'Huddles,' timeouts improve ED safety

Communication among caregivers is always important, but never more so than in the emergency department. A collaboration among hospitals across the country and a leading malpractice insurer has produced several simple but effective ways to improve communication.

The goal of the collaboration was to find ways to improve patient safety and outcomes in the ED, says Dana Siegal, RN, CPHRM, director of patient safety services with CRICO Strategies, the patient safety and medical malpractice company in Cambridge, MA, owned by and serving the Harvard medical community.

According to medical malpractice data from Crico's database, emergency medicine is among the top five areas with the highest malpractice claims, and diagnostic failure is the number one cause of medical liability in this area, she says. The effort revealed that communications problems and information gaps between physicians and nurses were a primary driver of diagnostic failure in the ED, Siegal says.

"One of the greatest vulnerabilities that has developed in the medical world is that the two most critical providers of care, the physician and the nurse, have — in part because of production pressure and hugely because of technology — begun to work in parallel tracks in caring for a single patient," Siegal says. "We discovered that in the course of care physicians and nurses can go entire shifts without speaking to each other."

This lack of communication is an unintended consequence of the growing use of electronic medical records and other technology, Siegal says.

Missed or delayed diagnoses in the ED are the leading cause of malpractice liability in emergency medicine, Siegal notes. In 2010, Crico and RMF Strategies, the consulting arm of Crico, convened the Emergency Medicine Leadership Council (EMLC) to address this challenge. Applying comparative malpractice data and their own experience and expertise, the EMLC participants, who were representatives from the Harvard-affiliated hospitals and RMF Strategies client organizations, worked to identify the underlying factors that contribute to missed or delayed diagnoses and patient adverse events in the ED.

Siegal notes that while diagnosis-related missteps are often attributed to cognitive error on the part of the physician, the group identified communication problems and information gaps as present in many of the malpractice cases. The EMLC discovered that some element of missing information and/or gaps in communication among physicians and nurses were involved in nearly 80% of the cases studied. Specifically, physicians often were missing essential pieces of information at the time of decision making, which led to misdiagnosis.

"We've seen it clearly in the cases we studied," Siegal says. "Nurses had information that clearly physicians did not seem to include in the equation. Or physicians were drawing assumptions that, had they seen all the information, they couldn't possibly have drawn."

A decline in the patient's status also can be overlooked because of a reliance on technology, Siegal says. Vital signs often are recorded automatically by machines that document the signs to the medical record, she notes, but is anyone actually looking at the trend? If the signs are automatically recorded, does the doctor ever have a chance to ask the nurse what might have caused the change in vital signs?

"No one is saying that this technology is bad or doesn't offer tremendous benefits, but we are realizing that it can discourage some of the face-to-face conversations that are so crucial to good patient care," she says. "Our participants developed strategies to get people talking again, to have people stop, look each other in the eye for minute and say, 'Did you see that her blood pressure is up? Should we be concerned that his saturation level is down?'"