Reduce the risks of patients falling between two stools
Patients travel across bridges when they move from the care of one professional to another. Communication between clinicians forms the structure of these handover bridges and is a known point of medico-legal risk. Dr Sarah Coope looks at the gaps in information, misunderstandings and assumptions that can increase the risk of errors, conflict and complaints.
We cannot have complete control over our patients’ illness and disease progression or the way they respond to interventions.
But we can take steps to ensure there is a strong bridge of communication to support effective continuity of care for the patient, give protection against adverse events and reduce medico-legal risk.
Imagine you are between appointments in your busy private clinic on a Friday afternoon and your colleague rings you..
She asks you if you mind covering for her this weekend, as she needs to go and visit her elderly mother who has had a fall; she has performed a routine operation on a private inpatient earlier that day and says everything is fine.
How do you respond? Most of us would agree to do this, knowing that these arrangements often need to be reciprocated. However, how strong is that bridge as the patient moves across to your care and responsibility, albeit temporarily?
More questions
No doubt, you would usually ask more questions before ending the call. You would seek to find out more about the patient’s background, to assess whether there is any likely risk of complication and establish what the plan is for his discharge.
You would likely check that your colleague has documented this conversation with you in the patient’s records for medico-legal reasons, but also so that ward staff know that you have agreed to be contacted if necessary.
However, would you make a note yourself of the patient’s details, history and current status so that you have this information available to remind you, now that you have taken over responsibility?
Frayed cables
For much of the time, despite any weakness in the communication bridge at the point of transition, these situations pass uneventfully. The patient recovers with no complications. You are not called by the ward and your colleague takes over their care again on Monday.
However, there are inevitably occasions when this is not the case. You accept a handover from a colleague, either a cover arrangement such as this or agree to give a second opinion, arrange an admission or transfer of your patient, and then things go wrong as they move between care providers.
Sometimes this is due to complications arising that you could not have foreseen, but other times analysis of adverse outcomes indicates that communication failure between colleagues around the time of the handover is frequently the root cause.
For example, a significant underlying condition is not mentioned, a drug is missed off their transfer sheet or a key abnormal observation or result isn’t alluded to. And not having this information may lead to poor decision-making or suboptimal management.
If the communication bridge has weak structure and gaps, the care of the patient can easily fall through.
Chance of errors
Often several health professionals are involved in a typical patient’s care journey, from the GP to consultant specialist, radiologist, theatre and ward staff, pharmacist, physiotherapist and back to the GP.
The more people who are involved, the more bridges the patient is crossing and the greater the chance of there being miscommunication and errors.
Many conversations about patient care with our colleagues take place over the phone rather than in-person. Remote communication can exacerbate the risks further, primarily due to a lack of visual and non-verbal information in the interaction.
The oft-stated phrase ‘words make up only 7% of your message’ resonates here. Aside from the content of your spoken words, the other 93% of the communication comes from the style of delivery.
This includes the speaker’s body language, tone of voice and attitude which all convey crucial meaning; however, much of this is missing on the phone.
And what is said is therefore more open to misinterpretation. So particularly for complex cases, discussing the patient over a video call might be a less risky option to consider if face to face isn’t possible.
Common causes of gaps
What stops us from transmitting key information when referring a patient or ensuring that we have received all the facts we need to know when accepting a handover remotely?
What jeopardises the strength in these telecommunication bridges, that can affect safe transition of patient care?
There are, in fact, a range of factors affecting either the quality of the interaction or of the information.
Those affecting the quality of the interaction include:
Barriers in access to, availability and approachability of colleagues;
Unstable connection and signal if using a mobile device;
High level of external interruptions, distractions and time pressure;
Existing dysfunctional relationships and lack of trust;
Reluctance to take responsibility.
These are not always easy to eliminate or resolve, but it is helpful to be aware of them and compensate, where possible, by consciously strengthening the factors that you can address.
Those factors affecting the quality of the information obtained include:
Inadequate preparation before the call;
Lack of relevant facts about the patient’s situation, current status or background;
Missing detail about the care received so far;
Unclear message, agenda or request;
Lack of confidentiality or privacy when taking the call;
Not building a positive connection or rapport;
Ignoring verbal cues;
Abrupt or dismissive manner;
Interrupting or talking over;
Assumptions about a colleague’s level of knowledge and skill;
Not clarifying areas that are ambiguous;
Not speaking up or challenging potentially suboptimal decisions.
Strengthening the transition conversation
All the above potential weak links are important. However, the key thing to focus on is ensuring that adequate, relevant information is included in a handover.
A framework can be helpful to have in the forefront of your mind, to aid preparation before making a call or during accepting a patient. You may already be familiar with the SBAR model widely used in clinical settings although initially developed by Dr Michael Leonard for the US military to assist with safe communication on nuclear submarines.
At Medical Protection, we have also developed another model for safe transfer of patient care which we teach in our Mastering Professional Interactions workshop (see box on the right)
So, how strong are your remote interactions with colleagues in these situations? Next time you pick up the phone to accept or make a patient handover, remember the bridge analogy and aim to build a safe, solid structure into your communication.
By reflecting on this, and making changes to the way that you present or receive vital information about a patient, you can fill in the gaps, strengthen the connection, increase the chance of a smooth transition of care and mitigate the associated medico-legal risk.
Overcoming risky remote interactions with colleagues, forms part of Medical Protection’s new four-part series of webinars on telemedicine. Medical Protection members can find out more about these webinars via our e-learning platform prism.medicalprotection.org.
Dr Sarah Coope (left) is senior medical educator at Medical Protection