital in Sydney. She had no nurse following this up which eventually leads to miscommunication  by the Registrar who informs Dr. Little that she is to be transferred to Westmead Children’s hospital. Even then the absence of a caregiver is quite obvious owing to the fact that Dr. Little was not informed that Vanessa was under her care, leave alone informing him that she was supposed to be transferred to another hospital. In addition to a lack of personalized care and treatment this shows a lack of proper communication channels between the various healthcare providers in the hospital. If proper communication channels were in existence, Vanessa would have been transferred to the appropriate hospital as soon as the directive was given. Dr. Little would also have been made aware that Vanessa was under care and would have made the right decisions at the right times which might have saved her life.

Another importance of communication in patient care is to ensure that all caregivers who attend to a patient have the full history and information regarding her case. Nurses are usually held accountable by their records, professionally, legally and ethically (Wood, 2015, p. 26). It is thus important to ensure that vitals and all relevant observations are charted not only for accountability reasons but to also ensure that caregivers are able to identify any problems and patterns and adequately plan for care (Twomey & Cummins, 2010, p. 5). In Vanessa Anderson’s case, the nurses failed to record observations after a second round. Medication charting was also missing. Dr. Ismail who did a round with Vanessa was not aware of the fact that she had ordered for Panadiene Forte. She thought that regular Panadiene is what had been administered to her. She was also not aware that analgesia was to be determined by the neurosurgical consultant or registrar. Dr. Ismail charts Vanessa for increased Endone after she complained of persistent pain. Her failure to record a maximum dosage was fatal. This brings into light another error in communication that show a flaw in medication charting by the caregiving staff.

The coroner identified system failures that contributed to Vanessa’s demise. She noted that there was a lack of proper admission procedure, inadequate supervision of junior staff, communication problems as discussed above, location of patient away from the nurses’ station and in the adult section and lack of a rigorous neurological observation (Milovanovich, 2008, p. 32). The coroner expressed the dire situation by stating that The Task “As Deputy State Coroner for the past six years I have regrettably presided over many inquests involving deaths in hospitals. In many of these cases one error or omission sometimes a serious one led to death, however, I have never seen a case such as Vanessa’s in which almost every conceivable error or omission was detected  and those errors continued to build one on top of the other” (Milovanovich, 2008, p. 4). Several changes were put in place at the RNSH hospital and in other NSW hospitals following the observations by the coroner.  The first change was that teenage patients needed to be nursed as close as possible to the nursing station to facilitate personalized and better care. A policy was also prepared for the nursing staff on the issue of performing routine observation on the patients. This was further emphasized by providing for continuous education on the importance of documentation of all orders concerning the patient (NSW, 2008).

Creating a favorable environment for communication

Training of various staff in various capacities was also introduced at the hospital. Guidelines that were to be used by the junior staff in notifying consultants were developed. Training of Junior Medical officers was also modified to include communication with consulting officers. Opioid prescribing and pain management training was further done for the in house nurses (Graema &  Dwyer, 2009, p. 81). There was also a change in the management style of the house in an effort to promote quality twenty four hour care. Adequate cover for periods when the registrar is away was introduced and documentation emphasized in such instances. The acute pain management policy was also modified to include the fact that the decision regarding the prescription of analgesia outside the available guidelines can only be made by neurosurgical registrar or consultant (NSW, 2008). These changes left nothing to chance seeing that many small errors eventually lead to fatalities as seen in Vanessa’s case. They trickled down to the Australian Health system introducing an aspect of better communication, care and management in the Australian Health system.

Notably, nurses are required to accurately and comprehensively conduct assessments in a systematic manner. In doing so, and as the nursing standards necessitate, they analyze information and data pertaining to patients and afterwards, they communicate the outcomes in accordance with the facets of the practice. Moreover, the assessments that are conducted by the registered nurse should be holistic as well as culturally appropriate. Aside from the wide range of techniques required in assessments and analyses, RNs are also required to work in partnerships in order to identify factors or potential effects that may be detrimental to the diverse patient populations that are under their care. Such an initiative would prove to be critical in determining the action plans or referrals to be taken so as to protect the well-being of their patients.

Similarly, and as revealed by studies, patient assessments proved to be one of the key factors that influenced RNs recognition and response to patient deterioration. Additionally, to further facilitate this process, RNs ought to know the patient by developing formidable patient-nurse relationships, educate themselves and also be aware of the environmental factors that might impact the patient’s health (Massey, Chaboyer & Anderson, 2017, p. 8). In responding to the deterioration of the patient’s health studies also reveal that nurses should strive to develop non-technical skills, improve access to support and exhibit negative emotional responses. In this light, it becomes apparent that these factors and practice coincide with the nursing standard requirements which mandate that nurses should accurately assess their patients and also work in partnerships so as to improve the health and identify potential factors that may be harmful to their patients’ health. Standard 4 of the Registered Nurse standards for practice stipulates (the Nursing and Midwifery Board of Australia, 2016,p 4) that “RNs will accurately conduct comprehensive and systematic assessments. They analyze information and data and communicate outcomes as the basis for practice.”

Importance of personalized care

RNs also have a critical role to play in the detection and reporting of clinical deterioration by monitoring vital signs in patients. Ideally, this practice has proven to conform to the requirements of important nursing assessments. However, RNs have fallen short of this practice. In these cases, research reveal that nurses tend to overlook this procedure and its significance in detecting patient deterioration but instead, RNs often perform vital signs monitoring only as part of the routine. Among the reasons for doing so have is the heavy workload that they face (Mok, Wang & Liaw, 2015, p. 98).Nonetheless, such evidence affirms the fact that it is the role of nurses to ensure that perform vital signs monitoring in order to facilitate detection and reporting of clinical deterioration (Mok et al, 2015, p. 209).

A death is usually reported to the coroner if the circumstances surrounding it are as outlined in section Section 13 of the coroner’s ACT. Vanessa died suddenly, unexpectedly in circumstances where the doctor was prohibited from issuing a certificate of the cause of death. The coroner identified a number of issues that possibly contributed to Vanessa’s death. The first is that RNSH lacked a proper pain management guideline. This led to an increased likelihood of prescribing multiple opioid medications that might have led to respiratory depression given that Vanessa was opioid naïve. Multiple team involvement in pain management beyond the primary care that was present due to a lack of guidelines and clearly defined responsibilities for treating pain and prescribing analgesia. The prescription of analgesia might have contributed further to respiratory failure in Vanessa’s case. The coroner also observed that there was unrealistic goals for pain relief for Vanessa given the level of knowledge and underst6anding of the clinicians from various disciplines. This led to an escalation in prescribing contributing to respiratory failure. Lastly, he noted that an increase in dosage and frequency of analgesia being prescribed resulting from illegibility of a written order may further have contributed to respiratory depression (Milovanovich, 2008, p. 34).

A gap was identified between health service management and the clinicians by the Garling report (Stewart, 2009). This issue contributed to Vanessa’s death given that there was no proper coordination of healthcare providers in the case. The junior clinician attending to her also lacked the skillset necessary to make an informed decision about her case. The report recommended a change in management by introducing an institute for Clinical Education and training which would develop and carry out leadership training for clinicians (RACMA, 2013, p. 3). This would solve the gap that had been identified in clinical leadership (Joseph & Hunyor, 2008, p. 471) Clinical leadership would further be reinforced by introducing the position of “Executive clinical director in all NSW clinical Centers. This individual would be responsible for improving the clinical practice in their centers, acts a spokesperson among other things (Graema & Dwyer 2009, p. 84). The report also identified a gap in interdisciplinary healthcare teams. Vanessa was transferred to RNSH, her doctor received the news way later with a different hospital destination, Westmead Children’s Hospital. This shows a lack of of proper communication in the relevant department. Some of the attendants that were supposed to be taking care of Vanessa were away and no one was around to replace them showing a shortage of caregivers at RNSH. The Garling report recommended that changes be made to ensure that the healthcare providers with the right mix of skills are available at all timers in healthcare facilities, annual performance reviews be conducted to keep the  care givers on their toes and measures be taken to ensure that there is no shortage of staff in hospitals (Garling, 2008, p. 3).   

Errors in medication charting

Conclusion

The RN has a major role to play in ensuring that patients receive the best care. They not only need to pay close attention to the one on one interaction with the patients but should also ensure that they put an equal amount of effort in documentation of their observations and patient’s vitals. Communication is vital in all this as it allows for a number of things including’ personalized care and treatment for the patients, collaboration of all care givers to ensure that correct decisions are made regarding a given case and that the patient receives the correct treatment. It is important for organizations to offer support to all their healthcare providers given the fact that human errors can accumulate to the point of death or fatalities as in the case of Vanessa Anderson.  It is good t0o note that the NSW healthcare facilities have implemented the recommendations from the Coroner’s report on the case of Vanessa Anderson and the Garling Report which sought to make the services offered by public hospitals better.

References

Garling, P. (2008). Final report of the Special Commission of Inquiry Acute care Services in NSW Hospitals. Retrieved from https://www.dpc.nsw.gov.au/?a=34194

Graema, S. &  Dwyer, J.  (2009). Implementation of the Garling Recommendations can offer Real Hope for Rescuing the New South Wales Public Hospitals. The Medical Journal of Australia 190 (2), 80-82.

Joseph, A. & Hunyor, S. (2008). The Royal North Shore Hospital Inquiry: an Analysis of the implications for quality and safety in Australian Public Hospitals. The Medical Journal of Australia 188(8), 469-472.

Koukota, L. (2014). Communication in Nursing Practice. NCBI. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3990376/

Lyndon, A. Zlatnik, M. G., & Wachter, R. M. (2011). Effective Physician – Nurse Communication. NCBI. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3219810/

Massey, D., Chaboyer, W., & Anderson, V. (2017). What Factors Influence Ward Nurses’ Recognition and Response to Patient Deterioration? An Integrative Review of Literature. Nursing Open, 4(1), 6-23. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5221430/

Milovanovich, M. (2008). Inquest into the Death of Vanessa Anderson. NSW Deputy State Coroner. Retrieved from https://www.heti.nsw.gov.au/Global/District-HETI/Westmead_coroners_court_inquest_Vanessa_Anderson.pdf

Mok, Wang, W., Cooper, S., Ang, E. N., & Liaw, S. Y. (2015). Attitudes Towards Vital Signs Monitoring in the Detection of Clinical Deterioration: Scale Development and Survey of Ward Nurses. International Journal for Quality in Healthcare, 27(3), 207-213. Retrieved from https://academic.oup.com/intqhc/article/27/3/207/2357301

Mok, W. Q., Wang, W., & Liaw, S. Y. (2015). Vital Signs Monitoring to Detect Patient Deterioration: An Integrative Literature Review. International Journal of Nursing  Practice, 2, 91-98. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26125576

Nursing and Midwifery Board. (2016). Registered Nurse Standards for practice. Retrieved from www.nursingmidwiferyboard.gov.au

The Royal AustralianCollege of Medical Administrators (RACMA). (2013). Reviews: The Garling Report NSW. The Quartely. Retrieved from https://racma.edu.au/index.php?option=com_content&task=view&id=159&Itemid=336

Stone, P. W., Hughes, R., & Dailey, M. (2008).  Creating a Safe and High Quality Health Care Environment.  NCBI. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK2634/

The University of New Mexico (TUNM). (2016).  Importance of Communication in Nursing. Retrieved from https://rnbsnonline.unm.edu/articles/importance-of-communication-in-nursing.aspx

Twomey, J. & Cummins, A. (2010). Good Record Keeping. WIN. Retrieved from https://inmo.ie/tempDocs/WIN%20Record%20Keeping_38,39.pdf

White, J. (2016). How Communication Problems put Patients, hospitals in jeopardy.  Healthcare Business and Technology.  Retrieved from https://www.healthcarebusinesstech.com/communication-patient-harm/

Wood, C. (updated 2015). The importance of Good Record Keeping for nurses. Nursing Times 99 (2), 26. Retrieved from https://www.nursingtimes.net/roles/practice-nurses/the-importance-of-good-record-keeping-for-nurses/205784.article