Miscommunication Found to be #1 Cause of Preventable Disability or Death in Hospitals

Imagine this: It's a busy Saturday evening at the hospital. You are understaffed and overworked and it's one of those days where everything seems to be happening at once. The medics bring in a patient suspected of having a STEMI. You know that when time is tissue, every second counts, so you follow proper protocol and, when you need to consult the cardiologist, Dr. Smith, you simply send him a page and continue on with your seemingly endless list of tasks and patients that need your attention.

A good while later, you realize that your probable-STEMI patient still has not been seen. "Where the heck is Doctor Smith??" you wonder. He's usually prompt and reliable, but today, no sign of him...

Another five minutes passes and finally you get a call back from Dr. Smith ... Why did he take so long?? "Hey there, nurse, I'm out on my Hawaiian vacation, but I got a call from the house-sitter saying my pager at home has been going off. What's up?"

Your heart drops. Oh. No. Your on-call list must have been wrong! How could you not have noticed? Your poor patient has just wasted so much time, it could be the difference between a full recovery and the nursing home ... or worse. 

A study published in JAMA Internal Medicine found that the situation described above is, unfortunately, far from a rarity. In fact, of the 14,000 admissions studied, communication failures were THE MOST COMMON CAUSE OF PREVENTABLE DISABILITY OR DEATH. And of those communication mishaps, sending a page to the wrong doctor makes up too large a portion. 

Over the study period, 14% of all pages sent were to the wrong physician when that doctor was off duty and 47% of these erroneous pages were about an emergency or urgent matter (needing attention within one hour). 

Now rewind and imagine this: It's that same busy Saturday evening; you send the alert to Dr. Smith for the probable-STEMI, and go about your business. But then just a moment after you've put your phone back in your pocket, you get an notification back from Dr. Smith. "Hey there nurse, just received an alert for this STEMI patient. I think your call list is wrong as I'm on vacation. I toggled my name off!" Bam. Just like that, with only a couple seconds used, you realize your mistake, toggle on the correct physician, Dr. Jones, and alert him. Just a few seconds later, your phone lights up again. You read the notification: “Dr. Jones has acknowledged your alert."

Whew. 

Sometimes patients don't respond to treatment. Sometimes patients are brought in too late after last known well. Sometimes they have contraindications that interfere with your care. These things are beyond our control. But there's no excuse for delaying life-saving care because of inefficient communication. With Pulsara, never lose another patient to miscommunication again.