Can paging the wrong doctor harm patients?

One of the worst places for pagers to work is a hospital itself. Operating suites, radiology, basements and sub-basements can be dead zones for transmission unless the hospital has properly installed repeaters inside the building. I can think of half a dozen incidents in hospitals I’ve worked at. No disasters, but some near-misses.

Coolest one was a hospital faculty meeting where the doctors had complained about dead zones at our teaching hospital, and doctors stat-paged did not get the message. The old nursing “Dr. so-and-so isn’t answering his page” when Dr. so-and-so is around the corner and the pager never went off.

So at this meeting, engineers were invited in as follow-up. They told us, “We found all the dead zones, and installed repeaters. Your problem is fixed.”

Couldn’t have been scripted better. Just then, nurse busted in the meeting, yelled to a doctor sitting there with a silent beeper. “We have a problem in the Emergency Room and we’ve been paging you the last twenty minutes!”

He threw his beeper at the engineer and ran out the door. And that’s how we found out the conference room was a dead zone for our beepers.

I’ve seen this sort of thing at several hospitals.

Very interesting topic. Let me give you another spin on this. I was a pharmacy resident last year, and part of my training involved staffing the medicine pharmacy on weekends. On the weekends, instead of having the typical 8-10 pharmacists out on units, participating on rounds and taking care of reviewing medication orders on a patient-by-patient basis, we condensed to just 2-4 pharmacists reviewing orders from the pharmacy. The result was a much higher workload for the pharmacists, and a LOT of cat-and-mousing with the doctors (paging prescribers to change or clarify orders). I often wondered about the patient safety issue: by the time I’ve paged the prescriber, he/she has already long moved on to the next patient. Now they’re getting calls/clarifications/clean-ups regarding orders of a patient they were with an hour ago. That disrupts the care of patient #2, and reduces the quality of care of patient #1. Seems totally inefficient and not very safe.

You can send text messages via pagers just the same, with fewer issues with dead areas. I’m not sure what advantage SMS offers, unless you’re in junior high.

This is a problem we see every day in our travels while speaking with doctors and nurses. The cause and effect varies, but incorrect pages (and phone calls) are a significant source of frustration and wasted time in both hospitals and practices.

We recently surveyed 1,100 doctors, of which 27% told us they have paging problems. In the 19 hospitals and 2,000 practices we’re plugged into, we’ve been able to significantly reduce incorrect calls and pages, decrease the time nurses spend contacting physicians, and save physicians time.

Many of our doctors happily decommission their pager since we can provide more message detail via SMS and have auto failsafe processes in place to cover for dead zones, dead batteries, etc.