Are your patients at risk?

Dr. Peraino discusses four common causes of medical mistakes and offers tips on preventing them.

Dr. Jones is finishing up the first of three new admissions from the ED. His pager is going off almost constantly. He finally stops writing to call the first of four unanswered pages. He addresses the nurse's question, ends the call, and dials the second number on his pager.

“Dr. Jones here, you paged?”


The same nurse says, “Oh, no, I just talked to you about the patient in room 441.”

When Dr. Jones finally goes back to the note he was working on, he inadvertently leaves out an important part of the patient's plan of care. In the middle of working up the second ED patient, the medical-surgical nursing unit pages him about the orders he wrote for the first patient.

“Dr. Jones, I see that this patient's diagnosis is pneumonia. The protocol calls for blood cultures. Do you want to order them?”

The first cause of medical mistakes, interruption, frequently leads to omissions that can delay patient care. Mistakes due to interruption can be a lot more serious, even life-threatening. If Dr. Jones had been focusing on the patient's medication allergies when the interruption occurred, he might have ordered a dangerous medication after returning the page. His original train of thought was supplanted by the buzzing pager and the perceived need to respond rapidly. If Dr. Jones began to delay responses to pages until he was finished with the patient in front of him, he would probably be criticized.

“Dr. Jones, this is Dr. Brown in the ED. I have three new admissions for you. When will you come here to admit them?” To please Dr. Brown, and mindful of criticism about tardy responses, Dr. Jones rushes through the central line placement he was about to start. The patient develops acute respiratory distress from a pneumothorax.

The second cause of medical mistakes is haste. Hospitals make money on volume, not individual patient reimbursement. The operative word is throughput: More patients put through the system means more income. Haste—real or perceived—causes physicians and nurses to lose focus, increasing the risk of a medical mistake and patient injury.

Until Dr. Jones actually begins to provide care, the three patients in the ED are Dr. Brown's responsibility. Since Dr. Jones has not seen the ED patients, a physician-patient relationship has not been established. Without that relationship, Dr. Jones has no fiduciary duty to care for them. His first duty is to the patients already in the hospital under his care.

“Code Blue, 4 North.” The message is repeated six times via the overhead paging system with five-second pauses between. Dr. Jones' pager also blares the same message repeatedly.

The third cause of medical mistakes is distraction. Some hospitals have 10 or more codes that are practiced several times each year. The fire alarm goes off, and everyone must stop what they are doing to proceed to their preassigned locations. The hallway cleaning machine passes by the doctors' work area at the nurses' station, clearly in need of a new muffler or tune-up. The noise levels in many hospitals are intolerable despite meeting OSHA guidelines.

Distraction is akin to interruption. Pagers can be distracting, and the physician's response to the pager is an interruption. Hospitalized patients have multiple chronic diseases and medications to complicate the acute problems that led to their admissions. Proper care requires intense focus, free of distractions and interruptions. If Dr. Jones not only delays his response to pages but also refuses to be interrupted when he is focused on one patient's care, he may be criticized as being rude or abrupt, when in truth he is doing his utmost to protect his patient from an inadvertent mistake or injury.

While Dr. Jones is finishing the central line placement, Nurse Smith enters the room and says, “Dr. Jones, the patient in room 21 has a blood sugar of 500. Do you want me to give extra insulin?” Dr. Jones tells her the dose to give. In the meantime, Nurse Carmen comes in and says, “Dr. Jones, your office called and five patients are in your waiting room.” Dr. Jones' train of thought is clouded now by a mental review of the patients in his waiting room, and he sticks himself with the needle while suturing the central line in place.

Dr. Jones stuck himself because he was multitasking, the fourth cause of medical mistakes, by dealing with another patient's blood sugar and mentally responding to the message from his office about waiting patients. Nurses make mistakes because of multitasking and the sense of urgency in almost everything they do, monitor and observe. Care of the patient in room 22 is interrupted while the nurse responds to the callback from the doctor about the patient in room 32.

How can hospitalists fix these problems? Personal and system-wide modifications can increase individual patient focus and minimize the chance of making a mistake. The following tips can help.

Formally establish allowable callback times across your organization. Twenty minutes for nonurgent situations is plenty of time to allow a physician to finish with the patient in front of her. If a call is urgent or emergent, a “2” or a “1,” respectively, can be added to the callback number.

Stay in touch. Although very few real emergencies occur in the day-to-day operation of a hospital, it may seem that every question and concern must be answered immediately by paging the hospitalist. Insuring that you talk with each patient's nurse during morning rounds and taking a brief walk around at the end of your shift if time permits can decrease the number of calls you get.

Conquer lab values. Many pages notify the hospitalist of abnormal and “critical” lab values more likely to be critical for the caller than for the patient. Discuss the role that notification of noncritical laboratory values plays in the incidence of medical mistakes with the laboratory director and the clinical pathologist if necessary. Ask them to modify their notification protocols.

Develop a set of standing orders that specifically address when a call is needed. The orders should include when to notify the hospitalist of the commonest abnormal values that trigger a call: electrolytes, magnesium, glucose, calcium, and phosphorus; vital signs; and changes in baseline abnormal values. The last is most important to avoid calls telling you that the BUN is 80 when it was 82 yesterday.

Preach what you practice, practice what you preach. To reduce the number of interruptions and distractions, resist being drawn into multitasking. Defuse the sense of urgency and haste by intensive and repetitive education of patient care personnel, particularly nurses and allied staff such as laboratory personnel. The educational effort should be formal and system-wide. Attempts to modify behavior through one-on-one interaction will not produce lasting change.

The recent trends to improve patient care are centered on the process improvement model or local variations of it: plan, do, check, act. The four causes of medical mistakes—interruption, distraction, haste and multitasking—are pertinent to organization-wide patient care and transcend all departments, service lines and processes of care. They have one common denominator: a loss of focus on the most important patient, the one right in front of you.