Chain of Command - MCIC Vermont Patient Safety Documents

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2 Healthcare Risk Control Failure to Pursue Physician Bedside Evaluation A 70-year-old female patient with asthma who was hospitalized for major depression on a psychiatric unit developed progressive respiratory difficulties leading to acute respiratory failure that necessitated intubation and admission to the intensive care unit (ICU). She ultimately recovered after several weeks of hospitalization and rehabilitation following discharge. Allegations in a liability suit brought by the patient included failure to monitor, failure to timely contact the physician, and failure to take aggressive action. The case was settled before trial by the hospital and the physician. The sequence of events is summarized below. • At 7 p.m. on the second day of her psychiatric admission, the patient developed shortness of breath and expiratory wheezing, unrelieved by her Proventil inhaler. Also, mild edema of the right ankle had increased significantly from earlier in the day. • At 7:30 p.m., the covering medical physician was notified and the patient was treated with a diuretic and a nebulizer, which were ineffective. • At 10:30 p.m., oxygen was applied and Ativan was administered, which were also ineffective, as the patient stated that she could not breathe. • At 11:30 p.m., the physician was notified and arterial blood gases (ABGs) were ordered, as were additional respiratory treatments, and then repeat ABGs. Initial ABGs showed hypercarbia and hypoxia, but following the respiratory treatments, the levels improved slightly. • Although tachypnic, the patient calmed down and rested between 1 and 3 a.m. • At 3:30 a.m., the patient again experienced respiratory distress and the physician was again notified. Sketchy documentation and missing records make it difficult to ascertain what, if any, interventions took place until another nursing entry an hour later, at 4:30 a.m., when the patient was described as being diaphoretic and having increased respiratory distress. • At 5:30 a.m., the physician was called again. The patient was taken to the emergency department where she was intubated during cardiopulmonary arrest, stabilized, and then transferred to the ICU. HRC Commentary: When the patient’s condition was clearly becoming worse and the physician did not come in to evaluate her, the psychiatric unit nurses and staff had a duty to aggressively pursue bedside medical evaluation. Additional calls to the physician were warranted in this case, as was utilization of the chain of command as necessary to obtain medical examination by a physician. Instead, the patient was allowed to remain in distress for several hours, which delayed appropriate management of her respiratory distress. The physician also under treated the patient at the time of the second notification at 11:30 a.m., when drug therapy (steroids, inhaled beta agonists, etc.) was indicated. • provide for patient advocacy in the institution, • support patient safety by maintaining the standard of care, and • support risk management by mitigating liability exposures. Chain of command should be used to affect a necessary intervention for a patient’s well-being if the responsible provider is delayed or is unable or unwilling to intervene. 5 Chain of command should also be used when the provider’s response or intervention is inappropriate to the degree of urgency dictated by the patient’s condition or when treatment is ineffective over time and the provider does not present to personally examine the patient. The scenario described in “Failure to Pursue Physician Bedside Evaluation” outlines the sequence of events in one case that demonstrates failure to use the chain of command. Communication, Culture, and Role Conflict Chain-of-command policies may be unused or underused for many reasons, including nursing staff’s reluctance for fear of causing trouble, a fear of the consequences of going over someone’s head, or a lack of knowledge and understanding of how to use the policies. 6 The involved caregivers should make the initial attempts to settle patient care conflicts through direct communication. But at times, this is more easily said than done. Difficulties in communication and collaboration between physicians and nurses have long been documented 7 and continue to be the subject of much study and debate. 8 Communication problems can plague physician-nurse relationships and negatively affect patient care. In a study of timely treatment of lower respiratory infections in nursing home residents, delays in treatment ©2004 ECRI. May be reproduced by member institution only for distribution within its own facility.
Risk and Quality Management Strategies 19 3 of acute infection were found to be partially rooted in a lack of confidence by physicians in the quality of nurses’ assessments, which stemmed from physicians’ dissatisfaction with the way nurses communicate information about the residents’ clinical status. 9 Another study of patient outcomes in intensive care units found that the greatest determinant of severity-adjusted death rates was how well nurses and physicians worked together in planning and providing patient care. 10 The need for teamwork and communication in healthcare was also addressed in the Institute of Medicine’s landmark 1999 report on errors in medicine. 11 Perhaps the worst type of communication breakdown occurs when a nurse or other health professional fails to provide the physician with important patient information because he or she believes it will not be addressed. Failure to inform the physician about a patient’s condition may breach professional practice standards, result in disciplinary action for failure to follow institutional policies, place the patient at risk of harm or result in actual harm, and constitute negligence. Perhaps the worst type of communication breakdown occurs when a nurse or other health professional fails to provide the physician with important patient information because he or she believes it will not be addressed. Hospital cultures that do not support teamwork and collaboration between disciplines, departments, and personnel present obstacles to safe patient care by inhibiting open communication and trust. 12 Traditional hospital hierarchies that place bedside caregivers at the bottom and physicians at the top can foster intolerance for nonphysicians’ input into plans of care, devalue the contribution of nurses and other healthcare workers, and allow the normalization of the use of inappropriate actions or words by those in authority. Alarmingly, this type of “culture of disrespect” was recently uncovered in U.S. hospitals through a survey conducted by the Institute for Safe Medication Practices (ISMP). The survey revealed that nurses, pharmacists, and other healthcare workers commonly reported intimidation and abuse. 13 Almost half of the ISMP survey respondents said that the “intimidating” behaviors of physicians and others had an effect on how they questioned or clarified potentially inappropriate medication orders. They either followed the order despite their concerns or asked another practitioner to question the order rather than interact with an intimidating prescriber. Clearly, a hospital environment that allows the use of condescending language, impatience with questions, and reluctance or refusal to answer telephone calls detracts from patient safety. Hospital managers and providers should consider correcting such an environment a high priority. Chain-of-command policies cannot be effective if the individuals who are expected to follow them feel uneasy about carrying out the steps that should take place even before invoking the chain of command — namely, communicating concerns about patient conditions, obtaining necessary medical orders and interventions, and questioning or clarifying potentially unsafe medical orders on behalf of patients. For more information on patient safety and communication, see the Risk Analysis “Communication” located elsewhere in your HRC System. Setting the Stage for Chain of Command Development of a new policy or revision of an existing policy on chain of command is ideally preceded by an assessment of the organization’s culture of safety. As noted above, a work environment in which intimidation is pervasive or where significant obstacles to frank communication exist is not conducive to a meaningful chain-ofcommand policy. Survey tools to assess the safety culture have been validated as useful in evaluating hospital staff perceptions of the ability to openly communicate and assert themselves in identifying unsafe patient care situations, work in teams, and report medical errors. 14 Safety culture surveys typically ask staff members to respond by agreeing or disagreeing with the types of sample statements listed below:* • Senior managers at my facility communicate to me that patient safety is a high priority. • Individuals are supported for reporting medical errors. • I work in an environment in which I can openly express my opinions about patient care. • The quality of communication between caregivers on my unit is a hinderance to safe care on my unit. • My organization has a clear process for handling disagreements with the safety of an order. * Sources for sample statements include Allina Medical Center’s patient safety culture survey, posted under “Sample Policies” at the HRC Members’ Web site (http://www.ecri.org); examples of questions asked on patient safety rounds in the box in “Improving patient safety: from rhetoric to reality,” in the October 2003 Risk Management Reporter; and the Institute for Safe Medication Practice (ISMP) Workplace Intimidation Survey, available from Internet at http://www.ismp.org/ Survey0311.asp. ©2004 ECRI. May be reproduced by member institution only for distribution within its own facility. September 2004
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Chain of Command - MCIC Vermont Patient Safety Documents

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