Communication, Communication, Communication

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Why is it so complicated when it comes to patient safety?
In real estate there is a common dictum about what most makes a property desirable – “location, location, location”. In healthcare there is also a dictum about what makes providing healthcare services so complicated – “communication, communication, communication”. Dys-communication, occurs so frequently and has so many nuances that it is often hard to fathom just how many opportunities there are for things to go wrong. What we say and how we say things to colleagues or patients and family members may lack accuracy and clarity resulting in lack of understanding and harm.
Communication challenges can arise whenever healthcare professionals speak to colleagues or staff or when healthcare professionals speak to patients. Perhaps we spend too much time speaking and not enough time listening or asking questions to assure communication is clear. Perhaps we do not actually hear what we say or how we say it so we do not understand how our message gets distorted. When we dys-communicate people may be harmed. Most of the time the harm is physical, but sometimes the harm is fear and anxiety; psychological harm. In this series of commentaries I plan to examine the range of communication difficulties that are pervasive in our profession.
Case Study: When conveying inaccurate information causes harm
A 60-year old woman presented to an emergency room with several hours’ history of protracted vomiting. Her past history was notable for gastro-esophageal reflux, well controlled with omeprazole. A week before presentation the patient had discontinued her anti-reflux medication abruptly, and on the morning of presentation she had taken some ibuprofen for a backache. Three hours later the vomiting began.
On examination, the patient was mildly dehydrated and had no focal abdominal findings. She was treated with intravenous fluids and anti-nausea medication, and after two hours felt much, much better. The ER physician was confident that her medication history probably explained her symptoms, i.e., she had medication withdrawal induced acid gastritis and reflux, but he ordered some lab work and a CT “just to be sure”. After four hours of observation the patient was feeling pretty well, her labs were fine and she was to be discharged home.
An ER physician, not the same one who started her evaluation as there had been a shift change, came to see the patient to discuss the CT findings and advised that her gallbladder was abnormal and characteristic of a “porcelain” gallbladder, a condition with widespread extensive calcification that is associated with about a 20% chance of malignancy. He was very forceful in his explanation and recommended that the patient see a surgeon very soon. “They like to take these out quickly.”
The next day the patient and her husband made arrangements for her to be seen by a general surgeon within one week and coincidently stopped by the hospital radiology department to see if they could obtain copies of the CT scan and the report. The report, surprisingly, did not mention anything about a porcelain gall bladder. The gall bladder appeared distorted to some extent and the possibility of gallstones was raised but there was no mention of anything really serious and there was a recommendation for an abdominal ultrasound if symptoms persisted.
When the patient saw the surgical consultant a week later, he advised that though gallstones might be present this was not certain, an ultrasound might be warranted, but as she was asymptomatic, a wait and see approach would be a reasonable option. He stated that the patient certainly did not have a “porcelain” gall bladder.
Where the ER physician got the idea the patient had a porcelain gallbladder was a mystery, and why he had conveyed the certainty of this diagnosis and the urgency to see a surgeon was not apparent.
This patient and her husband were harmed by dys-communication, in this case sharing of inaccurate information that led to anxiety, stress and social disruption. The ER physician’s incorrect interpretation of the CT scan, completely at variance with the official radiology report, and his comments, not supported by sufficient clinical evidence, resulted in considerable unnecessary distress, i.e. harm, for this patient and her husband. This patient’s harm, could and should have been avoided.
Lesson: Be careful what you say. Know what you know, know what you don’t know, and know how to convey the message!


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