Cases & Commentaries

Hard to Swallow

Commentary By Jeffrey Driver, JD, MBA

The Case

An elderly man underwent hernia surgery.
Postoperatively, the patient developed a transient ischemic attack
(TIA) and respiratory difficulties. The nurses noted that the
patient, whose speech was normal before surgery, now had slurred
speech and choked on thin liquids. The neurologist recommended a
swallowing study.

A speech pathologist evaluated the patient and
found him to be at high risk for aspiration. On the consultation
form, she recommended that the patient be made NPO. She didn't
think the recommendation was important enough to "bother" the
physician, and recorded it only on the consultation form. In
keeping with standard practice at the hospital, speech
pathologists, respiratory therapists, and physical therapists write
their notes in a special section of the chart, not in the core
daily progress notes area, which is the part of the chart that all
physicians read. The physician did not see the form, and the
patient continued to receive thickened liquids. Two days later, the
patient suddenly aspirated, arrested, and died.

The hospital investigates all critical incidents
through the Quality Management Department and the Vice President of
Medical Affairs. This particular case was reviewed within an hour
of the patient's death. Subsequently, the VP of Medical Affairs
submitted a protocol to the medical staff executive committee
concerning swallowing evaluations. This protocol, now in effect,
permits the speech pathologist to write the order to make the
patient NPO if the bedside swallowing evaluation is suspicious for
the risk of aspiration. Hospital personnel felt that physicians
would accede to speech pathologists' recommendations to keep a
patient NPO (for aspiration risk), and that it was safer to have
the physicians "pre-authorize" an NPO order than risk a repeat of
this scenario by waiting for a physician's order.

The Commentary

The critical error in this case, often classified
by risk managers broadly as "a failure to treat," has deeper roots
in the failure of communication, both written and verbal. Some
studies cite practitioner communication skills as a factor in
Furthermore, the tragic outcome in this case might have been
avoided if protective actions were implemented pending the
completion of the diagnostic evaluation (ie, if the patient were
made NPO pending the outcome of the swallowing evaluation).

Although its main purpose is to document patient
care, the patient's medical record is also a tool for collecting,
storing, and processing information. Moreover, the record can be a
conduit of communication between the physician and other members of
the health care team.(3)
However, it is by no means the perfect or only tool for
communication. Based on work in adult learning (4), risk managers recommend promoting effective
communication by transmitting information repetitively and by way
of several different modalities. These modalities include written
(eg, letters written by consultants to referring clinicians),
person-to-person verbal (eg, telephoning the referring clinician
after finishing a consultation), and red flag signals of newly
posted critical information (eg, the notes sometimes left by nurses
on the front of charts to draw the attention of treating physicians
to a particularly important recent lab result or problem with an

Risk managers analyze medical records while
performing root cause
analysis and/or medico-legal review to determine what events
and contributing factors led to a particular medical injury or
event. Ultimately, these analyses serve two purposes: they set
patient-protective controls to reduce the chances that an accident
will recur, and they support preparation for potential litigation.
Surprisingly often, these retrospective reviews reveal subtle (or
not so subtle, as in this case) medical information, which, had it
been detected by the clinicians at the time, could have led to
follow-up actions to mitigate or avert an adverse patient

How can we be sure that important patient
information is communicated and received? First, clinicians must
identify the subset of patient-related data (lab results,
diagnostic evaluation, etc.) that represents critical information.
A fail-safe mechanism also must be in place to communicate and
receive critical medical information in a timely and effective
manner. While several methods can facilitate the communication and
receipt of critical information, one-to-one verbal communication
should never be replaced, nor should sole reliance be placed on
written communication (because the latter is not fail-safe).
Critical medical information must be communicated verbally, and
receipt of such information should be documented in the medical
record. In this case, since the patient was receiving a normal
diet, it would have been appropriate for the speech therapist to
communicate the need to change the diet orders in a more timely and
direct fashion than solely writing in the patient's medical record
(eg, by phoning the attending physician). However, the
responsibility hardly falls on the speech therapist alone. The
neurologist who requested the consult should either have been
watching for the results or advised the primary team to do the
same. At a deeper level, physicians need to make sure they do not
contribute to a culture in which non-physician providers avoid
direct communication for fear of "bothering the doctor." The speech
therapist's decision not to communicate directly may reflect past
experiences in which she sensed exasperation or impatience on the
part of a physician she had paged with similar information.

The medical record plays an important role in
providing a back-up to one-to-one verbal communication. The
problem, as illustrated in this case, is that sometimes information
in the medical record is not promptly given to those clinicians who
should act on it. This delay occurs primarily because medical
records are voluminous and often organized in ways that promote
segmentation of information. How the medical record was organized
in this case is not unusual, nor is the illusion that certain parts
of the record do not require review by all clinicians.

A number of methods have been implemented to
simplify medical record keeping and thereby highlight critical
information. Chart flags, color-coded consult notes, follow-up
checklists, and multidisciplinary problem lists have all been used
to enhance communication and receipt of critical medical
information. Also, in combination with these methods, nurses (and
sometimes other medical care providers) may use a process of
"charting by exception," which means that under specific written
protocol, certain medical information can be assumed because the
patient observations fall within a safe range as dictated by the
This effectively reduces the volume of entries in the medical
record, thus theoretically leaving a medical record filled with
only the most relevant medical information. In addition, a number
of innovations in medical record keeping such as computerized
physician order entry (CPOE) and the electronic medical record
(EMR) create safety mechanisms to assure that important
communication occurs. These include automatic digital paging
(7) and
e-mail notification (8,9)
as well as warning screens in CPOE and the CMR that alert
clinicians to critical information. Speech recognition systems and
electronic word-entry systems are being developed to recognize
words and values, alone or in combination, that trigger an
electronic alert to clinicians. (For a full list of medical record
best practices, obtain the practice brief published by the American
Health Information Management Association.[10]) Finally, frequent multidisciplinary patient care
rounds (11),
Crew Resource Training (12),
and Patient Safety Rounds (13)
may help enhance clinical communication and thus reduce medical
accidents due to failed communication, such as the one in this

Finally, let's consider some of the specifics of
this case. Risk managers are charged with finding the root cause of
medical accidents, near misses, and accidents-waiting-to-happen,
and putting steps into place to reduce the likelihood of accidents,
thus protecting patients from medical injury. In addition, risk
managers are duty-bound not only to protect patients from injury,
but also to protect clinicians and the organizations they work in
from legal liability. In this case, liability could be attributed
to the physicians, the speech therapist, and the nurses caring for
the patient. All of them failed to communicate and/or receive
critical medical information, and their failure led to the
patient's aspiration.

The hospital where this case occurred has
suggested an organizational solution to the problem. Having a
standard order to allow speech therapists to place patients on NPO
status when necessary is sound risk management because it provides
a high level of patient protection. This effectively reduces the
possibility of aspiration from the time of the physician's order to
the time the diagnostic test results or consult is reviewed and an
order for NPO status is continued or discontinued by the physician.
Less clear, however, is whether this hospital has addressed the
underlying communication problems that led to this
accident—problems that could recur in another situation.

Medical errors and accidents due to communication
mishaps are complex and multifaceted. Hospitals and clinicians
should be cautious of quick fixes or reliance on a single
prevention technique. Any one of the methods used alone (including
those suggested here) might fail. Reason has described improving
safety as akin to fighting mosquitoes: we have to drain the swamp,
rather than just swat at individual mosquitoes.(14) This means that we need to be careful that, after an
accident investigation or root-cause analysis, we don't design
protocols that prevent only the specific error from happening
again. In this case, an NPO order was the problem, but the root
cause analysis revealed general problems with communication. The
chance that another patient will die due to lack of a timely NPO
order is relatively small. However, the chance that problems in
inter-professional communication will cause other adverse events is
high. The institution needs to make sure it does something about
the latter, not just the former.

Truly, the best practice is to undertake
comprehensive risk assessment (15) by
understanding communication processes, learning where they are
subject to fail, and identifying the results of each failure. Only
then can multiple and redundant solutions be implemented to address
those critical points. Promoting fail-safe communication of
important medical information can reduce patient harm and medical

Jeffrey Driver, JD,
Chief Risk Officer
Stanford University Medical Center


1. Beckman HB, Markakis KM, Suchman AL, Frankel
RM. The doctor-patient relationship and malpractice. Lessons from
plaintiff depositions. Arch Intern Med. 1994;154:1365-70.[ go to PubMed ]

2. Vincent C, Young M, Phillips A. Why do people
sue doctors? A study of patients and relatives taking legal action.
Lancet. 1994;343:1609-13.[ go to PubMed ]

3. Amori G. Communication with patients and other
customers: the ultimate loss control tool. In: Carroll R, American
Society for Healthcare Risk Management (ASHRM), eds. Risk
management handbook for health care organizations. 4th ed. San
Francisco, CA: Jossey-Bass publishing; 2003:821.

4. Knowles MS, Holton EF, Swanson RA, eds. The
adult learner. The definitive classic in adult education and human
resource development (managing cultural differences). 5th ed.
Woburn, MA. Butterworth-Heinemann publishing; 1998.

5. Murphy J, Beglinger JE, Johnson B. Charting by
exception: meeting the challenge of cost containment. Nurs Manage.
1988;19:56-70.[ go to PubMed ]

6. Charles EJ. Charting by exception: a solution
to the challenge of the 1996 JCAHO's nutrition care standards. J Am
Diet Assoc. 1997;97(10 Suppl 2):S131-8.[ go to PubMed ]

7. Kuperman GJ, Teich JM, Tanasijevic MJ, et al.
Improving response to critical laboratory results with automation:
results of a randomized controlled trial. J Am Med Inform Assoc.
1999;6:512-22.[ go to PubMed ]

8. Henault RG, Eugenio KR, Kelliher AF, Alexis G,
Conlin PR. Transmitting clinical recommendations for diabetes care
via e-mail. Am J Health Syst Pharm. 2002;59:2166-9.[ go to PubMed ]

9. Triola MM, Blaser MJ. An email alert system
for internal medicine physicians. Proc AMIA Symp. 2003:1035.[ go to PubMed ]

10. Fletcher DM. Practice brief: best practices
in medical record documentation and completion. [American Health
Information Management Association Web site]. November 15, 1999.
Available at: [ go to related site ]. Accessed August 12,

11. Uhlig PN, Brown J, Nason AK, Camelio A,
Kendall E. John M. Eisenberg Patient Safety Awards. System
innovation: Concord Hospital. Jt Comm J Qual Improv.
2002;28:666-72.[ go to PubMed ]

12. Pizzi L, Goldfarb NI, Nash DB. Crew resource
management and its applications in medicine. In: Shojania KG,
Duncan BW, McDonald KM, Wachter RM, eds. Making health care safer:
a critical analysis of patient safety practices. Rockville, MD:
Agency for Healthcare Research and Quality; 2001: 501-510. AHRQ
publication 01-E058. Evidence report/technology assessment. no. 43.
Available at: [ go to related site ]. Last accessed October 14

13. Frankel A, Graydon-Baker E, Neppl C, Simmonds
T, Gustafson M, Gandhi TK. Patient Safety Leadership WalkRounds. Jt
Comm J Qual Saf. 2003;29:16-26. Available at: [ go to related site ]. Accessed September 20,

14. Reason JT. Foreward. In: Bogner MS, ed. Human
error in medicine. Hillsdale, NJ: Lawrence Erlbaum Assoc.;

15. McCaffrey JJ, Hagg-Rickert S. Development of
a risk management program. In: Carroll R, American Society for
Healthcare Risk Management (ASHRM), eds. Risk management handbook
for health care organizations. 4th ed. San Francisco, CA:
Jossey-Bass publishing; 2003:111-4.