Improving Patient Safety Through Provider Communication
A patient was given 30mg of Toradol in the operating room (OR); however, the medication was not reported to the recovery nurse. During the patient’s first 15 minutes in the post-acute care unit, the patient was restless and disoriented and complained of pain. One recovery nurse attended to the patient while a second recovery nurse retrieved Toradol per the post-operation orders. The first nurse drew up the Toradol and administered another 30mg to the patient, not knowing that the patient had already received Toradol in the OR. After the patient was resting and calm, the first nurse read through the chart, discovered her mistake, and immediately informed the anesthesiologist and surgeon.
-Event reported to the Commission
The Agency for Healthcare Research and Quality (AHRQ) recently released the sixth annual edition of the Hospital Survey on Patient Safety Culture: 2012 User Comparative Database Report, which provides survey results from 567,703 staff from 1,128 U.S. hospitals. The survey revealed that handoffs and transitions were the second most commonly identified area needing improvement. AHRQ reported that “only 45 percent of hospital staff have positive perceptions of handoffs and transitions across hospital units.”
Engaging Patients & Families for Safe, Quality Care
A 71 year-old male was discharged home following a colonoscopy. A short time later the patient started having progressively severe abdominal pain and went to the ED where a CT scan revealed evidence of a bleed and a slightly enlarged spleen. It was discovered that the patient had not discontinued his Coumadin prior to surgery as indicated in his pre-surgical instructions. He was admitted for monitoring and received six units of blood.
- Event reported to the Commission
Breakdowns in communication were one of the top three leading root causes of sentinel events reported to The Joint Commission in the United States between 2004 and 2011. These communication breakdowns occurred among healthcare professionals and also between healthcare professionals and patients or families. The Oregon Patient Safety Commission’s aggregate summaries of events reported in 2010 by Oregon hospitals, nursing homes, and ambulatory surgery centers identified similar trends in Oregon. In hospitals, communication concerns were a contributing factor in two out of every three events reported (66% of the time). In both nursing homes and ASCs, communication was among the top three reported factors that contributed to adverse events.
