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Olle ten Cate, PhD; November 2018
An ICU patient with head and spine trauma was sent for an MRI. Due his critical condition, hospital policy required a physician and nurse to accompany the patient to the MRI scanner. The ICU attending assigned a new intern, who felt unprepared to handle any crises that might arise, to transport the patient along with the nurse. While in a holding area awaiting the MRI, the patient's heart rate fell below 20 beats per minute, and the experienced ICU nurse administered atropine to recover his heart rate and blood pressure. The intern worried he had placed the patient's life at risk because of his inexperience, but he also felt uncomfortable speaking up.
Journal Article > Study
A policy-based intervention for the reduction of communication breakdowns in inpatient surgical care: results from a Harvard surgical safety collaborative.
Arriaga AF, Elbardissi AW, Regenbogen SE, et al. Ann Surg. 2011;253:849-854.
Communication failures in the surgical setting are a known threat to patient safety and the second most common root cause of adverse events (following technical errors). This study implemented a set of tailored policy and education initiatives at 4 teaching hospitals in an effort to increase timely and consistent resident–attending communication and promote attending visits with surgical patients. Investigators analyzed more than 200 critical events and 1300 patient cases and noted significant improvements in communication between residents and attendings. The number of patients not visited by attendings on weekends decreased by half, and the improved communications resulted in attending-level changes in patient management a third of the time. An accompanying editorial [see link below] discusses the study's findings and emphasizes the importance of simply setting clear and explicit expectations for communication. A past AHRQ WebM&M perspective discusses surgical safety with this study's senior author, Dr. Atul Gawande.