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Vol. 30 No. 5 September/October 2008
Gaps in Pediatric Clinician Communication
and Opportunities for Improvement
Donna M. Woods, Jane L. Holl, Denise B. Angst, Susan C. Echiverri, Daniel Johnson, David F. Soglin,
Gopal Srinivasan, Laura B. Amsden, Julia Barnathan, Teri Hason, Leonard Lamkin, Kevin B. Weiss
Patient safety is an important concern in healthcare and has received increased attention since
the 2000 publication of the Institute of Medicine
(IOM) report, To Err Is Human. Patient safety
issues contribute to morbidity and mortality
for all patient populations (Thomas et al., 2000).
Based on a conservative estimate, every year
70,000 children experience a patient safety event
serious enough to lead to an increased hospital
stay or disability at discharge. This represents
approximately 1 out of every 100 hospital admissions of children (Woods, Thomas, Holl, Altman,
& Brennan, 2004). It has been demonstrated that
children experience a different epidemiology of
patient safety risk (Miller, Elixhauser, & Zhan,
2003; Slonim, LaFleur, Ahmed, & Joseph , 2003;
Woods et al., 2004), yet research into the specific
contexts of risk or the development of specific
priorities for patient safety improvement in
pediatrics are still limited.
The Joint Commission, through its regulatory authority, asks accredited institutions to
submit all sentinel events (the most serious
and harmful patient safety events) to the Joint
Commission. These institutions reported that
70% of the sentinel events reported to the Joint
Commission involve breakdowns in communication between clinicians (Joint Commission,
n.d.). This finding focused attention on the
need to improve the reliability of clinicianto-clinician communication in healthcare to
improve patient safety. To date, little has been
done to redesign the delivery of medical care in
order to address the risks resulting from breakdowns in communication between clinicians,
and little investigation into the specific nature
of communication breakdowns in pediatrics
has been conducted.
Clinical communications between clinicians
(e.g., treatment orders, critical test result reports,
transfer instructions, handoffs) are a significant
part of providing healthcare (Hanna, Griswold,
Leape, & Bates, 2005; Poon & Haas, 2004). Given
that many of these communications are critical,
the reliability of such communications is essential to safe, high-quality healthcare (Sutcliffe,
Abstract: Teamwork and good communication are central to
the provision of high-quality care. in. A standardized focusgroup protocol was used. Analysis assessed emergent themes
of patient safety–related effective and problematic clinician
communication. Sixty-three focus groups were conducted
with clinicians from five Chicago Pediatric Patient Safety
Consortium hospitals. Effective and problematic clinician-toclinician communication themes were described in all focus
groups and at each participating hospital. Problematic communication contexts included the communication process
for orders, consultations, acuity assessment, management
of surgical and medical patients, and the discharge process.
Organizational policies and systems leading to patient safety
risk included a lack of clear responsibilities and expectations
for clinicians and for clinical communication and a lack of a
clear chain of responsibility for communication when hierarchical communication barriers affected safe patient care.
Results of this investigation highlighted gaps in pediatric
clinician communication and opportunities for improvement.
Lewton, & Rosenthal, 2004). Until recently,
the focus of attention related to communication in healthcare has been on communication
between the clinician and patient rather than
on the reliability of communication between
clinicians in the process of providing care.
It has become increasingly obvious that communication between clinicians during healthcare delivery (e.g., in orders for tests or medications, during transitions of care, among the
members of a care team) involves substantial
risks of disconnection and miscommunication,
resulting in patient safety risk that negatively
affects patient outcomes (National Transitions
of Care Coalition [NTOCC], 2008; Schiff, 2005;
Sutcliffe et al., 2004; Woods et al., 2005[AU:
PLS SPECIFY WHICH WOODS ET AL 2005;
THERE ARE 3 IN THE REFS]). The effectiveness of communications between clinicians in
healthcare has perhaps been taken for granted
because clinicians, being highly trained and
Key Words
adverse event
communication
medical errors
patient safety
pediatrics
safety
Journal for Healthcare Quality
Vol. 30, No. 3, pp. x–x
© 2007 National Association
for Healthcare Quality
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Journal for Healthcare Quality
skilled, are assumed to communicate effectively. Establishment and evaluation of communication systems to ensure effective and
reliable clinician communication are just now
beginning to be studied, developed, and implemented.
Communication in healthcare is a routine
and ever-present component of most clinical
tasks; it occurs in all clinical contexts, uses various methods, and can take many forms (Arora,
Johnson, Lovinger, Humphrey, & Meltzer, 2005;
Sutcliffe et al., 2004). A few examples include
resident sign-out, shift changes for nurses, communication of care plans, treatment orders, and
consultations about or communication of the
patient’s status to other members of the clinical
team.
Cognitive psychologists have long known
that errors in even routine tasks are particularly
likely to happen when individuals are working
in suboptimal conditions (Norman, 1988). In
the healthcare environment many examples of
these conditions exist. For example, sleep deprivation, distractions, emotional preoccupations,
and overwork are all a part of the current medical care culture, and all predispose capable clinicians to make errors (Carayon, 2007; Morray,
1994). In a typical hospital, understaffing, conflicting demands, distractions, and other errorfacilitating conditions are the norm (Carayon;
Hickam et al., 2003[AU: THIS CITATION
IS NOT IN THE REFERENCES. PLS ADD
THERE OR DELETE HERE]). Therefore, it is
critical to develop and implement processes
and systems that support reliable and robust
communication between clinicians, reduce the
occurrence of inevitable errors in the processes
of clinical communication, and will make the
occurrence of misconnections more detectable
in order to mitigate the impact when they do
occur (Greenberg et al., 2007; Stebbing, Wong,
Kaushal, & Jaffe, 2007).
This study was designed to investigate the
nature of effective and problematic clinician
communication in pediatric hospital-based settings.
Methods
The Chicago Pediatric Patient Safety
Consortium
The Chicago Pediatric Patient Safety Consortium
(Chicago Pediatric Consortium) was established
as an initiative of the Chicago Patient Safety
Forum, a program of the IOM–Chicago, to
conduct research on pediatric patient safety.
The Chicago Pediatric Consortium consists of
five Chicago area hospitals: Advocate Hope
Children’s Hospital, Advocate Lutheran General
Children’s Hospital, Children’s Memorial
Hospital, John H. Stroger Jr. Hospital of Cook
County, and Mount Sinai Children’s Hospital.
Annually, 46,202 pediatric patient admissions
are made to Chicago Pediatric Consortium hospitals. The Chicago Pediatric Consortium offers
a sufficiently large and varied population of
pediatric patients for the research findings to be
generalizable, to be able to provide information
about different pediatric hospital settings (e.g.,
teaching hospital, community hospital, freestanding children’s hospitals, general hospitals,
urban hospitals, suburban hospitals) and ensure
sufficient confidentiality protection to the participating institutions.
This study was approved by the institutional
review board (IRB) of Northwestern University
and through the IRBs of each of the participating hospitals.
Data Collection
Data collection for this study consisted of focus
groups composed of hospital-based pediatric
clinicians providing medical care in the five
Chicago Pediatric Consortium hospitals. Focus
groups are part of a qualitative research methodology used to provide insight related to a
question or set of questions (Morgan, 1997).
Focus groups have been shown to be an effective method for identification and understanding of systemic patient safety risks (Woods,
Holl, Ogata, & Magoon, 2005). Clinicians participating in the focus groups in this study
included attending physicians, residents, midwives, nurses, pharmacists, transport teams,
and respiratory therapists currently involved
in the delivery of pediatric patient care in the
five Chicago Pediatric Consortium hospitals.
Focus groups were convened by profession and
professional level (nurse managers, staff nurses,
attending physicians, fellows, resident physicians, etc.) and by discipline (neurology, surgery, emergency, medicine, etc.). Clinicians were
selected on the basis of their service, profession,
and professional level (e.g., a group of neurology attending physicians, a group of neurology
residents and fellows or nurses from the pediatric intensive care unit). This purposeful data
collection strategy was intended to enhance the
participants’ comfort level and willingness to
speak freely about their experience of commu-
Vol. 30 No. 5 September/October 2008
Table 1. Number of Focus Group Participants by Clinician Type
Clinician Type
Number of Focus Group Participants
Attending physicians
66
Residents and fellows
70
Nurses
107
Nurse managers
12
Other (e.g. respiratory therapists, transport team
members, pharmacy, and imaging technicians)
19
Total
nication in the course of delivering healthcare
to pediatric patients.
The 90-minute focus-group sessions were
conducted using a standardized protocol and
were audiotaped and transcribed verbatim.
Trained focus-group facilitators conducted the
sessions. The number of focus groups was
determined by saturation, the point at which
additional data collection no longer generates
new understanding (Strauss & Corbin, 1998).
Focus-group discussions were confidential.
The transcriptions contained no identifiable
information about patients, clinicians, or institutions.
Analysis and Interpretation of Data
The initial focus-group transcripts were
reviewed by two investigators (Donna Woods
and Jane Holl) to inductively develop codes
for themes of both effective and problematic
communication using the constant comparative method (Creswell, 1994). Each code was
defined. These themes were refined through
review of the remaining focus-group transcripts
across all of the Chicago Pediatric Consortium
investigators. The focus-group transcripts and
the classification taxonomy of patient safety–
related effective and problematic communication were entered into the analytic software
ATLAS.ti to code the data and conduct the
analysis.
The reliability of the investigators’ coding
using this classification was assessed through
initial independent coding of each transcribed
focus group by at least two independent
reviewers. The coded transcripts were then
reviewed, and when discrepancies occurred,
reconciliation was finalized through consensus, according to the code definitions and
the transcript language. An additional crossinstitutional reviewer also reviewed four or
five transcripts per institution to further ensure
consistency of the coding across the Chicago
274
Pediatric Consortium.
Results
In all, 63 focus groups were conducted, which
included a total of 274 clinicians. The distribution of clinicians by type is shown in Table 1.
The mean number of clinicians per focus group
was 4.
Clinicians across professions and professional levels, in all of the focus groups, and at
all of the participating institutions described
patient-safety-related effective and problematic
communication.
For effective communication, 59 themes and
subthemes were identified, and for problematic
communication, 123 themes and subthemes
were identified. We organized these themes
of effective and problematic communication
into primary categories related to methods of
communication, contexts of communication,
and organizational systems and policies for
communication.
Effective Communication
Table 2 provides a frequency distribution of the
themes identified for effective communication
related to patient safety, across all participating
institutions. Clinicians in all of the participating institutions described effective methods,
contexts, and clinical organization. The methods
described included rounds as a direct in-person
method for communication. Clinical rounds
were described as effective when they were
scheduled and structured and when all key
members were present. Indirect communication methods described as effective included
well-designed clinical databases and technical
communication tools such as telephones, text
pagers, and personal digital assistants (PDAs).
Features of electronic clinical databases that
were described as effective included summary
lists of orders, medications, laboratory studies and results, consultations, standardized
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Journal for Healthcare Quality
Table 2. Frequency
Distribution
Primaryand
Effective
Communication
lists, and
accessibleofinpatient
outpatient
effectivenessThemes
of rounds as a method for cliniNumber ofcal
Focus
Focus Groups
Institutions
records.
communication
across the team
degraded
Groups
(%)members were not
(%)present.
Effective communication contexts included
quickly if all key
team culture and the specific composition of 63Problematic indirect
Effective Communications*
100 communication
100methods
the pediatric clinical team, which could con- included handwritten, typed, or hard-copy
Methods
Effective methods*
63
100
100
tribute to effective communication and support clinical documents. These were described as
Direct in-person communication*
59
94
100
improved patient safety. Effective team culture cumbersome, illegible, and not available in
Rounds
39
62
100 needed.
was most often described as consisting of posi- many situations in which they were
Clinical conferences
17 were described
100as probtive respectful
relationships within a service or 11Electronic databases
teaching
situations,
not
unit orOther
positive
respectful
relationships
existing 11lematic when these
systems
were
fragmented
17
80
rounds services or units. Specific addi- or difficult to navigate through and when
across different
Indirect
89
tions
to thecommunication*
pediatric clinical team considered to 56they did not communicate
well 100
with each
Telephones
34
54
improve the safety of communication included other. Problematic communication100
was also
Electronicadvanced
clinical databases
49 of telephones, text
100 pagers,
pharmacists,
practice nurses, hospi- 31described in the use
talists,
and atext-pagers,
pediatric surgical
Pagers,
PDAs liaison. Each of 28and PDAs.
44
100
theseStandardized
additions to
the
pediatric
clinical
team
Communication
that
was
described
lists, forms
24
38
100 as probwas
described
as
enhancing
effectiveness
by
lematic
in
the
context
category
included
situContext
Contexts of communication*
63
100
100
providing
pediatric
clinical
expertise
and
assisations
when
communication
occurred
across
Team culture
61
97
100
tance with coordinating care.
transitions, when there was insufficient staffing
Organization of clinical team
46
73
100
Effective clinical organization included orga- for the volume and acuity of patients, when the
Individual
Initiative
31
49
100pediatric
nizational clarity through policies, protocols, available clinicians lacked sufficient
Clinical
Policies
and
systems
to
enhance
and guidelines that would make explicit clini- 53medical knowledge,
team
84 when a problematic
100
Organization
communication*
cians’
responsibilities
and
expectations
regardculture
existed,
and
when
there
was
a
lack
of
Responsibilities and expectations for
65 responsibilities
100
ingclinicians
clinical communication and provide a clear 41execution of clinician
related to
clinical
of responsibility” to address 38communication. Additional
problematic
comChain of“chain
responsibility
60
100
hierarchical
barriers
to
communication
and
munication
contexts
included
the
communiCommunication about errors and
16
80
enable
knowledge
to supersede rank in critical 10cation process for
orders, consultations,
and
patient
safety
care
management
situations. A quotation from 8acuity assessment;
of
Standardized
orientation
13 and the management
80
aIncentives
focus group
participant
provides
an
example
surgical
and
medical
patients
and
the
process
to enhance communication
2
3
20
of how a clear chain of responsibility is thought of discharge.
Leadership agreement
2
3
40
to be effective:
Organizational policies and systems related
Note. PDAs = personal digital assistants.
to
problematic communication were a mirIf itwith
is an
issue to
with
a resident
. . I
*Includes all focus groups
references
this theme
and its.subthemes.
ror
image of those described as effective. The
would discuss a patient with a resident
clinical
organization category contains concerns
and, if I am still not happy, [or still not]
regarding
to patient safety risk including a
satisfied that they have decided the right
lack of clear responsibilities and expectations
thing or if I don’t understand where they
are coming from, I can call the attending
for clinicians and for clinical communication
(MD), and if there are still issues, the
and a lack of a clear chain of responsibility.
staff therapist can involve the clinical
Regarding the chain of responsibility, several
team leader. The clinical team leader can
specific problems were described as leading
involve our manager.
to problematic communication: (1) the role of
the teaching facility, where trainees who sometimes had minimal pediatric clinical experience
Problematic Communication
Table 3 provides a frequency distribution of were responsible for patient care management
the themes identified for problematic com- at the bedside and were communicating with
munication related to patient safety, across all supervisors frequently in remote locations and
participating institutions. Clinicians in all of the disregarding the concerns of experienced pediparticipating institutions described problem- atric nursing clinicians; (2) an ineffectively
atic methods, contexts, and clinical organization applied chain of responsibility; (3) the lack of
an explicit system or policy detailing the chain
related to patient safety.
Methods described as problematic included of responsibility; and (4) the lack of identificadirect in-person communication in the con- tion of clinicians at each level of the chain of
text of rounds, particularly when all key team responsibility (not knowing whom to call and
members were not present or when clinicians how to proceed if it appeared that a trainee’s
were not available for communication. The patient assessment and communication of the
Vol. 30 No. 5 September/October 2008
Table 3. Frequency Distribution of Primary Problematic Communication Themes
Number of
Focus Groups
Focus Groups
(%)
Institutions
(%)
Problematic Communication
63
100
100
Methods
Problematic methods*
60
95
100
Direct, in-person communications*
45
71
100
Rounds
Availability of clinicians
28
24
44
38
100
100
Indirect communication*
Handwritten, typed, or
hard-copy documents
50
39
79
62
100
100
Electronic databases
Telephones (cellular or land line)
Pagers, text pagers, PDAs
Computerized physician order
entry (CPOE)
Walkie-talkies
Overhead pages
27
22
18
13
43
35
29
21
100
100
80
80
2
2
3
3
20
40
Problematic contexts of communication*
Clinical team*
Staffing
Team culture
62
62
56
56
98
98
89
89
100
100
100
100
Problematic execution of clinical
responsibilities and expectations
56
89
100
Communication during transitions of care
Acuity assessment
Orders
Consultations
Management of surgical patients
Management of medical patients
Discharge
Language barriers
60
40
56
42
38
36
24
10
95
63
89
67
60
57
35
16
100
100
100
100
100
100
100
80
Clinical organization*
Lack of organization policy/guideline
62
58
98
92
100
100
Chain of responsibility
46
73
100
Communication about errors
Equipment and technological devices
Confidentiality issues
20
14
4
32
22
6
100
80
60
Context
Clinical
Organization
Note. PDAs = personal digital assistants.
*Includes all focus groups with references to this theme and its subthemes.
patient’s status were inaccurate).
Discussion
This study confirms and extends prior work that
presents clinician-to-clinician communication as
a major patient safety challenge that exists in
many forms and permutations. Through focus
groups of frontline clinicians describing their
experience of communication in healthcare, we
were able to uncover in candid detail how these
challenges are experienced in the everyday
practices of clinicians across disciplines and
across pediatric healthcare environments.
Problematic and effective communication
methods, contexts, and clinical organization
related to patient safety were identified in 100%
of the focus groups, suggesting that communication problems are ubiquitous but that some
effective methods from which to draw potential
improvement opportunities are already avail-
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Journal for Healthcare Quality
able. Clinicians described the nuanced organization of communication in healthcare, and
they described the ways in which particular
communication methods, contexts, and patterns of clinical organization were effective, as
well as the features that degraded their effectiveness and led to problems in the provision of
reliable communication and safe care.
The organization and environment in which
pediatric care is delivered has a significant
impact on clinician-to-clinician communication in the life-critical practice of medicine that
leads to patient safety risks. In many of the participating institutions, problems arose related
to the lack of clearly defined expectations and
processes in clinician-to-clinician communication, especially when the communication
crossed disciplines, professional levels, units,
or departments. Although many clinicians did
report the existence of a chain of responsibility
when problems arose, in practice, these were
poorly communicated, ignored, or unsupported by senior clinicians or administrators.
The need to increase the awareness of the
problems involved in clinical communication in
healthcare and develop methods for improvement is therefore critical (NTOCC, 2008).
Rounds
The conducting of rounds is an old standard
of medical care communication and teaching.
In all of the participating institutions, rounds
were described as both an effective method of
communication (62% of focus groups) and a
problematic method of communication (44%
of focus groups). Clinicians described rounds
as an effective method of communication for
several reasons. One clinician summed this up
nicely:
I think rounds are reasonably efficient. . .
. So you gather information, you go into
the rooms, and you have an opportunity to
actually confirm whether everything you
have heard is exactly as it is or not.
Rounds brings the teams together face to
face in a familiar format where clinicians have
come prepared and have the opportunity to
evaluate and confirm the accuracy of the information presented. Clinicians articulated the
features of effective rounds: they are scheduled,
structured, and of a set duration, and all key
members are present.
The effectiveness of rounds, however, was
described as degrading rapidly when participa-
tion was fragmented; when all key team members were not present to provide input, receive
information, or discuss patients’ daily care
plans; when nursing input was not included;
and when rounds were inconsistently scheduled. The results of this study provide criteria
for designing effective rounds and corroborates
the work by Thompson et al. (2005) on methods
for establishing daily goals.
Electronic Databases
As in the case of rounds, clinicians of all participating professions and professional levels
found that electronic clinical databases hold
a lot of promise (49% of focus groups), but in
their current form have considerable drawbacks
(43% of focus groups). Problems described
included the current fragmented organization
and the lack of interoperability of various electronic systems. Frustrations were expressed
about the discrepancy between the potential
for systems—systems that are clearly organized
and navigable, that support clinical thinking,
and in which information is easily accessible
in comparison—and the current state of most
electronic systems. In most institutions, the current generation of electronic clinical databases
cannot communicate information across inpatient and outpatient settings or across facilities.
These systems have not been designed with the
perspective of the clinician user in mind or contoured to meet the workflow needs of the clinician user, leading at times to critical delays or
interruptions in clinical tasks. At times clinicians
described extraordinary work-arounds to meet
critical clinical task demands that were blocked
by the current organization of electronic systems. These systems did address the legibility
problems of handwritten notes. However, computer availability and the need for establishing
communication passwords for secure access
created new organizational requirements and
demands that have not yet been satisfied for
smooth application and use of these systems.
Team Culture
Team culture was a significant factor that promoted effective clinician-to-clinician communication. Positive, respectful team culture was
identified as a significant contributor to effective
communication (97% of focus groups). Across
all of the participating institutions, adversarial,
disrespectful team culture—with hierarchical
barriers to communication that did not include
key team members and in which assumptions
Vol. 30 No. 5 September/October 2008
were made about clinical tasks or information—
led frequently to problematic communication
(89% of focus groups). When team culture
was cited as an important tool for facilitating
effective clinician communication, focus group
members identified respect as a key component
to successful communication. Unfortunately,
clinicians across all of the participating institutions and in most of the focus groups described
team communication as frequently adversarial and disrespectful (67% of focus groups).
Hierarchical barriers to communication also
played an important role (49% of focus groups)
and led to the withholding of significant clinical
information and to the ignoring or disregarding
of important clinical information. Although not
a systematic intervention, the individual initiative of clinicians was described as a method for
overcoming these barriers.
Transitions
Transitions have been identified in the literature
as a context of risk in healthcare. These risks
were described by clinicians in this study as
well. Clinicians described the many types of
transitions that occur in the course of medical
care and the risks that are frequently associated
with them.
In our analysis we categorized the types of
transitions as clinician change (shift change
for nurses, resident sign-out, attending physician’s change of service), patient change of
service, patient change of unit, intrainstitutional transport (e.g., a patient being brought
to imaging for a diagnostic test), and interinstitutional transport. A primary finding from
this study was the extraordinary complexity of
transitions in healthcare environments. To date,
improvement of communication in transitions
has been focused on unilateral transitions from
one clinician to another clinician. We found
that although this work is important, it does
not address the complexity of many transitions
that occur.
We found, for example, that in a “simple”
transition from the emergency department (ED)
to the floor, multiple transitions occur, on multiple levels. The patient is changing units (from
the ED to the floor unit); the patient is changing
service (from the ED service to the floor service); clinicians are changing (attending physicians, residents or fellows, nurses). This simple
transition can be even further complicated by
the timing of the transition. For example, the
ED nurse may transition care to the receiving
floor nurse, whose shift then ends before he or
she receives the patient, and the receiving nurse
then transitions care to still another nurse. The
same level of complexity could also occur with
the ED and floor residents.
Interfacility transport adds another layer of
complexity to the transition communication.
In Emergency Care for Children: Growing Pains,
the IOM (2006) reported that the vast majority
of pediatric hospital visits are made to general
hospitals that treat both adults and children,
that only about 23% of EDs have a pediatric
emergency physician on staff, and that most
EDs lack basic pediatric equipment and supplies essential for emergency medical care.
To truly improve the reliability of communication across transitions in healthcare, the
effect of the increasingly complex transitions of
care will require further study, and additional
improvement strategies will need to be developed.
Orders
Problematic communication related to orders
was described as taking several forms: incorrect orders, incomplete or unperformed orders,
conflicting orders, and orders that were not
communicated or documented. In this study,
the concern expressed most frequently related
to orders that were not communicated or performed. An additional source of described risk
was the problem of conflicting orders given by
multiple clinicians on the same service (e.g.,
orders for different medications or medication
regimens) or dramatically changed plans for
case management (e.g., preparation for surgery
vs. discharge to home). More problematic was
that physicians were frequently unaware of the
conflicting management orders, which resulted
in the front line—nurses and trainee physicians—being left to reconcile management.
Consultations
Problems with consultations were frequently
described (67% of focus groups). The accessibility and timeliness of consultations was described
by clinicians as the most frequent patient safety–
related problem associated with consultations.
This finding is important because consultations
were also described as an effective method to
give needed pediatric or subspecialty clinical
information to the medical team. Improving
accessibility and timeliness of consultations can
provide healthcare workers the necessary clinical knowledge needed to effectively manage a
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Journal for Healthcare Quality
child’s care. A frequent contributor to the lack of
accessible and timely consultations was inaccessible or inaccurate on-call lists. However, increasing the ability to easily identify the appropriate
clinician on a service to contact for a consultation was described as a way to support effective
communication and systemically improve the
consultative process. Furthermore, problems
of accessibility and timeliness of consultations
were reported as being more problematic on
nights and weekends.
Participants described a lack of standard and
systematic methods for acknowledging, following up, and providing or receiving feedback for
a consultation. Incorporation of a process for
“closing the loop” in consultation communication would improve the reliability of consultation communication and leave less room for
error.
Pediatric Priorities
Participants described areas of concern that
had particular applicability to pediatric medical care, that involve high risk, and that are
underlying factors deserving attention as priorities for pediatric patient safety improvement.
These problematic issues arise either from the
differences presented by children to healthcare
delivery—“child specific factors” (Woods, Holl,
Mehra, et al., 2005)—or from structural differences that exist in the organization of pediatric
medical care. We called these problematic communication themes leading to patient safety risk
in pediatric healthcare pediatric priorities.
Two pediatric priority areas are described:
clinicians’ pediatric knowledge and experience
and pediatric acuity assessment.
Clinicians’ Pediatric Knowledge and
Experience
It is accepted, although the observation is
described as worrisome by clinicians, that many
clinicians caring for pediatric patients do not
have pediatric training or training in a specific
pediatric subspecialty in which they are providing care. This knowledge and experience
gap places clinicians at the bedside who do not
have the requisite pediatric knowledge and
experience to sufficiently and effectively manage the care of pediatric patients and “may not
know what they don’t know.” Communication
becomes unreliable when the meaning, significance, relevance, and priority of clinical information are uncertain. Miscommunications and
erroneous conclusions can result. This issue was
described across all of the participating institutions and by all clinician groups. The structural
contributors to this problem are common across
pediatric hospitals, and many work-arounds
and idiosyncratic arrangements were described
to address the risks resulting from this challenge in the organization of pediatric care. Three
particular contexts were described in this study
where the lack of a pediatric knowledge base
led to patient safety risk:
1. Surgical residents. Rotating through a
pediatric surgical service, surgical residents, who by design may not have
had much or any pediatric training, are
responsible for the management of pediatric surgical issues as well as pediatric comorbid medical conditions (most
children admitted for surgery have
comorbid medical conditions, because
uncomplicated surgeries are now frequently performed in an ambulatory
setting). These residents were frequently
described as “not knowing what they
don’t know.” The variations in normal
signs and symptoms and in the size,
weight, and morphology of pediatric
patients, which are different from those
of adults, lead to management challenges and problematic patient safety
events. Children are also qualitatively
different in their presentation and needs
for management (Woods et al., 2005[AU:
PLS SPECIFY WHICH WOODS ET AL
2005; THERE ARE 3 IN THE REFS]).
These differences in children at a time of
a crisis and high acuity create formidable
challenges for clinicians lacking pediatric training. [AU: NEXT SENTENCE
WAS MOVED FROM ABOVE.]Surgical
residents are also charged with leading
pediatric trauma teams, but at the same
time, they have significant additional and
competing training responsibilities in the
operating suite, limiting their availability
at the bedside for managing both the
surgical and the medical conditions of
pediatric patients. One focus-group participant observed,
They [surgical residents] do not know
how to calculate calories on a child, they
do not know what the differences in the
formulas are, and they would not have any
way of knowing.
2. Experienced physicians: Most emergency
rooms do not have pediatric emergency
Vol. 30 No. 5 September/October 2008
medicine physicians on their staff, and it
is not uncommon for pediatric patients
to be assessed by non-pediatric-trained
clinicians and prepared for transport,
as was described in the focus groups of
this study and also described in the IOM
(2006) report Emergency Care for Children:
Growing Pains. The communication was
described as problematic in these situations and as leading to patient safety risk.
One focus-group participant remarked,
I have seen multiple cases of let’s say an
early phase of shock that was missed, and
that if it would have been caught earlier,
the therapy would have been much more
effective than being caught in a later
phase.
3.
Nursing: Concern was expressed about
experienced nurses with minimal or no
pediatric training who float onto a pediatric unit or experienced pediatric nurses
who float onto a subspecialty service’s
unit for which they have had little or
no training or experience, because they
were needed on those units. Pediatric
subspecialties frequently have specific
protocols, requirements, and priorities
that are unique to that subspecialty.
Nurses who have general pediatric
experience but lack specific subspecialty
knowledge and experience may also
“not know what they don’t know” about
care in that subspecialty. This situation
was described as contributing to misunderstanding certain clinical signs or
symptoms or in misprioritizing order
completion. The need for nurses to provide care, in a time of shortage, leads
institutions to assign nurses without
specific pediatric training or without
specific subspecialty experience. One
focus-group participant spoke of the
case of a 7-year-old girl with new-onset
diabetes:
What happens is these kids are at risk if the
labs change a lot. The labs were ordered,
but they weren’t drawn on time at the
bedside. The patient ended up having
mental status changes. It was someone
(the nurse) who was not seasoned in
taking care of pediatric patients and did
not appreciate the seriousness of what
this could be—just thinking this child is
a diabetic, and, okay, we have to manage
these things, but not being aware of the
serious consequences of why these things
needed to be done right away in this case.
Development of systems and methods to
accommodate these vulnerabilities is necessary.
Specific additions to the composition of the
pediatric clinical team were described as one
method for addressing these aspects of problematic communication in pediatric medical
care. In some cases, the addition of pediatrictrained advanced practice nurses, hospitalists,
or pediatric pharmacists, or the addition of a
pediatric surgical liaison to the clinical team,
was experienced as addressing some of the
issues generated by these problems. Further
study of the impact of these additions to the
pediatric team composition is needed.
Acuity Assessment
The problem of clinicians’ “not knowing what
they don’t know” was described as affecting
clinicians’ ability to accurately assess the status
of pediatric patients, to recognize signs and
symptoms of clinical status change and increasing acuity, and to adequately present the status
of a patient. The lack of recognition of signs of
clinical deterioration or instability is a high-risk
problem in pediatrics, and the severity of consequences resulting from events in which clear
signs of clinical deterioration or clinical instability are carefully watched but unrecognized
is high. The knowledge and experience gaps
described in this article contribute to the problem, but there are additional contributing issues
such as problematic hierarchical communications structures in healthcare. Unheeded concerns of subordinate clinicians were described,
and the methods described for addressing this
issue related to taking individual initiative
and learning to move to the next level in the
chain of responsibility. Workers in aviation and
other life-critical high-reliability industries have
found that decision making and action are best
assigned to those members of the team with the
best information and knowledge, regardless
of their rank. In healthcare carrying out these
principles must become a required responsibility, much as a surgical time-out is required and
is not the idiosyncratic action of a plucky clinician. These high-risk, life-critical, and socially
complicated situations can be further improved
by establishing clear, agreed-upon, age-groupbased criteria that are posted. Also needed
are required methods to seek help and further
assessment, such as a clear chain of responsibility, and building-alert tools with effective criteria
51
52
Journal for Healthcare Quality
and a required response embedded in an electronic pediatric early warning system (PEWS)
(Duncan, Hutchinson, & Parshuram, 2006).
Learning About Communication Risks
Related to Patient Safety
The focus-group qualitative methodology provides an effective means for understanding
systemic and underlying risks related to communication. This method provides a review of
the interconnected and complex nature of the
existing risks that the investigation of individual
errors or events does not produce. For example,
clinicians described communication problems in
the context of communication related to the management of surgical patients that led to medication errors, diagnostic errors, procedural errors,
and ordering errors (Woods, 2007).[AU: THIS
CITATION IS NOT IN THE REFERENCES. IF
YOU ARE REFERRING TO THIS ARTICLE,
CITATION NOT NECESSARY]
Conclusions
Key patient safety risks related to clinician communication were identified. We found that the
complexity of transitions is greater than is currently described in the literature and for which
interventions are designed. The significant contribution of team culture to safety is increasingly
being recognized. This study underscores the
importance of team culture as a source of problematic communication in the form of adversarial and disrespectful communications and
as a source of strength and effectiveness when
relationships have been established within and
across clinical teams. The study also describes
the unreliability of routine communication concerning tasks such as orders, consultations,
and transitions. Many of the themes identified
through this study were described as existing in
all of the participating institutions and suggest
generalizable concerns that can provide direction for communication-related safety improvement activities. The study identified specific
pediatric priorities that warrant further research
and targeted attention to improve pediatric
patient safety.
The focus-group method was effective for
identifying clinician perspectives on key systemic patient safety–related communication
risks that are generalizable across institutions.
Clinicians are a good source of information
about patient safety risks related to clinician
communication in their medical work environment. Improvement in the reliability of clini-
cian communication will take many forms. It is
important to seek to understand, from the clinicians’ perspective, which methods, contexts,
and organizational systems are problematic
and which are effective. This understanding
can form the foundation on which to build
efforts for improvement and redesign.
Acknowledgments
The Michael Reese Health Trust funded the
Chicago Patient Safety Forum to support the
Chicago Pediatric Patient Safety Consortium’s
conducting of this study to investigate strategies for improving clinician communication in
pediatric medical care. The Otho S. A. Sprague
Foundation provided seed funding support for
the initial development of the Chicago Pediatric
Patient Safety Consortium, and each of the participating institutions— Advocate Hope Children’s
Hospital, Advocate Lutheran General Children’s
Hospital, Children’s Memorial Hospital, John
H. Stroger Cook County Hospital, and Mount
Sinai Children’s Hospital—provided in-kind
support for the activities of this project.
The authors would like to acknowledge the
support, direction, and mentorship of Kevin B.
Weiss and his assistance with the initial founding of the Chicago Pediatric Patient Safety
Consortium and its continued development.
The authors would also like to acknowledge
Gregory Makoul for his communications expertise, as well as for the advice and consultation
he provided on the standardized focus-group
protocol at the outset of this investigation.
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Authors’ Biographies
Donna M. Woods, PhD EdM, is an assistant professor
at the Institute for Healthcare Studies, Feinberg School
of Medicine, and the Graduate School at Northwestern
University, Chicago, IL, and serves as the codirector of the
Northwestern Graduate Programs in Healthcare Quality
and Patient Safety. She is also cochair, with Jane L. Holl, of
the Chicago Pediatric Patient Safety Consortium.
Jane L. Holl, MD MPH, is an associate professor of pediatrics and preventive medicine as well as the director of the
Institute for Healthcare Studies, Feinberg School of Medicine
at Northwestern University, Chicago, IL. She is the medical
director for patient safety at Children’s Memorial Hospital,
McGaw Medical Center, Northwestern University.
Denise B. Angst, PhD RN, is the director of the Advocate
Center for Pediatric Research, Advocate Health Care, [AU:
CITY], IL.
Susan C. Echiverri, MD, is chair of the Division of Genetics
and Metabolism at Stroger Hospital of Cook County
as well as an assistant professor of pediatrics at Rush
Medical College, Chicago, IL. She cochairs the Patient
Safety Committee of the Stroger Hospital and is a member
of the drug and formulary committee of the Cook County
Bureau of Health.
Daniel Johnson, MD FAAP, is associate professor of pediatrics, associate chair of patient care services, and section
chief of the section of academic pediatrics at the University
of Chicago, Chicago, IL.
David F. Soglin, MD MHPH, is chair of the department of
pediatrics at Stroger Hospital of Cook County and associate
professor of pediatrics at Rush University Medical Center,
Chicago, IL.
Gopal Srinivasan, MD, is the associate chair of the department of pediatrics at Mount Sinai Children’s Hospital,
Chicago, IL, and professor of pediatrics at Rosalind Franklin
University [AU: CITY AND STATE] and Chicago
Medical School.
Laura B. Amsden, MSW MPH, is project coordinator for
the National Children’s Study: Greater Chicago Study
Center at Northwestern University’s Institute for Healthcare
Studies, Chicago, IL.
Julia Barnathan, BA, is currently earning her MSEd degree
from Northwestern University’s School of Education and
Social Policy, Chicago, IL.
Teri Hason is a health care planner at IBI Group Architects,
Toronto, Ontario, Canada.
Leonard Lamkin, MPA, has served as the executive director of the Chicago Patient Safety Forum, Chicago, IL, since
2004. He is the immediate past president of the Illinois
53
54
Journal for Healthcare Quality
Association for Prevention.
Kevin B. Weiss, MD, is president and CEO of the American
Board of Medical Specialties. A professor of clinical medicine, he holds appointments in the Division of General
Medicine and in the Institute for Healthcare Studies in the
Feinberg School of Medicine at Northwestern University,
Chicago, IL.
For more information on this article, contact Donna Woods
at [email protected].