Case Study: Miscommunication
Mr. Salib is a 35-year-old man who comes to the hospital with severe abdominal pain. He is diagnosed with an incarcerated abdominal hernia that requires surgery. The doctor orders the patient to fast overnight to be ready for surgery in the morning. Mr. Salib is kept in a double room and put on the schedule for surgery next morning. In the morning, the food service worker working the floor fails to confirm the identity of Mr. Salib and gives him his roommate’s food tray. The registered nurse sees the tray being delivered to Mr. Salib and asks the food service worker to make sure he is giving the food to the right patient. The food service worker compares the names of the patients on their wristbands with his delivery list and confirms that Mr. Salib is not the patient in the room who should get the food tray.
Discussion Questions
- Identify the members of the team mentioned in this case study and state, in terms of interprofessional communication, what each of them could have done to prevent this problem.
- Which specific Sub-competencies in the Core Competency of Teams and Teamwork apply to this case study, either because they were or were not demonstrated?
- Which specific Sub-competencies in the Core Competency of Roles/Responsibilities apply to this case study, either because they were or were not demonstrated?
- Propose a policy that may prevent this problem in the future.
1. Team Members & Communication Improvement:
- Doctor: Could have clearly communicated the importance of fasting to both Mr. Salib and the nursing staff, emphasizing the necessity for correct identification before any food is given.
- Nursing Staff: Should have reiterated the fasting requirement to Mr. Salib and ensured the food service worker was aware of the fasting status before food delivery.
- Food Service Worker: Needs to confirm the patient’s identity before delivering any food, perhaps by cross-verifying details beyond just the names on wristbands.
- Patient: Could have actively confirmed with the staff about the fasting requirement to avoid confusion.
2. Sub-competencies in Teams and Teamwork:
- Communication: Demonstrated by the nurse who questioned the food delivery. Lacking in terms of initial communication from the doctor about the fasting requirement.
- Shared Decision-Making: Absent, as there was no collaborative decision-making process in this scenario.
3. Sub-competencies in Roles/Responsibilities:
- Role Clarity: The doctor’s role was clear in ordering the fasting, but there might have been a lack of clarity among other team members about their roles in ensuring adherence to this instruction.
- Adaptability: Demonstrated by the nurse who questioned the food delivery, showing adaptability in rectifying the situation.
4. Proposed Policy for Prevention:
- Patient Identification Protocol: Implement a strict protocol that requires double verification of patient identity (using more than just wristband names) before delivering any service or item (such as food, medication, etc.). This could involve unique identifiers like date of birth or patient ID numbers.
- Communication Protocol Enhancement: Develop a standardized communication protocol where any crucial instructions from doctors regarding patient care (like fasting) are communicated not only verbally but also documented clearly in patient records accessible to all involved staff.
- Training & Education: Conduct regular training sessions for healthcare staff emphasizing the importance of clear communication and strict adherence to protocols regarding patient care instructions.
Implementing these policies could significantly reduce the risk of similar miscommunications in the future, prioritizing patient safety and accurate care delivery.