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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 43 44 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 45 46 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- 47 48 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 49 50 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. References [AU: FOR ALL REFERENCES NOT CITED IN TEXT: PLS. CITE IN TEXT OR DELETE FROM REFERENCE LIST.] Agency for Healthcare Research and Quality. The effect of health care working conditions on patient safety (Evidence Report/Technology Assessment No. 74). (Prepared by Oregon Health & Science University under Contract No. 290–97–0018.) Rockville, MD: Author. [AU: NOT CITED IN TEXT; NEED YEAR] Altman, D. E., Clancy C., & Blendon, R. J. (2004). Improving patient safety five years after the IOM report. 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(2003). Patient safety events during pediatric hospitalization. Pediatrics, 11, 1358–1366. Morgan, D. (1997). Focus groups as qualitative research (2nd ed.). London: Sage. Norman, D. (1988). The design of everyday things. New York: Doubleday. National Transitions of Care Coalition. (Web site.) Retrieved February 28, 2008, from www.ntocc.org. Poon, E. G., & Haas, J. S. (2004). Communication factors in the follow-up of abnormal mammograms. Journal of General Internal Medicine, 19, 316–323. Schiff, G. (2005).Introduction: Communicating critical test results. Joint Commission Journal on Quality and Patient Safety, 31(2), 63–65, 61. Slonim, A. D., LaFleur, B. J., Ahmed, W., & Joseph, J. G. (2003). Hospital-reported medical errors in children. Pediatrics, 111, 617–621. Stebbing, C., Wong, I. C., Kaushal, R., & Jaffe, A. (2007). The role of communication in paediatric drug safety. Archives of Disease in Childhood, 92(5), 400–405. Strauss, A., & Corbin, J. (1998). Basics of qualitative research: Techniques and procedures for developing grounded theory (2nd ed.). Thousand Oaks, CA: Sage. Sutcliffe, K. M., Lewton, E., & Rosenthal, M. M. (2004). Communication failures: An insidious contributor to medical mishaps. Academic Medicine, 79(2), 186–194. Thomas, E. J., Studdert, D., Burstin, H. R., Orav, E. J., Zeena, T., Williams, E. J., et al. (2000). Incidence and types of adverse events and negligent care in Utah and Colorado. Medical Care, 38, 261–271. [AU: PLS VERIFY AUTHORS]Thompson, D., Holzmueller, C., Hunt, D., Cafeo, C., Sexton, B., & Pronovost, P. A. (2005). A morning briefing: Setting the stage for a clinically and operationally good. day. Joint Commission Journal on Quality and Patient Safety, 31(8), 476–479. Woods, D. M., Holl, J. L., Angst, D., Echiverri, S., Johnson, D., Soglin, D., et al. (in press). [AU: PLS UPDATE] Advances in patient safety: New directions and alternative approaches. [AU: NOT CITED IN TEXT] Woods, D. M., Holl, J. L., Mehra, M., Shonkoff, J., Ogata, E. S., & Weiss, K. B. (2005). Child specific risk factors in patient safety. Journal of Patient Safety, 1(1), 17–22. Woods, D. M., Holl, J. L., Mohr J. J., Mehra, M., Thomas, E. J, Ogata, E., Lannon, C. M. [ED: CHANGE TO ET AL. IF REFERENCE IS RETAINED] (2005). Anatomy of a patient safety event: A taxonomy for pediatric patient safety. Quality and Safety in Healthcare. 14, 422–427. [AU: NOT SPECIFICALLY CITED IN TEXT; SEE TEXT QUERIES] Woods, D. M., Holl, J. L., Ogata, E. S., & Magoon, P. (2005). Systemic patient safety risks: Lessons learned from focus groups. Journal of Patient Safety, 1(1). [AU: NEED PAGE NUMBERS] Woods, D. M., Thomas, E. J., Holl J., Altman, S., & Brennan, T. A. (2004). Adverse events and preventable adverse events in children. Pediatrics.[AU: NEED VOL, ISSUE, AND PAGE NUMBERS] 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].