By Jeremy Groves, Council Member

Article in JICS examines incidents that are associated with a failure of communication in critical care. Antony Thomas and John MacDonald have looked at 1,694 reports from 30 units in the North West of England over a 6 year period.

It is said that to err is human, to forgive divine; yet I worry that, in our micromanaged working environment, forgiveness may not be forthcoming and stress result.  Perhaps a better expression for 21st century healthcare would be “to err is human, to report mandatory, to learn, reflect and act essential”.

Read the full article here

Thomas and MacDonald’s findings give us the opportunity to learn from and improve how we use our incident reporting systems. Here are 5 observations from their article:

1. The commonest categories were medication incidents, access to beds and transfer, and incidents relating to equipment.

2. About a quarter of the incidents, when classified by stage in the critical care pathway, were during transfer in to critical care.  Most of these during transfer from theatres.

3. In terms of method of communication, verbal communication was highlighted in about a third of all the incidents, with a larger proportion of these leading to harm than in the 200 odd incidents where written communication was to the fore.  Interestingly electronic records are not fool proof being cited in 97 incidents.

4. Central lines produced the most problems when equipment was taken into consideration.  Nasogastric tubes and epidurals came next.  Radiology produced 71 incidents of which 10 were related to nasogastric tube placement, 3 leading to intrapulmonary feed being given.

The discussion focuses on the transfer issue and the necessity for meticulous handover.  On transferring to the ward, antibiotics, insulin dosage and transfusion thresholds warrant particular attention. When moving to and from theatres appropriate labelling of invasive lines should be checked.  Worryingly, on occasions there was no handover at all. The authors conclude that increased use of structured handover and check lists would be beneficial.

It is always good to be able to relate to an article.  Years ago I misidentified a patient when talking to a relative over the phone.  My response has been always to have the patient’s notes with me when talking to relatives either on the phone or in person.   I’ve always had a nagging fear that I was the only person ever to have done such a thing.  This article, in addition to highlighting learning points that I can take back to everyday practice, also provided some reassurance that I am not the only one to have erred.  Fortunately the relative concerned in the incident I was involved in was divinely forgiving.

Patient safety incidents associated with failures in communication reported from critical care units in the North West of England between 2009 and 2014. Antony N Thomas, John J MacDonald. JICS, May 2016 vol. 17 no. 2 129-135.

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