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How a Small Miscommunication Nearly Cost a Life: A Firsthand Account

By Shane Elmore, RN



If you've been following our blog for any amount of time now, you've heard us refer to the "communication crisis" in healthcare. Occasionally, those of us who work for Pulsara have the opportunity to experience first-hand how the crisis impacts care teams and their patients. This is part one of two posts on an up-close-and-personal encounter I had just last week. I hope you enjoy!

On a recent business trip, I was hospitalized and had to have surgery. I chose the hospital on the suggestion of my Uber driver, since neither hospital in town was a customer of ours, and I really knew nothing about either.  The experience that followed gave a perfect example of how miscommunication mixed with a lack of accountability can have a negative impact on patients.

The unlucky victim of this unfortunate situation was my 98-year-old roommate who was in a dire situation and was a very sick man. On top of being diagnosed and undergoing treatment for rectal cancer, the doctor admitted him for acute renal failure, his hemoglobin was low, and he had a stat order written for blood. So much for HIPAA, right? I knew more about what was going on with this patient than the nurses did, unfortunately.

He arrived at our shared room just after 4:00pm and the nurses on the unit were all upset — and rightfully so. This man had an order to give blood that was written just after 12:00pm in the Emergency Department, and it hadn't even been started. I know it takes some time to type and cross a unit of blood, but not this long. What I heard next blew my mind: The RN on the floor said that she wasn't going to give it because she had too much going on. Instead, she was going to leave that for the night nurse, who would take over in three hours. At least her righteous indignation did prompt her to call and find out why the blood wasn't started in the Emergency Department. The reason? A communication failure that caused the order to be completely missed.

Can you guess what time this man finally received his unit of blood? Well, let me take you through what happened next: When the night shift came in, they gave report at the bedside … but, in keeping with our trend of failed communications, the day nurse did not mention that the blood hadn’t been transfused.

Later, when the frantic night nurse picked up on this fact, she tried asking the hearing-impaired patient whether he had gotten his transfusion. Confused and tired, the poor guy did not understand. Because I could now recite the entire script of the day’s Blood Transfusion Soap Opera, I filled her in on what had happened.

So, what time did you guess that this man received his blood? If you said 10:00pm — a full TEN HOURS after it was ordered — you were right.

People feel so safe when they go to the hospital. But if they only knew how dangerous it was, they would choose their hospitals a little more carefully. These aren't "bad" people who are "bad" nurses who work for a "bad" hospital. These are people who probably got into this profession to make a difference and help people. I'm not taking personal accountability out of the equation, but much of the fault is on the system. We need to do better for our patients, using communication tools that meet the demands of our modern workflows and demands. It is up to us to make the change. As Tom Northrup said, "All organizations are perfectly designed to get the results they are now getting. If we want different results, we must change the way we do things."


ARTICLE CATEGORIES: Communication, Emergency Medicine
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Shane Elmore, RN

Shane Elmore, RN

Shane is Pulsara's Vice President of Clinical Innovation, and is certified in CCRN, CEN, and CFRN. Shane is a former Chest Pain Coordinator at Trinity Mother Frances Health System.

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