Hospital Injuries From Miscommunication

by Garry M. Walsh | Sep 24, 2018 | Hospital Policy & Regulatory Expert

As a Joint Commission survey preparation specialist during the past 30 years, my natural inclination has been to focus motivational training towards guiding leadership efforts to create and adhere to effective written patient care plans, policies, staff training modules as well as quality and performance measurement and improvement initiatives. Never taking my eye away from the procedural mechanisms that must be devoted to eliminating hospital injuries. Recently, while serving as an expert witness for an attorney representing a patient as the Plaintiff who was injured due to a non-response to a Critical Test Result, my vision of a patient protection gained meaningful clarity.

By Definition

It is universally accepted that Critical Test Results are defined as any values/interpretations for which delays in reporting can result in serious adverse outcomes for patients. Once identified, the objective is to provide the responsible licensed caregiver these results within an established time frame so that the patient can be promptly treated.

All hospitals – especially those who are preparing for their Joint Commission or CMS survey – should confirm that they have defined the full scope of critical tests associated with their laboratory, cardiology, radiology, and other diagnostic tests in the inpatient, emergency, and ambulatory settings as the starting point.

Actions Speak Louder Than Words

The first step is to accept that, defining and improving your Critical Test Results policy is just the starting point. While necessary and well-meaning, a policy is crafted to only define intentions. Accordingly, in this case analysis, the policy is the first document I reviewed…to learn of the hospital’s planned intentions to avoid hospital injuries.

Based on my review of the case documents, on behalf the Plaintiff, the hospital – to their credit – had a solid policy that checked-off all of the following key performance elements that such a policy should include, by clearly stipulating:

1. What test results require timely and reliable communication;
2. When the test results should be actively reported to the ordering provider and other staff who are qualified to initiate clinical interventions. And they established explicit time frames for this process;
3. Who should receive the results;
4. Who should receive the results when the ordering provider is not available;
5. How to notify the ordering provider(s) and other staff who are qualified to initiate clinical interventions.

After assessing the contents of the hospital’s relevant policies to learn of their intentions, I naturally undertook a comprehensive review of the following information sources:

The patient’s hybrid medical record (EMR and paper chart).

• Did the staff follow the Critical Test Results documentation and timeliness requirements, as promoted within the policy, to avoid hospital injuries?
• As hybrid medical records are two-part documentation tools, is the right information documented in the right component of the hybrid record?

The key HR documents such as the orientation module, annual education updates, position descriptions, competency assessments, etc. relevant to the multiple staff members associated with this avoidable injury.

• Did the hospital offer appropriately detailed orientation and training on Critical Test Results to the suitable staff who engage in performing the tests and diagnostic procedures?
• Did their position descriptions and competency documentation include information related to identification and reporting of Critical Test Results, as this is considered a “High Risk” activity to minimize hospital acquired injuries?

The deposition transcripts of the staff associated with the patient’s avoidable injury.

• While under oath, did their narrative testimony of actions taken and reporting timeliness align with the written words within the hospital’s policies, as well as their medical record entries? Their performance expectations reflected in the HR position description and competency files?

• Did they place the Critical Test Result in the medical record and proceed onto their next diagnostic procedure, without telling anyone?

A Failure to Act

My review of the pertinent documentation referenced above, revealed that the hospital, once again to their credit, had a well-defined policy. But the policy’s intentions alone did not protect the patient from harm.

It was confirmed that multiple forms of miscommunication contributed to the patient’s unfortunate – and avoidable – injury, based on my review of the of the documentation germane to this matter. And these miscommunication lapses precipitated the failure to act and thereby a failure to protect the patient. It is critically important for me to note that, under no circumstances, would anyone declare the staff members associated with this adverse event to be unprofessional or uncaring. This was yet another experience whereby the people were good…but the coordination and integration processes were not.

A Failure to Prevent a Hospital Injury

The following is a summary of the failures to act, as a result of my review of the documented evidence. In addition to updating the Critical Result policy, I recommend that the reader consider this summary listing below to be the minimum self-assessment targets to improve the ability and timeliness of identifying and reporting Critical Test Results.

1. Review HR Files. The staff member’s HR position description and competency form referred to simply placing “one of the two copies (of ECG) directly into the chart”. There was no instruction to first read the computerized interpretation which would reveal the evidence that a critical result was recorded as a result of the ECG. Nor, as the medical record consisted of two (2) parts (EMR and paper chart), what is meant by the term ‘chart’.
2. Review Care Coordination Procedures. The staff member’s HR documents did not reference the need to promptly notify a patient care professional, as per policy requirement. In this case, it would have been the Unit Nurse caring for the patient – before placing the ECG report into ‘the chart”. Or to notify the ordering physician by telephone. The ECG test result was just placed into the paper chart, as she was trained to do.
3. Review Equipment Training. The staff member’s deposition revealed that there is a defined method to upload the ECG report into the EMR…but “she was never trained on that procedure.” (This failure to act prevented a subsequent care team from seeing the ECG report).
4. Review Hand-off Communication Procedures. Shortly after the patient had the pre-op ECG, she was transported to the Surgical Services Department. Appropriately, the patient was transported with the paper chart and understandably the OR staff would have access to the patient’s EMR. However, the Pre-Op Nursing staff did not review the paper record – only the EMR.
5. LIP and AHP Training Procedures. It was notable that this EGG test was performed in accordance with the Anesthesiologist’s pre-procedure “standing orders” protocol. The deposition testimony revealed that the Anesthesiologist did not review the patient’s paper record which was readily available. Only the EMR.
6. In conclusion, this patient had a pre-operative ECG test performed, which revealed a Critical Test Result and it went completely unnoticed. The patient unfortunately suffered a cardiac arrest in the PACU.

If you wish to learn more about the types of healthcare communication that must be assessed and improved to eliminate miscommunication errors to reduce injuries in a healthcare setting, you can view this video on those strategies at your convenience.