Photo By Danny Kim
The short answer, in my opinion, is yes.
The long answer is slightly more nuanced. As it turns out, studies suggest that one’s relative risk of death is increased in teaching hospitals by about 4-12% in July. That likely represents a small, but significant uptick in avoidable errors. It has been very difficult to quantify and document error rates related to inexperience. Intuitively we all know that professionals get better at what they do with time and practice… but how bad are doctors when they start out? Probably not equally so… and just as time is the best teacher, it is also the best weeder. Young doctors with book smarts but no clinical acumen may drop out of clinical medicine after a short course of doctoring. But before they do, they may take care of you or your loved ones.
It has been argued that young trainees “don’t practice in a vacuum” but are monitored by senior physicians, pharmacists, and nurses and therefore errors are unlikely. While I agree that this oversight is necessary and worthwhile, it is ultimately insufficient. Let me provide an illustrative example.
When I was a new intern I was assigned to a patient with curious eyelids. He was a mildly obese, middle aged man with a beard who spoke in hushed tones. What struck me the most was that he had voluminous upper eyelids. They were so strange that I couldn’t stop staring at them. He didn’t have any hives or red blotches on his skin, and his eyeballs were clear and white. There was no pus or discharge of any kind. I was so perplexed that I began to search through his medical record for answers before I embarrassed myself by asking for a consult. After many hours of digging, I discovered the smoking gun.
Apparently, he had been given repeat boluses of 1 Liter of IV normal saline by dutiful interns and residents who had not communicated with one another about who would write the order. So they all did. This man was so fluid overloaded that his eyes were literally bugging out of his head. No one had noticed the edema because of his size, and because (thank God) his heart and kidneys were young and healthy enough to handle the load without going into outright failure. Also, normal saline is such an innocuous medication that it didn’t flag any concerns by the nurses (who were also rotating through the service and busy swatting the more obvious mistakes being made by the fresh crop of interns).
If this poor patient had congestive heart failure or kidney disease, he could have been killed by well-meaning, diligent interns with salt water. Fortunately for him, he made a full recovery – and because there was technically “no harm done” I don’t even think this case was discussed in M&M (morbidity and mortality) conference, and I also doubt that anyone was reprimanded. Sounds crazy, but there are bigger fish to fry in July.
So my point is this: rookie mistakes are not always tracked, documented, addressed, or perhaps even noted. But they are real. They are scary. And they are lurking at every teaching hospital in this country. We must all remain on high alert – and question everything. Because even eyelids offer important clues, and water can kill.
If you or a loved one insist on falling ill in July, I recommend finding a hospital with a culture of carefulness or bring a patient advocate with you.
As I travel the country providing coverage for inpatient rehab units, I have been struck by the generally high quality of nursing care. Excellent nurses are the glue that holds a hospital unit together. They sound the first alarm when a patient’s health is at risk, they double-check orders and keep an eye out for medical errors. Nurses spend more time with patients than any other hospital staff, and they are therefore in the best position to comment on patient progress and any changes in their condition. An observant nurse nips problems in the bud – and this saves lives.
Not only are nurses under-appreciated and under-paid, they are suffering as much as physicians are with new digital documentation requirements. Just as patients are receiving less face time with their physicians, they are also suffering from a reduction in bedside attention from nurses. The need to record data has supplanted our ability to listen to the patient, causing anguish for patients, physicians, and nurses alike.
This being our lot (and with continued “quality improvement” policies that will simply add to the documentation burden) we must find ways to optimize patient care despite inane bureaucratic intrusions. I believe that there are some steps that nurses and doctors can take to improve patient care right now:
1. Minimize “floating.” (Floating is when a nurse is pulled from one part of the hospital to fill in for a gap in coverage in a different unit). It is extremely difficult for nurses to take care of a floor full of patients they’ve never met before. Every time that care of a patient is handed off to someone else (be they MD or RN), there is a risk of forgetting to follow through with a test, procedure, or work up. Simply knowing what “normal” looks like for a given patient can be incredibly important.
For example, left sided weakness is not concerning in a patient with a long-time history of stroke, but what if that is a new finding? If you’ve never met the patient before, you might not realize that the weakness is new and constitutes an emergency. How does a nurse know if a patient’s skin ulcer/rash/pain etc. is better or worse than yesterday? Verbal reports don’t always clarify sufficiently. There are endless advantages to minimizing staff turnover during a patient’s hospital stay. Reducing the total number of nurses who care for individual patients should be a number one priority in hospitals.
2. If you see something, say something. There are a host of reasons why nurses may be hesitant to report patient symptoms. Either they don’t know the patient well and think that the new issue could be “normal” for that patient, or perhaps the physician managing the patient has been unreceptive to previous notifications. However, I am always grateful when a nurse goes out of her way to tell me her concerns, because I generally find that she’s on to something important. My general rule is to over-communicate. If you see something, say something – because that episode of patient anxiety in the middle of the night could be a heart attack. And if I don’t know it’s happening, I can’t fix it.
3. Please don’t diagnose patients without input. I’ve found that nurses generally have excellent instincts about patients, and many times they correctly pinpoint their diagnosis. But other times they can be misled, which can impair their care priorities. For example, I had a patient who was having some difficulty breathing. The nurse told me about it immediately (which was great) but then she proceeded to assume that it was caused by a pulmonary embolism. I explained why I didn’t think this was the case, but she was quite insistent. So much so that when another patient began to have unstable vital signs (and I requested her help with preparing for a rapid response) she stayed with the former patient, believing that his problem was more acute. This doesn’t happen that frequently, but I think it serves as a reminder that physicians and nurses work best as a team when diagnostic conundrums exist.
4. Help me help you. Please do not hesitate to come to me when we need to clean up the EMR orders. If the patient has had blood glucose finger stick checks of about 100 at each of 4 checks every day for 2 weeks, then by golly let’s reduce the checking frequency! If the EMR lists Q4 hour weight checks (because the drop down box landed on “hour” instead of “day” when it was being ordered) I’d be happy to fix it. If a digital order appears out of the ordinary, ask the doctor about it. Maybe it was a mistake? Or maybe there’s a reason for Q4 hour neuro checks that you need to be aware of?
5. Let’s round together. Nurses and physicians should really spend more time talking about patients together. I know that some physicians may be resistant to attending nursing rounds due to time constraints, but I’ve found that there’s no better way to keep a unit humming than to comb through the patient cases carefully one time each day.
This may sound burdensome, but it ends up saving time, heads off problems, and gives nurses a clearer idea of what to look out for. Leaving nurses in the dark about your plan for the patient that day is not helpful – they end up searching through progress notes (for example) to try to guess if the patient is going to radiology or not, and how to schedule their meds around that excursion. Alternately, when it comes time to update your progress note, isn’t it nice to have the latest details on the patient’s condition? Nurses and doctors can save each other a lot of time with a quick, daily debrief.
6. Show me the wounds. Many patients have skin breakdown, rashes, or sores. These are critically important to treat and require careful observation to prevent progression. Doctors want to see wounds at regular intervals, but don’t always take the time to unwrap or turn the patient in order to get a clear view. Alternatively, some MDs simply unwrap/undress wounds at will, leaving the patient’s room without even telling the nurse that they need to be re-wrapped. In some cases, it takes a lot of time to re-dress the complex wound, adding a lot of work to the nurse’s already busy schedule (and offering little benefit, and some degree of discomfort, to the patient).
Nurses, on the other hand, have the opportunity to see wounds more frequently as they provide dressing changes or peri-care at regular intervals. Most nurses and doctors don’t seem to have a good process in place for wound checks. I usually make a deal with nurses that I won’t randomly destroy their dressing changes if they promise to call me to the patient’s bedside when they are in the middle of a scheduled change. This works fairly well, so long as I’m willing/able to drop everything I’m doing for a quick peek.
These are my top suggestions from my most recent travels. I’d be interested in hearing what nurses think about these suggestions, and if they have others for physicians. I’m always eager to improve my patient care, and optimizing my nursing partnerships is a large part of that. 😆
Improving handoffs from the emergency room back to the primary care physician will require changing how electronic health records are used, better reimbursement to both the hospital and ambulatory doctors, and malpractice reform, according to a study. The rising use of hospitalists and larger primary care practice sizes has contributed to the difficulties faced when an ER doctors tries to reach a physician who best knows the patient.
Haphazard communication and poor coordination can undermine effective care, according to a new research conducted by the Center for Studying Health System Change. Researchers conducted 42 telephone interviews between April and October 2010 with 21 pairs of emergency department and primary care physicians, who were case-matched to hospitals so the perspective of both specialties working with the same hospital could be represented.
Among the findings in the report, telephone communication was essential in some cases, but particularly time-consuming. Both emergency and primary care physicians reported successful completion of each telephone call often required multiple pages and lengthy waits for callbacks. While placing and receiving telephone calls might seem straightforward and quick, providers said each small action multiplied across dozens of patients can become a daunting burden, with little immediate reward or reimbursement. Read more »
*This blog post was originally published at ACP Hospitalist*
One of the most dangerous times for a patient is during the transition, or “handoff,” between providers. This is due to a number of reasons. First, the original provider(s) may not relay all the information he or she knows about the patient to the next provider(s). Second, the accepting team may take it for granted that everything is known about the patient, and therefore not take a complete history or perform an adequate physical examination. Third, if the patient initially looks good, the accepting providers may be lulled into a false sense of security, and not anticipate a deterioration in the patient’s condition.
We know this problem to exist in the hospital setting. Survey of doctors-in-training suggests that handoffs may commonly lead to patient harm. Last year (2008) in September, there was a blog written by Elizabeth Cooney in the Boston Globe that stated, “a 2006 survey of resident physicians at Massachusetts General Hospital found that handoffs commonly lead to patient harm, according to an article in The Joint Commission Journal on Quality and Patient Safety.” More than 50 percent “of the 161 medical or surgical residents who responded to the anonymous survey said they recalled at least one occasion in their last month-long rotation when a patient suffered from flawed handoffs.” Approximately “one in nine said the harm that resulted was significant.” The respondents said that “if the patient was coming from the emergency department or from another hospital, problematic handoffs were more likely.”
This holds true in the field. Unless the new treatment team makes the assumption that they need to begin their assessment of the patient’s condition from scratch, they are more likely to make a mistake. Obviously, such caution depends on the possible severity of the patient’s condition and the rescue/environmental situation. If I can get a decent handle on a patient’s condition, and there is little or no risk of me missing something, I will tailor my questioning and examination to suit the circumstances. However, I always start from the position that something has been hidden from me, of course not intentionally, and that the patient’s initial assessment has underestimated the problem(s).
I cannot begin to tell you how many times I have found something that was missed, or have accepted the care of a patient just as he or she began to “crash.” This is in no way a criticism of others, just a common fact of medical care. Previous rescuers may have been tired, the conditions may not have been conducive to a full examination, the patient may have been withholding information, or the situation may have just taken its natural course and worsened. Regardless, it’s my responsibility to learn what I can as quickly as I can about my patient, so that nothing slips through the cracks.
Here are some simple rules to follow:
1. If the situation permits, ask your new patient to repeat his or her history. If they are reticent to engage in a long conversation, at least try to get them to relate current relevant events.
2. Repeat as much of the physical examination as you can. Explain to the patient that you have assumed their care, and that in order to do the best that you can on their behalf, it’s important for you to understand their issues and to be able to monitor their progress based up the exam.
3. Assume that until you have talked to the patient or otherwise obtained a comprehensive history, and performed a physical examination with your own hands, eyes, and ears, that you do not know as much about your patient as you could.
4. If a patient is under your care for a prolonged time, or if you are managing a situation prone to rapid or undetected deterioration, interview and examine your patient as often as is necessary and practical. If you must be absent from a patient for a longer period than is prudent between examinations, delegate the responsibility to someone else.
image of leg splinting courtesy of www.princeton.edu
This post, Dropping The Ball In Patient Care: Provider Handoffs, was originally published on
Healthine.com by Paul Auerbach, M.D..