In my last column, I described how miscommunication, lack of demarcation of duties and a company environment unresponsive to suggested safety improvements led to scores of deaths in a horrific car ferry accident. An important point: I was not writing just about ships. Consider the following letter I received not long ago from a nurse at the Johns Hopkins Hospital (some of the details of which have been omitted or changed by me to avoid pointing fingers):
To Whom It May Concern:
I would like to give you a recollection of an admission on 3/18 of a post-op patient with a left-ventricular assist device who went back to the GOR for bleeding. I will try to outline the issues of communication between team members in the ICU. Unfortunately it took 10 hours before the surgical fellow (senior resident) ultimately took charge of the situation.
The patient was taken back to the OR for bleeding and upon readmission to the ICU cardiac output was fine. The Attending Surgeon had informed me before the patient came back that the patient was on epinephrine and milrinone. When the patient returned he was not on milrinone and the resident gave the order to start it at 0.25mcg/kg/min. In the following 90 mins I noticed a downward trend of the arterial pressure and decreased cardiac output to 3.3. Temp increased to 38.7 also. I noted that we had no lung sounds in lower lobes and expressed my concerns to the resident and received the response ‘we’ll discuss this during rounds.’ Rounds start late on Thursdays and when the team came in the room it was 10 a.m. I approached the surgical fellow with my concerns who looked at the CXR for me. The attending intensivist gave me the impression that he does not like nursing input or interruptions during rounds. I was, however, able to squeeze my concerns in. The rounding plan was to increase the milrinone and give a bolus. Patient had no CVP but my interpretation of his vital signs and the temp indicated that the patient may be dilated and in need of more fluid volume rather than milrinone. I clarified with the intensivist if I had to give the milrinone and he said ‘yes – the only thing that can happen is some hypotension,’ but it was also decided that I could give him 2 more liters of fluid.
I noted that the junior resident had written an incorrect dose for the milrinone bolus so I clarified it with the POC pharmacist. It was not that I refused to execute an order, but instead just that I tried to postpone it I guess. Again I spoke with the surgical fellow who said fluid replacement might help but that he did not know enough about the left-ventricular assist device to make changes. Shortly after this the mean arterial pressure dropped to 50 and the cardiac output to 2.8, so I called in the resident while giving fluid, increasing the epi and pausing the milrinone. The resident agreed with the fluid but insisted that the milrinone had to be put back on. I called the left-ventricular assist device coordinator and updated her and she was relieved that I had not given the entire milrinone bolus. She came to the floor and assessed the situation and called the surgical attending. However she never contacted the ICU team to describe their conversation.
We inserted a Swan-Ganz catheter to evaluate cardiac function and hydration; it seemed that the patient was hypovolemic and peripherally dilated and needed more i.v. fluids. The attending surgeon then called me and gave me orders of how to take care of the patient but he also spoke with the residents and gave them orders conflicted with the information he gave me.
It took until 1600 when the surgical fellow on-call took charge. He ordered more fluid, converted the epinephrine to norepinephrine and stopped the milrinone. To say that I am frustrated by the lack of collaboration between our ICU team members is an understatement. I have more than 20 years of ICU experience and when I express my concerns I would like to be at least acknowledged. I feel that this miscommunication puts the nurse in a very difficult situation. What is even of more concern: would a less experienced nurse have allowed the milrinone bolus and further imperiled the patient?
This letter characterizes one of many situations that are occurring at the Johns Hopkins Hospital every single day. Our superspecialized silos have grown up over the years in such a way that communication of critical information often fails to occur, and key caregivers are unable to provide the best possible patient outcome. Just like in the needless sinking of the Herald of Free Enterprise, this letter demonstrates how patient safety can be compromised, even with the best of intentions.
Failures of communication, absence of teamwork and lack of appropriate leadership are probably responsible for the majority of patient safety mistakes that occur in hospitals across the country. Yet our culture, and, indeed, the entire educational training of healthcare workers, is antithetical to the concepts of teamwork and optimal communication. I will have more to say about this in my next column.
Lack of Teamwork Sinks Ships
(and Hospitals)
In my last column, I described how miscommunication, lack of demarcation of duties and a company environment unresponsive to suggested safety improvements led to scores of deaths in a horrific car ferry accident. An important point: I was not writing just about ships. Consider the following letter I received not long ago from a nurse at the Johns Hopkins Hospital (some of the details of which have been omitted or changed by me to avoid pointing fingers):
To Whom It May Concern:
I would like to give you a recollection of an admission on 3/18 of a post-op patient with a left-ventricular assist device who went back to the GOR for bleeding. I will try to outline the issues of communication between team members in the ICU. Unfortunately it took 10 hours before the surgical fellow (senior resident) ultimately took charge of the situation.
The patient was taken back to the OR for bleeding and upon readmission to the ICU cardiac output was fine. The Attending Surgeon had informed me before the patient came back that the patient was on epinephrine and milrinone. When the patient returned he was not on milrinone and the resident gave the order to start it at 0.25mcg/kg/min. In the following 90 mins I noticed a downward trend of the arterial pressure and decreased cardiac output to 3.3. Temp increased to 38.7 also. I noted that we had no lung sounds in lower lobes and expressed my concerns to the resident and received the response ‘we’ll discuss this during rounds.’ Rounds start late on Thursdays and when the team came in the room it was 10 a.m. I approached the surgical fellow with my concerns who looked at the CXR for me. The attending intensivist gave me the impression that he does not like nursing input or interruptions during rounds. I was, however, able to squeeze my concerns in. The rounding plan was to increase the milrinone and give a bolus. Patient had no CVP but my interpretation of his vital signs and the temp indicated that the patient may be dilated and in need of more fluid volume rather than milrinone. I clarified with the intensivist if I had to give the milrinone and he said ‘yes – the only thing that can happen is some hypotension,’ but it was also decided that I could give him 2 more liters of fluid.
I noted that the junior resident had written an incorrect dose for the milrinone bolus so I clarified it with the POC pharmacist. It was not that I refused to execute an order, but instead just that I tried to postpone it I guess. Again I spoke with the surgical fellow who said fluid replacement might help but that he did not know enough about the left-ventricular assist device to make changes. Shortly after this the mean arterial pressure dropped to 50 and the cardiac output to 2.8, so I called in the resident while giving fluid, increasing the epi and pausing the milrinone. The resident agreed with the fluid but insisted that the milrinone had to be put back on. I called the left-ventricular assist device coordinator and updated her and she was relieved that I had not given the entire milrinone bolus. She came to the floor and assessed the situation and called the surgical attending. However she never contacted the ICU team to describe their conversation.
We inserted a Swan-Ganz catheter to evaluate cardiac function and hydration; it seemed that the patient was hypovolemic and peripherally dilated and needed more i.v. fluids. The attending surgeon then called me and gave me orders of how to take care of the patient but he also spoke with the residents and gave them orders conflicted with the information he gave me.
It took until 1600 when the surgical fellow on-call took charge. He ordered more fluid, converted the epinephrine to norepinephrine and stopped the milrinone. To say that I am frustrated by the lack of collaboration between our ICU team members is an understatement. I have more than 20 years of ICU experience and when I express my concerns I would like to be at least acknowledged. I feel that this miscommunication puts the nurse in a very difficult situation. What is even of more concern: would a less experienced nurse have allowed the milrinone bolus and further imperiled the patient?
This letter characterizes one of many situations that are occurring at the Johns Hopkins Hospital every single day. Our superspecialized silos have grown up over the years in such a way that communication of critical information often fails to occur, and key caregivers are unable to provide the best possible patient outcome. Just like in the needless sinking of the Herald of Free Enterprise, this letter demonstrates how patient safety can be compromised, even with the best of intentions.
Failures of communication, absence of teamwork and lack of appropriate leadership are probably responsible for the majority of patient safety mistakes that occur in hospitals across the country. Yet our culture, and, indeed, the entire educational training of healthcare workers, is antithetical to the concepts of teamwork and optimal communication. I will have more to say about this in my next column.
