Every time you receive healthcare you place your life in the hands of a team of health professionals who want to make you better. The doctors, pharmacists, nurses and other professionals should work together to achieve health or alleviate suffering without committing harmful mistakes. This is the Hippocratic Oath: “First, do no harm.”
But, to work together and make you healthy, your health care team needs to communicate well.
When they fail to do this, the results can be devastating. I encountered a case where the hospital’s new computer system for managing medication orders led to patient errors.
YOUR HEALTH @ RISK
A quick story illustrates this: A doctor ordered a Heparin protocol for a patient that was clotting irregularly. These protocols consist of a weight based dose of Heparin dependent on certain lab values, but with a maximum dose not to be exceeded no matter how much the patient weighs.
Unfortunately, the new system no longer displayed the maximum dose information to the nurses who administered the drug. In this case, a particularly heavy patient was given 2.5 times as much as the maximum dose. Heparin therapy was stopped and then restarted later because of the incident. A few days later, after other complications developed, the patient died. It was unclear what role, if any, the original error played in the death. After all, the patient was very sick. But we do know two things for sure. First, the error should have never happened. Second, we would not be left to wonder how it affected the patient if it had not occurred in the first place.
The root of the problem was that medication orders did not appear the same way to the doctors, nurses, and pharmacists in the new computer system. In other words, the people who were supposed to work together to protect patients had a communication barrier that they did not even know about.
SO WHAT SHOULD YOU DO TO PROTECT YOURSELF?
To gauge and manage risk when you receive health care, ask your healthcare providers the following questions:
- How is your healthcare team communicating? (Handwritten orders? A computer system? Over the telephone?)
- How long have they been communicating this way? (Does it look like that they have worked out the bugs?)
- How long have the professionals on your team been working together? (Is the nurse new? The doctor? Have these particular people worked together on patients with a similar problem as yours?)
- Can you tell that they are on the same page in regard to your treatment plan? (Talk to each of the professionals and make sure their stories match up. If there are discrepancies, do you understand the source of the discrepancy? (i.e. new results, different fields of expertise?))
- Do you understand what they are doing and how it should help you? Have they explained in layperson’s language what they are doing? (They should be able to explain your care to you in a way you understand. If they can’t communicate well with you, how can they do so with each other?)
Your Health Shield: Communicate clearly your expectations and requirements, and demand that your providers do so as well.
Bio:
Thomas Lilley graduated Magna Cum Laude from the UNLV School of Nursing Bachelors of Science program. He also achieved Magna Cum Laude recognition during his J.D. work at Drexel University and his biology degree from UNLV. His unique experience includes clerical experience sorting thousands of reports on various patients, clinical experience as a student nurse, observation of mock trials of medical malpractice and other cases, and lay experience providing care for his parents and grandparents. His ability to examine problems from both provider and patient perspectives and recognize systemic breakdowns is informed by these experiences and provides the basis for https://insights.cermacademy.com/category/yourhealthrisk-thomas-lilley/.
Disclaimer:
Opinions and views shared in YourHealth@Risk are solely those of the author. These articles are intended for informational purposed only and should not be construed as individual health advice. You should see your primary care provider for specific information pertaining to your healthcare.