Five Team Behaviors that Stop Communication Failure in Health Care

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Ebola, a disease feared like the fictionalized ones in deadly virus movies, has recently come to the United States. Of course it was just a matter of time before an infected person arrived from West Africa where Ebola has been devastating, but our healthcare system was primed, we were told, by the CDC to care for Ebola patients and patients with other serious contagious diseases as well. Among the staff teams who were specifically trained in CDC protocols to handle Ebola was the one at the Texas Health Presbyterian Hospital ER in Dallas, where the first affected person was seen. The ER nurse, who first saw the patient, had a checklist which included a question about travel to West Africa for people who showed up with fever and abdominal pain, headaches and weakness. The patient who came in with similar symptoms answered that he’d been in Liberia recently, and the information was reportedly “entered into his electronic records”. The patient was also given blood tests for infections, but not for Ebola. And, compounding the issues, the patient was sent home with antibiotics which are not appropriate for viral infections. Those are the basic facts we’ve been told up till now.
So, where did the communication break down, when it should have alerted the entire staff to the potential seriousness of this patient’s illness? I believe the answer is: everywhere, at every touch point to the patient. But it was about more than information; it was about understanding the implications of the information the patient told the staff. From the first person to see this patient, to the nurse who did the initial intake interview, to the doctor who examined and prescribed antibiotics, each of these people is culpable. Communication needs to be inclusive, clear, on target and relevant to the “context of a situation”, so that the care and safety of patients, staff and others isn’t compromised. Some situations require that bells and whistles and sirens and red flags be raised – and in Dallas they should have been. The intake nurse entered information about the patient’s travel history into an electronic record but clearly that wasn’t enough.
Nurses are entrusted with making diagnoses based in their sphere of knowledge and practice. They don’t have to ask for empowerment, they have it. When I was being educated as an RN at University, it was drummed into my head that I was ultimately responsible for ensuring that the doctor had and understood all the information he needed to accurately assess or treat a patient. If there was a medication prescribed in error by the physician, I had to sound the alert, provide the correct information and even go so far as to refuse to administer it to the patient. I was also charged with making immediate decisions and taking action related to patient care.
With this patient’s travel information and symptoms, alarms should have gone off. The isolation precautions outlined by the CDC needed to have been followed immediately. The nurse should have made sure that the doctor was quickly alerted to the symptoms and travel history verbally, whether he had or hadn’t yet read the chart or made the connection between the information and its meaning. “Better safe than sorry” tests for the Ebola virus should have been ordered. I’ve read articles that fault the nurse or the doctor, and others that relieve any individual of blame by faulting the system or saying that protocol was followed. Apparently, reading information in a computerized chart is not enough. No, no. It’s the lack of human interaction, the failure of vital information being taken seriously, listening for understanding and transmitting the data between caregivers that was the culprit. And it was the lack of appropriate action based on that information by the professionals involved that permitted a breach of common sense and has put the public in jeopardy.
As an Organization Development Consultant, I work with hospital personnel to amplify teamwork, communication and timely decision making. If any of the caregivers in this situation, from intake to discharge, had interpreted the pertinent information and taken responsibility for appropriate actions, the hospital would not have discharged a sick patient with the possibility of transmitting this deadly virus to the community. Decisions to isolate and test this patient for Ebola could have been suggested by the nurse, ordered by the doctor and quickly set in motion.
Inter-professional team communication needs to trump all aspects of teamwork. Without it, lifesaving decisions can’t be made. Of all the pandemic possibilities, Ebola is the most fearsome because we have no vaccines or proven cures, but it is only one of the many infectious diseases that could endanger public health and are sure to show up in hospital emergency rooms.
How do we ensure against similar failures? These five team based behaviors are vital to the difference between public safety and the spread of a deadly virus and need to be done by all members of an ER team with each other and with patients:
1. Engage in knowledgeable observation, known as “situational awareness”
2. Ask the right questions, pay attention to the answers and understand the implications
3. Communicate relevant, on target information to the people who need to know
4. Make appropriate decisions based on information and
5. “Err on the side of caution”

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