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Impact of Poor Communication on Patient Care

Discuss about the Communication and Human Medical Errors for Clinical Medicine.

Patient safety is one of the greatest concerns that every practitioner needs to adhere and ensure that they meet the required standards thus preventing errors and reducing human harm. Goncalves, Rocha, Anders, Kusahara, & Tomazoni (2016) suggest that medical errors result in adverse effects of care that can be both harmful and less harmful to the patient.  These include, injury, incomplete diagnosis of disease, behaviour, infection or any other ailment that the patient can contract due to practitioner errors. Rimal & Lapinski (2011) suggests that it has been difficult measuring the frequency of medical errors since the mistakes and errors made vary from simple to complicated situations. Sometimes the effects of the error can be realized earlier through the effects of the error and sometimes this never happens in the case where the error is less fatal thus the signs and symptoms show up later. In the Vanessa case the Deputy State Coroner indicated that the case was different since the conceivable errors of omission were detected but continued building up on top of each other. This indicated that there was a challenge in putting proper mechanisms in place to reduce these errors. This essay analyses the case of Vanessa focusing on the application of human communication strategies to reduce errors, which had been detected in the case but continued being repeated.

According to Standard 4 of the Registered Nurse standards for practice, registered nurses should accurately conduct comprehensive and systematic assessments through analyzing information and data to communicate the outcomes of the situation with other practitioners for proper mechanisms on mitigating the situation. Medical errors range from mistakes and violations that affect patient outcome. Richter & Ford (2016) argues that communication allows relaying and interpreting of information between physicians, caregivers and patients to provide the best care and patient outcomes. Patient care is a team sport that relies on effective relaying of information from one level to another. Since the care of patient is dependent on several efforts of different practitioners, then it means that communication is key in achieving quality outcomes. The accident model suggests that failures in healthcare settings are a consequence of latent failures that create conditions of work which lead to active failure. Dr. Little only discovered that Vanesa was under her care after midday when the patient has been in the hospital for a while. This lapse on communication between practitioners can impact the health of a patient and at the same time delay medical intervention like in the case. 

The Role of Communication in Promoting Quality Care

The role of communication in an organization is to reduce human failures through real-time detection of errors and addressing them. Since care is a team process, then communication plays an instrumental process throughout the patient’s entire healthcare process (Shitu, Hassan, & Aung, 2018). This process allows transfer of information and knowledge from one point to another. Communication is thus the heart of effective quality care through interaction of patients and practitioners to meet the needs of the organization (Morello, Lowthian, Barker, Dunt & Brand, 2013). Practitioners play different roles in the process of patient care which means that they have to communicate with each other as they hand over the patient from one profession to another. Jin, Choi, Kang, & Rhie (2017) argue that documentation allows practitioners to communicate with each other allowing all those who are engage with the patient to understand the nature of the situation. In the case study there was a documentation challenge which means that the medication and care process that followed was not based on the diagnosis and analysis results but personal interpretations of the situation.

Effective communication means improved care and reduced human factor errors. The reason why errors in Vanessa’s situation kept piling is the absence of clear communication that allows practitioners to share their experiences on patient care. Poor communication means that the practitioners did not properly share information regarding the situation of the patient to understand the errors that have been made and how to address them to reduce their effects to the patient (Amutio-Kareaga, Garcia-Campayo, Delgado, Hermosilla, & Martinez-Taboada, 2017).This means that as the patient was reassigned from one practitioner to another, there was no proper information that can inform the approach and decisions to be made. When Dr. Williams prescribed endone increase to 5-10mg after every three hours, the maximum dose was not indicated to the nurse to limit the amount that the patient took. Further, Dr. Williams made the wrong prescription yet he was not the one to do it rather the neurosurgical consultant was the one to do it. This indicates a challenge in communication between entities in the facility which impact the patient. 

According to Berman & Chutka (2016) communication is a process of reducing medical errors focusses on four themes of situation, background, assessment, and recommendation. This process is called SBAR which was initially designed for application in acute setting due to its ability to increase communication time thus improving the transfer of information, perception of the safety culture and patient satisfaction as a result of clear clinical processes. Through clear communication, practitioners can share patient details to develop strategies that can be put in place to mitigate the situation (Mazurenko, Richter, Swanson-Kazley, & Ford, 2016).  In this scenario, clear and effective communication between practitioners could have resulted in reduction of the errors through early identification and development of strategies for addressing such errors. The relationship between Nurse Perrin, Dr. Williams, Nurse Becker, and Dr. William is poor due to communication issues in the facility. There is a documentation challenge where the practitioners were not documenting the observations and interventions thus creating confusion and relaying little information to each other which compromised the quality of care for the patient. 

The Use of Communication Tools to Improve Patient Outcomes

Lafaa, Shay, & Winship (2017) suggest that effective communication can be used to reduce medical errors that arise through miscommunication between caregivers during transfer of patients as seen in the case of Vanessa. The handoff sign-out protocol allows practitioners to assess patient situations during handover to determine areas that need to be addressed (Kuo & Balakrishnan, 2013). This allows understanding of the challenges that the other practitioner faced and putting strategies in place to address them. Through complete, accurate and timely sharing of patient information, medical errors can be reduced to create increased care outcomes.

Throughout the case study, human errors developed as a result of poor communication between practitioners and lack of proper organizational guidelines. The role of policies in an organization is to communicate the approaches that practitioners need to take like documentation of clinical notes during observation to allow another practitioner to use the same notes for reference (Amutio-Kareaga, Garcia-Campayo, Delgado, Hermosilla, & Martinez-Taboada, 2017). Further, the doctor did not give clear instructions to the nurse on the care to be given to Vanessa after every required duration to monitor the changes in the patient like doing  GCS scan incase the situation became worse. From Westmead (2007) the following were findings from the inquiry into Vanessa’s death. There was poor communication between different practitioners that were working on the patient.

The prescriptions of the drugs given were not based on pharmaceutical standards like the maximum dose and the level of allergies.

Dr. Ismail was to work under supervision to demonstrate satisfactory performance which never happened.

Dr. Ismail violated the ethical code of prescription by not communicating to the nurses on proper dispensing of oxycodone and failing to document the instructions.

The observations on the patient were not documented at all times.

Vanesa died of respiratory arrest form depressant effect of opiate medication which was avoidable.

After the death of Vanessa, the Coroner asked for a holistic inquiry into the hospital and identify the errors and the reasons why the errors were repeating themselves and leading to tragic situations like the case of Vanesa (Westmead, 2007). This led to a professional and standards committee inquiry which is constitutionally mandated to hold an inquiry regarding the conduct in which a patient was handled by the Dr. in charge. The standards committee found professional issues in the work of Ismail and recommended the need for her to undergo clinical communication training to improve her competencies and be more professional in the field of practice. The fact that she had been placed on clinical supervision means that she needed proper training to on clinical processes to improve her abilities.

Case Analysis: The Vanessa Case

Other changes that took place in the hospital were institution of proper policies for guiding practitioners during clinical processes. One notable challenge that the facility witnessed in the case of Vanessa was lack of proper policies and procedures that practitioners need to follow. For example, documentation of clinical observations and medicines administered to patients can be critical in achieving the intended clinical outcomes. By instituting policies, then practitioners will be accountable to the clinical actions that they engage in. Further, management was required to offer training to all practitioners to equip them with clinical skills for response and handling different clinical outcomes. The fact that the death of Vanessa was as a result of several errors that were repeated from one level to another means that the hospital system lacked a proper framework for managing patients. The errors revolved mostly around the role that the RN plays in managing the condition of the patient and reporting deterioration. 

Freitas, Preto, & Nascimento (2017) argue that nurses are care givers thus spend more time with the patient than any other practitioner. By working with patients, nurses are required to monitor the progress and the way patients respond to medication or other therapeutic processes and share the information with physicians, doctors or any other concerned professionals. Registered nurses are supposed to use observation strategies to asses the clinical deterioration or improvements in the patient. Mok, Wang, & Liaw (2015) argue that nurses can monitor vital signs like shortness of breath, failing to respond to simple commands like calling their names and signs of increased pain to determine if the patient is improving or not. Further, Salmon & Young (2017) adds that doctors need to give specific instructions to the registered nurse on the expected responses and thus any signs that is against the expected signs means the patient is deteriorating and thus the need to report the matter.

According to Westmead (2007), the following are contributing factors that led to Vanessa’s death which could have been avoided.

Poor patient analysis diagnoses, documentation and record keeping of the patient’s progress to inform clinical decision making.

Failure to follow Dr. Little’s chart and administration of Dilantin.

Failure to communicate allergic concerns raised by Vanesa mother to other practitioners.

Failure by Dr. Ismail to identify that the patient was chattered for Panadeine Forte for referral.

Failure by Dr. Ismail to consult Dr. Little on the level of dosage increase in analgesia.

Findings and Recommendations

Failure to conduct neurological examination after every three hours as required.

Failure by of the nurse to consult with the doctor on the events that occurred from 1 am on 8/11/05.

The death of Vanessa led to an investigation on the facility and Dr. Ismail’s conduct about the death of the patient. Since the Coroner found so many errors that were repeated by the practitioners that led to the death of the patient. The investigation was supposed to address the circumstances that led to the death of the Vanessa since her death could have been avoided. By the fact that she died from complications related to drug overdose rather than the injury that she had, it means that somebody was supposed to take responsibility at one point in time.

The investigation on Dr. Ismail was based on the fact that she had been placed under clinical supervision where she was to work with the assistance of other practitioners to minimize medical errors. It means that her clinical duties were limited and she did not have the right to administer specialized medications unless under the assistance of another practitioner. 

Reprimanding of Dr. Ismail and an order for her to complete the clinical communication program for general practitioners from a cognitive institute to improve clinical communication abilities (Profesional Standards Committee Inquiry, 2009).

Implementation of policies for managing closed head injuries to ensure that such errors do not occur in future.

Introduction of new organizational policies that guide different responsibilities that practitioners need to take when handling patients.

Educating of staff on proper documentation and management of patients to ensure that patient information is properly captured to inform clinical decision making.

Develop record auditing strategies to ensure the level of documentation within the organization and how the established standards are being made.

Educate staff on use of electronic tools like radiological analysis of data to increase clinical decision making.

From the case study, it is evident that human failures of poor communication between practitioners caused the death. The death was avoidable since Vanessa died of respiratory arrest due to the depressant effect of opiate overdose. Despite having an allergic history of Dilantin, the concerns raised by her mother were not communicated to Dr. Little for advice. On the other hand, the dosage level of analgesia was not communicated to the nurses to determine the maximum amount that should be administered to the patient to avoid any side effects. What is seen in the case is a set of human errors that came as a result of poor communication between the practitioners who were handling the patient. The process was a team activity that required proper documentation and taking of clinical notes to allow every practitioner to understand medical interventions receives by the patient. However, this was the opposite since all the practitioners failed to document serious medical issues that the patient was facing thus leading to a series of mistakes that led to Vanessa’s death. From the analysis, she did not die from the injury that she had sustained but rather an overdose from a series human medical errors. The case of Vanessa should have mitigated or she had a better chance of surviving if there was clear communication among the practitioners. 



Amutio-Kareaga, A., Garcia-Campayo, J., Delgado, L. C., Hermosilla, D., & Martinez-Taboada, C. (2017). Improving Communication between Physicians and Their Patients through Mindfulness and Compassion-Based Strategies: A Narrative Review. Journal of Clinical Medicine, 6(33), 1-17. doi:i:10.3390/jcm603

Berman, A. C., & Chutka, D. S. (2016). Assessing effective physician-patient communication skills: “Are you listening to me, doc? Korean Journal of Medicine, 28(2), 243-249. doi:  10.3946/kjme.2016.21

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Mazurenko, O., Richter, J., Swanson-Kazley, A., & Ford, E. (2016). Examination of the relationship between management and clinician agreement on communication openness, teamwork, and patient satisfaction in the US hospitals. Journal of Hospital Administration, 5(4), 20-30. doi:10.5430/jha.v5n4p20

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