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- Noncognitive Errors ("Slips & Lapses")
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Stephanie Mueller, MD, MPH; February 2019
To transfer a man with possible sepsis to a hospital with subspecialty and critical care, a physician was unaware of a formal protocol and called a colleague at the academic medical center. The colleague secured a bed, and the patient was sent over. However, neither clinical data nor the details of the patient's current condition were transmitted to the hospital's transfer center, and the receiving physician booked a general ward bed rather than an ICU bed. When the patient arrived, his mentation was altered and breathing was rapid. The nurse called the rapid response team, but the patient went into cardiac arrest.
Journal Article > Study
Evaluation of a problem-specific SBAR tool to improve after-hours nurse-physician phone communication: a randomized trial.
Joffe E, Turley JP, Hwang KO, Johnson TR, Johnson CW, Bernstam EV. Jt Comm J Qual Patient Saf. 2013;39:495-501.
The SBAR (situation, background, assessment, recommendation) communication tool has been implemented in an effort to improve nurse–physician communication, particularly by telephone. For this simulation study, 20 nurse–physician pairs were enrolled and the nurse in each pair was randomized to receive six written clinical scenarios to convey to the physician (three using the SBAR format, three in the usual format). Investigators found that relevant information was often not communicated by the nurse nor elicited by physicians, and use of SBAR did not improve communication.
Eban K. Self Magazine. November 2011.
This magazine article reports on cases in which outsourcing the interpretation of radiology tests contributed to patient harm.