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Failures in Communication – “…things we don’t know we don’t know”

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I would like to address some egregious instances where communication of important facts simply never occurred, resulting in the potential for, or actual, catastrophic consequences.
A while back I assumed oversight of a hospital infection control program and committee. The committee met monthly to summarize hospital surveillance data regarding healthcare associated infections, antibiotic resistance patterns and the impact of community-based infection trends on hospital services. Since I was largely unfamiliar with the dynamics of this committee and the individual personalities of the participants, I decided to sit back and see how the meeting flowed without providing specific comment regarding reporting and analysis processes until I had observed the long-established workings of this group.
Every month the antibiotic resistance patterns of bacteria were discussed, with specific focus on MRSA (methicillin-resistant Staph aureus). At this point in time, MRSA was an organism most commonly associated with orthopedic care services and was most prominent in chronic care and rehabilitation nursing facilities, not acute care hospitals. You can imagine my surprise and alarm when the data revealed that 25% of Staph aureus culture isolates from this acute care hospital were MRSA, and that this pattern had been reported monthly for nine consecutive months. As a senior clinician, I had never been informed of this although I commonly treated patients with Staph aureus skin infections and cellulitis, and even a recent case of orbital cellulitis requiring operative intervention.
After the meeting, I held a private session in my office with the infection control officer, the head of the microbiology laboratory and the hospital’s chief public health officer. To my profound amazement and disappointment, none of them seemed to recognize the urgency of doing anything with the information at hand. Some of the processes of the committee were working well, reports received and summarized and filed, but the meaning of the reports escaped the comprehension of the committee members. I paused and then shared some carefully considered, yet very strong words with my staff. This kind of complacency was unacceptable and would not be tolerated in the future. Committee processes would change immediately!
While this group was still in my office, I called the local community public health authorities and laboratory directors of two other hospitals in our area to alert them of our MRSA issues, and not surprisingly learned that MRSA rates in these settings were less than 1.5 %, completely at variance with my hospital’s experience and more aligned with the patterns reported nationally.
I instructed the director of the microbiology laboratory to immediately investigate our testing procedures and to send any current or future presumed isolates of MRSA to an outside reference lab for confirmatory testing. Most important, I sent a personal email to hospital executives, all wards, clinics, remote settings and all members of the medical/surgical/dental professional staff alerting them of the findings of the infection control committee, with a recommendation for use of alternative antibiotics until such a time as the situation might be clarified. I then had the staff hand deliver the same message to the managers of every ward and clinic.
Within one week, the reference lab refuted the testing results of my hospital’s lab, which upon investigation had been found to be using outdated testing reagents. The hospital’s 20 most recent MRSA isolates were all, in fact, methicillin sensitive.
Fortunately, no one was harmed by this incident, but the key issue here was that the committee was functioning in isolation from the meaning of its work. There was a lack of committee leadership and committee “followership”. Complacency ruled instead of critical thinking! The committee lost sight of its key stakeholders, i.e., the patients we care for and the front-line clinicians who provide that care.
Similar instances of failures to communicate crucial information to appropriate authorities have recently received public notoriety, including an outbreak of highly virulent Carbapenem resistant Klebsiella pneumonia at a distinguished research hospital1 and a failure to report known instances of inadequate cleansing and sterilization of endoscopes resulting in infections due to Carbapenem-resistant Enterobacteriaceae2.
Processes controlled by individuals working in settings removed from the direct patient care environment contributed to serious harm and were complicated by the complacency of staff involved. Clinicians and communities were kept in the dark, patients were endangered and some harmed. We should have done, and can do, better. The use of automated triggers and bulletins are necessary and appropriate interventions, and individuals also must be held accountable.
We cannot know what we have not been told!
“There are known knowns. These are things we know that we know. There are known unknowns. That is to say, there are things that we know we don’t know. But there are also unknown unknowns. There are things we don’t know we don’t know.”
Donald Rumsfeld
Secretary of Defense, United States of America, 2001-2006
References
  • 1. Snitkin ES, et, al. Tracking a Hospital Outbreak of Carbapenem-Resistant Klebsiella pneumonia with Whole-Genome Sequencing. Sci Transl Med. 2012 Aug 22;4(148).
  • 2. Notes from the Field: New Delhi Metallo-β-Lactamase–Producing Escherichia coli Associated with Endoscopic Retrograde Cholangiopancreatography — Illinois, 2013. MMWR Weekly January 3, 2014; 62(51):1051-1051 (accessed at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6251a4.htm?s_cid=mm6251a4_w).
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