October 2004 Bulletin

Patient safety tip

Communicate, communicate, say it again!

Patient safety depends on consistent, ongoing communication

By Robert L. Brooks, MD, PhD

Location,” goes the old bromide, “is the number one factor determining the value of real estate.” The number two and three factors? “Location, and location.”

In the same sense, if one were to ask several experts in the field of patient safety “What are the most important factors in protecting patients?”, the top three responses are likely to be “communication, communication, and communication.” Lawyers experienced in medical malpractice defense agree: Communication is the key to protecting patients from harm and avoiding lawsuits when the inevitable adverse outcome occurs.

The importance of communication errors as a source of inadvertent harm was recognized by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in its Patient Safety Goals established for hospitals. JCAHO emphasized the importance of system changes to minimize opportunities for misunderstanding. Nurses and physicians are now required to “repeat back,” or echo, all verbal and telephone orders. Further, the orders should be first written down and then “read back” to prevent lapses or faulty memory.

Communication safety tips

Five of the “Top 10 Tips” posted on the AAOS Patient Safety Web site involve clear communication. Two of the five emphasize good informed consent. Two others recommend calling patients before and immediately after surgery. The fifth, submitted by John Wickendon, MD, of Rockport, Maine, calls on patients to take a strong role in understanding and corroborating their own medication regimens.

“Patients,” wrote Dr. Wickendon, “when you are hospitalized, always know what medicines your doctor has ordered and always ask the dispensing nurse to tell you which medicine you are being given.”

Involving the patient or the family is one more layer of security to prevent errors.

JCAHO also recognized the practice recommended by Dr. Wickendon as a valuable principle for patient safety.

JCAHO has asked all American hospitals to distribute to patients a brochure titled “Speak Out.” This program encourages all patients to be actively involved in their care and safety. Practices such as knowing their medications and asking caregivers to wash their hands are specifically mentioned.

Orthopedic surgeons are trained to give careful and complete informed consent before all procedures. However, most of us continue to rely on our personal qualities and skills, tempered by experience, to make this communication effective. There is opportunity to improve communication by designing process changes that include the consent.

L. Pierce McCarty, MD, of Chestnut Hill, Mass., recommended an easy-to-remember checklist before surgery. “Be S.A.F.E. in the operating room. Sign your site. Antibiotics preoperatively. F is for InFormed consent. Embolism—take precautions.” Frederick Meyer, MD, of Mobile, Ala., combines the ideas of sign-your-site with informed consent. “In addition to marking the operative site,” wrote Dr. Meyer, “draw the incision on the patient as you explain the surgical procedure to him/her.”

Before and after surgery

Two other “Top 10” safety tips recommend communication in the peri-operative period. A. J. Yates, MD, of Rochester, N.Y., suggested “Call patients the afternoon or evening before elective surgery.” Kevin Smith, MD, of Seattle has a complementary recommendation: “Surgeons should call patients a day or two after their hospital discharge to see how they are doing.” Incorporating regular communications into our routine of care avoids possible errors of misunderstanding, detects any problems early and proactively and inspires confidence in our patients.

In my experience, night-out-surgery phone calls are quick, effective and memorable. Patients always remember that you cared.

Orthopaedics and its related industries have made huge technological advances in the last three decades. Many of our best surgeons are now applying the science of “human factors” engineering to complement their surgical virtuosity.

Commonly performed procedures are combined with seamless programs that begin when surgery is first contemplated. These programs educate and prepare the patient using multidisciplinary teams, manage the expectations of patients and their families, and continue through the recovery period until full function is achieved. The surgical experience becomes only the centerpiece of such integrated programs.

Patient satisfaction, quality outcomes and patient safety are all improved by systematically engaging in communication and education. Surgeons invariably report improved satisfaction as well. By integrating systematic communication tools into our care delivery, we again “turn the wrench” to improve patient safety.

Robert L. Brooks, MD, PhD, is a member of the AAOS Patient Safety Committee.

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