Communicating with colleagues
Precise communication with the right degree of detail can make the difference between good patient care and an adverse event
Handovers on a busy night shift
Dr J notices that the patient is still in heart failure and from the notes, it is apparent that Dr A has not carried out any of the tasks he had agreed to do
Dr J is a busy SHO working on a medical night shift. He takes a call from an intern, Dr A, in the ED, who wants to refer an elderly patient who has come in with sudden breathlessness. Dr A has taken a history and examined the patient and diagnosed congestive heart failure.
Dr J agrees to admit the patient, but asks Dr A to investigate and treat the patient in the ED before transferring her to the acute assessment unit. Dr A agrees that he will give a diuretic, perform a chest x-ray and take the bloods before transferring her to the acute assessment unit.
Later in his shift, Dr J is asked to see an elderly female patient – it is the patient Dr A was referring. However, Dr J notices that the patient is still in heart failure and from the notes, it is apparent that Dr A has not carried out any of the tasks he had agreed to do.
After treating the patient, Dr J wants to clarify what happened, so he contacts Dr A. Dr A says he had not had time to perform the investigations as he was rushed off his feet and he forgot to tell Dr J. Dr J stresses upon him the importance of clear and concise communication with his colleagues, and of accurate handovers.
A case of mistaken identity
Dr S is on duty in the children’s area in ED. She has just seen Jack, a two-year-old child with a high temperature. She sits down to write his notes and takes the opportunity to ask one of the nurses to give Jack 180mg of paracetamol (appropriate for his weight). The nurse asks for it to be prescribed, but Dr S insists that she needs the ED card to write her notes, and the child is in the cubicle opposite the nursing station (she points to it), “you cannot miss him”, she says. The nurse agrees reluctantly and goes to get the medicine and Dr S concentrates on writing on the card.
The nurse walks into the cubicle and gives the child the paracetamol. Dr S finishes her writing and approaches the cubicle to find out that there is now a different child sitting there – Alex. She anxiously turns to the nurse and asks her if she has given the medication to the boy who is now in the cubicle, and she says “yes”.
Dr S informs Alex’s family of what has happened and explains that the paracetamol was not prescribed for their child. She apologises profusely. Luckily Alex is a bigger child, and has not taken any paracetamol recently, so no harm has been done. Dr S makes sure Jack gets his paracetamol, and fills in an incident form; she apologises to the nurse involved and they discuss what happened, and agree that it was an easily preventable mistake. Later that day Dr S discusses the incident with her consultant.