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Team communication


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Effective communication


  • Good teams have a "shared mental model."
  • Good teams communicate "often enough.

Safe care depends on sharing information appropriately and effectively. Good teams share a mental model for what should happen — everyone is on the same page. Good team members communicate what is necessary, when it is necessary.

Case: Fracture leads to paraplegia
Elderly male in wheelchair

Background

An emergency physician identifies a compression fracture of the ninth thoracic vertebra (T9) on the X-ray of a middle-aged patient who had fallen two weeks prior.

The patient has a known alcohol addiction, a history of ankylosing spondylitis, and cervical spine fracture. Despite the correct diagnosis, the emergency physician fails to document his assessment or X-ray interpretation in the patient record prior to admission.  

The next day, the radiologist reports the mild loss of T9 vertebral body height, either acute or chronic, and recommends further investigation. However, he fails to document the 2 mm shift or report the fracture as unstable. The family physician does not see the X-ray and the report is not available for several days. He also fails to investigate the patient's back pain.

Background continued

When the patient becomes confused and starts thrashing about the bed, the family physician prescribes chemical and physical restraints for suspected alcohol withdrawal.

The following day, the nurse notes a fever, increased abdominal distension and urinary incontinence, which she documents in the nurses' notes. However, she reports only the fever to the family physician, and the family physician does not read the nurses' notes.

The next morning, signs of paraplegia are evident. A CT myelogram reveals a posterior process fracture of T9 with fragment shift and large epidural hematoma resulting in cord compression. The patient undergoes spinal surgery, but he remains paraplegic.

Think about it

What information should have been shared between team members?

Lessons learned

  • The emergency physician should have advised the family physician verbally or in writing of his interpretation of the X-ray of the T9 compression fracture.
  • The radiologist should have noted the 2 mm vertebral shift and reported the T9 fracture as unstable.
  • The family physician should have read the nurses' notes.
  • The nurse should have documented the patient's neurological symptoms in the patient record, and communicated all of the patient's symptoms to the family physician, not just the fever.
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Case: A developing infection
Close-up of male surgeon in surgery

Background

Following an uneventful lung removal and post-operative course, the thoracic surgeon writes an order that the patient could be discharged the following morning. The patient's temperature spikes late that evening.

The on-call general surgery resident, who is covering for thoracic surgery, orders bloodwork and a chest X-ray. As the white blood cell count (WBC) is elevated, he documents in the patient record that he suspects an infection, but he does not inform the thoracic surgeon.

The next morning, the thoracic surgeon and team visit the patient. The nurse reports that the patient had a fever the previous evening, but he now appears to be fine. She does not mention the elevated WBC and the order for a chest X-ray. The thoracic surgeon also does not personally review the patient's chart. Unaware of the on-call resident's concerns the previous evening, the patient is discharged as planned.

Outcome

Five days later, the patient dies of a lung infection.

Lessons learned

There were three communication breakdowns by different members of the healthcare team.
  • The on-call resident did not advise the thoracic surgeon that he suspected a post-operative infection based on the patient's elevated WBC.
  • The nurse reported some — but not all — of the relevant information about the patient to the thoracic surgeon.
  • The thoracic surgeon did not read the patient's chart before discharging the patient.

Had any of these communication breakdowns been avoided, the lung infection would likely have been diagnosed and treated.

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Communication risk factors

The following circumstances increase the risk for miscommunication and the loss of important patient information:
  • multitasking and frequent interruptions
  • noise and visual distractions
  • multiple providers
  • not knowing who is on the team
  • ambiguity about roles and responsibilities; dynamic leadership
  • changes in team personnel (e.g. during surgical operations)
  • lack of orientation of new members to the team
  • frequent handovers
  • hierarchies that inhibit speaking up
  • differences in terminology and cultures of health professions and subspecialties
  • different languages and societal cultures for both patients and providers
  • fatigue
  • assumptions that team members know how to work as a team and communicate


Think about it

It's a long list! Can you think of others?