Communication for Patient Safety
Sam

Sam

Patient Safety Competencies

The overall goal of this exercise is to increase patient safety by enhancing health professions education. As you read on, we would like you to keep in mind the six domains of The Safety Competencies:

 

1.    Contribute to a Culture of Patient Safety.  Meaning a commitment to applying core patient safety knowledge, skills and attitudes to everyday work.

2.    Work in teams for Patient Safety. Working within interprofessional teams to optimize both patient safety and quality of care.

3.    Communicate Effectively for Patient Safety. Promoting patient saety through effective health care communication.

4.    Manage Safety Risks. Anticipating, recognizing and managing situations that place patients at risk.

5.    Optimize Human and Environmental Factors. Managing the relationship between individual and environmental characteristics in order to optimize patient safety.

6.    Recognize, Respond to and Disclose Adverse Events. Recognizing the occurrence of an adverse event or close call and responding effectively to mitigate harm to the patient, ensure disclosure, and prevent reoccurrence.

 

The story you are about to read is true, however the name and some of the details have been changed to protect Sam’s identify.

 

Sam - I’m not a prop in your play!

 

Sam sat at the cafeteria table with a huge cup of mint tea, and a large glass of water. She joked that her doctor had told her she could not afford to get dehydrated, as she needed to flush the remaining chemotherapy from her kidneys.  Sam’s story began back in the latter part of 2008.  Her journey was, like many of those diagnosed with cancer, a roller coaster ride made easier or more difficult by the people she encountered along the way.

 

Sam, an obviously intelligent 27 year-old began her story in the emergency room of the local hospital.  She had gone to hospital with chest pain, and as it turned out she had a cancerous tumour in her chest.  Prior to the hospital visit, Sam had noticed she was tired much of the time, and had lost weight.  She was attempting to hold down a new temporary job as an aesthetician, but had found her days agonizing due to chronic fatigue, weakness, dizziness and nausea. On what turned out to be her last day on the job, Sam could no longer stand up.  At the insistence of staff, she took herself to the emergency room of the local hospital, and it was here that her long journey as a cancer patient began. Sadly Sam’s memories were of being treated as an experiment as opposed to a patient.  She cited examples such as a nurse telling her ‘toughen up’ when she winced at having blood taken.  She was also told she was too thin and should ‘get more meat on her bones.’  It was unknown to either the patient or the nurse, that Sam was losing weight due to cancer.  Sam went on to talk about the time period she was in the ER, where she saw “thirty people” and felt like a “prop in an ER drama.”  She said she never knew who was who, as many of the medical staff did not properly introduce themselves. Sam said she was “clueless” about a possible diagnosis, and watched this “drama” unfold before her eyes, but never feeling like an active participant. Sam said she was alone throughout the examination process, in a “cold, white room with nothing in it except examination table and medication equipment.”  She said “no one suggested she phone her family or a friend”, no did they suggest a social worker.  In the telling of this story, Sam was reminded of several incidents that she found strange or difficult to understand. She remembered that one doctor raised his voice to her because when he “poked” her (feeling for the tumour) she wiggled due to discomfort.  Sam said she was told she “should be thankful” for the care she was receiving. She said that someone had come in with a ‘living will’ with the expectation she fill it out, and it was at this point Sam “lost it” and told the woman to leave her alone; after which she burst into tears. Sam also remembered an “intern” who came in to tell her there was a “partial diagnosis.”  She was baffled at this statement.  Finally when she got her diagnosis of cancer, she was alone in the same drab, cold room. The doctor who gave her the news told her she had to be admitted immediately. Then he left her alone. This doctor, according to Sam, seemed to realize that breaking such bad news to a young woman without any supports present had not been a good idea, and returned to ask if she would like to see someone.  She declined. Sam said she was too numb to think properly, and did not realize the full impact of what she had been told.  Sam said she had no idea that she could ask questions, so she  sat passively and watched a procession of medical professionals come to see her, and repeat many of the same procedures, and ask the same questions, over and over.  Sam at this point was becoming concerned about her dog who was home alone, and about her family.  She told one of the doctors that she couldn’t come in right away because she had a dog at home that needed to be taken out, and she had to phone her parents who lived a distance away.  Sam said the doctor was adamant that she stay in the hospital. According to Sam the doctor seemed to think she was refusing treatment, and he told her she was ‘mentally incompetent’ and insisted that she remain in the hospital. Eventually Sam was given permission to go home, as long as she returned four hours later. When Sam returned to the hospital, she was told that she really did not have to come back until the next morning.

When morning arrived Sam was admitted as an inpatient. One of the first things she had to do was get a PICC line and it was here she found her first compassionate doctor or technician, she wasn’t sure, who supported her.  He told her she was she was “doing awesome.”   Sam felt comfortable sharing some of her experiences from the previous day in emergency, and he advised her to look at each person’s identification tag, and if she did not feel comfortable she could refuse to see that person. He also told her there was no such thing as a partial diagnosis.

 

Sam was then taken to the inpatient floor where many other cancer patients were admitted. She said she met with a variety of nurses, most of whom were very supportive.  She also met a social worker who helped with emotional and psychological supports, as well as helping her look at income options.  Sam successfully went through her treatment and returned as an outpatient for a continuation of chemotherapy and radiation treatments.  During her radiation treatments, she did however encounter another medication problem. Sam had been given antibiotics for a possible infection from a doctor in the community.  She felt she needed to wait to take the medication until she saw her oncology doctor.  Luckily this had been a good decision, as the prescribed medication was contraindicated with the treatment she was receiving.

 

When asked to reflect on her hospital experience, and provide suggestions as to what she might want to improve Sam had several thoughts.  She said she did not know her rights (especially as a “young person”), and she should have been referred to a professional who could have guided her through the whole experience. She did not see anyone who could have explained possible side effects of the medication she was receiving, which would have reduced her anxiety dramatically, as she had reacted to various medications.  Sam also felt communication between the community nurse who followed up with her care, and the hospital could be improved. Sam said there were times for example when she had pain in her chest, the nurse did not check in with her doctor to consult to see if Sam should go into the hospital to get checked out.

 

 

1.

What safety competencies do you think came into play here. Note: for a more detailed explanation of the six safety competency domains go to:

www.patientsafetyinstitute.ca

2.

Could you see a role for a social worker, dietitian, nurse, physiotherapist, occupational therapist, pharmacist, volunteer, or any other health professional? If so, where would they have been useful in Sam’s case? Choose a safety competency that fits your answer.

3.

What did you think about the communication in this story? Which safety competency would you chose to illustrate your point?

4.

Sam was given a ‘partial diagnosis,’ which patient safety domain would fit best. You can choose more than one, if you think it fits.

 

 

Safety Competencies to think about: Perhaps some of the patient safety issues when looking at this patient’s story would include:

 

“Working in Teams”, there was a distinct role for a social worker in ER when patient told about cancer when she was alone; there appeared to be little communication among the various professionals involved in the assessment and care of this individual; conflicting information about admission procedures, time away from hospital, etc

 

“Communicate Effectively for Patient Safety,”  between hospital and community in order to provide a seamless model of care; was patient shown respect and empathy/were procedures explained clearly and adequately in ER –patient’s story suggests she did not receive empathic or informative treatment.

“Creating a Culture of Patient Safety” the term ‘partial diagnosis’ was not explained and staff gave opposing views about this, increasing patient’s confusion and anxiety...did the person who inserted the PICC line raise the issue of partial diagnosis with team in ER, for example. Staff did not encourage a questioning attitude from the patient or one another.

 

“Recognize, Respond to and Disclose Adverse Events” a pharmacist would have been of great assistance for patient when beginning chemotherapy treatment so as to reduce patient’s anxiety regarding chemo medications, and patient would have known to flag a nurse if she was being to feel side effects; patient luckily waited to take medication that was prescribed to her.