Skip to content
  • About
  • Contact
  • Contribute
  • Book
  • Careers
  • Podcast
  • Recommended
  • Speaking
  • All
  • Physician
  • Practice
  • Policy
  • Finance
  • Conditions
  • .edu
  • Patient
  • Meds
  • Tech
  • Social
  • Video
    • All
    • Physician
    • Practice
    • Policy
    • Finance
    • Conditions
    • .edu
    • Patient
    • Meds
    • Tech
    • Social
    • Video
    • About
    • Contact
    • Contribute
    • Book
    • Careers
    • Podcast
    • Recommended
    • Speaking

Communication protocols exist for a reason

Michael J. Grace, JD
Conditions
December 11, 2022
Share
Tweet
Share

An excerpt from The Mumbo Jumbo Fix: A Survival Guide for Effective Doctor-Patient-Nurse Communication.

Team building is a popular trend in health care.  It promotes cooperation, trust and respect, improves communication, and enhances patient outcomes.  Most of the time.

But the camaraderie and familiarity of working with the same group of people can carry unappreciated risk to patient safety—a breakdown of standardized communication protocols based on a misplaced trust in one another.  Working daily with the same team of highly trained colleagues both impresses and lulls us into letting down our guard and skipping steps in defined processes.  In the world of risk assessment and mitigation, this phenomenon is known as a human risk factor.

Standardized health care procedures took their inspiration from the disciplined field of aeronautics.  Cockpit protocols are step-specific behaviors written in checklist form and audibly confirmed by another team member.  No matter how many flight hours a pilot and co-pilot have logged together, each and every time they prepare to take-off or land they methodically perform the required drill.  Without exception.  Who among us would feel safe flying on a plane if we were told the cockpit opted to skip the checklist that day?

The “time-out” universal protocols in operating rooms are a good example of the use of required checklist behaviors.  No surgery should commence without first taking the time to confirm out loud in the presence of the entire OR team the identity of the patient, the nature of the surgery, and the specific surgical site.  And it works almost all the time—unless the OR is running behind schedule and the surgeon tries to skip the “time-out.” It takes a strong and confident nurse to speak up and challenge a time-pressed surgeon.  After all, the surgeon is probably very experienced, and the correct patient and procedure were probably already confirmed in the pre-op area by another nurse—unless he was also pressed for time.

Pre-operative sponge counts by two nurses (or a nurse and a scrub tech) are required to ensure a correct baseline count before surgery begins.  During surgery, each sponge brought into the operative field is logged on a board, and a tally of used sponges is reconciled at the end of the procedure before closing the patient.  Of course, the entire process breaks down if the initial count was inaccurate.  The first experienced nurse had been through the drill hundreds of times without an error, so there was probably minimal risk when the second required person slipped off to perform some other necessary pre-surgical task.  No one has ever miscounted, right?

Administration of potentially dangerous medication requires the presence of two health care providers for a read-back to confirm the correct patient is receiving the prescribed medication in the proper dose.  Occasionally busy providers trusting each other to do the job properly dispense with the read-back.  What could possibly go wrong if a newborn baby in the neonatal ICU receives an adult dose or another baby’s potent medication?

As a risk manager who investigated multiple examples of each of these scenarios, the common thread was a skilled team member trusted a known experienced colleague to do the job correctly.  Usually because the team member felt time pressure to do other tasks.  In the rush of the moment, the communication protocol was rationalized as unnecessary and “probably safe this time.” What the field of risk assessment and mitigation reminds us is communication protocols exist for a reason.  We are all human; all human beings make mistakes.

Michael J. Grace is an attorney and author of The Mumbo Jumbo Fix: A Survival Guide for Effective Doctor-Patient-Nurse Communication.

Prev

A physician in denial after being diagnosed with COVID-19

December 11, 2022 Kevin 0
…
Next

Every physician should own a timeshare [PODCAST]

December 11, 2022 Kevin 0
…

Tagged as: Hospital-Based Medicine, Malpractice

Post navigation

< Previous Post
A physician in denial after being diagnosed with COVID-19
Next Post >
Every physician should own a timeshare [PODCAST]

More by Michael J. Grace, JD

  • Building trust with patients: the power of credibility, trustworthiness, and likeability

    Michael J. Grace, JD

Related Posts

  • A medical student finds a reason to dance

    Nikita Mittal
  • 3 medical student tips to improve patient communication

    Subha Mohan
  • Communication with insurers: a pandemic problem the vaccine won’t fix

    Anupama Balasubramanian
  • Give your psychiatric patients a reason to trust

    Anonymous
  • This physician is burned out. But not for the reason you think.

    Anonymous
  • The expanding role of specialists in value-based care

    Martin Lustick, MD

More in Conditions

  • Overcoming the lies of depression: Senator John Fetterman’s struggle with mental health

    Harvey Max Chochinov, MD, PhD
  • Proposed USPSTF guideline update: Advocating for earlier breast cancer screening at age 40

    Hoag Memorial Hospital Presbyterian
  • The rising threat of lung cancer in Asian American female nonsmokers

    Alice S. Y. Lee, MD
  • Urgent innovation needed to address growing mental health crisis among children and families

    Monika Roots, MD
  • The importance of listening in health care: a mother’s journey advocating for children with chronic Lyme disease

    Cheryl Lazarus
  • The unjust reality of racial disparities in pediatric kidney transplants

    Lien Morcate
  • Most Popular

  • Past Week

    • A physician’s typical day, as envisioned by a non-clinician health care MBA: a satire

      Jennifer Lycette, MD | Physician
    • Is chaos in health care leading us towards socialized medicine? How physician burnout is a catalyst.

      Howard Smith, MD | Physician
    • Revealing America’s expansion: the dark truth of Native American suffering and unjustified abuses

      Anonymous | Physician
    • The tragic story of Mr. G: a painful journey towards understanding suicide

      William Lynes, MD | Physician
    • The rising threat of lung cancer in Asian American female nonsmokers

      Alice S. Y. Lee, MD | Conditions
    • From Moscow Mule to the opioid crisis: Unveiling the tragic legacy and urgent solutions

      Osmund Agbo, MD | Meds
  • Past 6 Months

    • “Is your surgeon really skilled? The hidden threat to public safety in medicine.

      Gene Uzawa Dorio, MD | Physician
    • Breaking the cycle of racism in health care: a call for anti-racist action

      Tomi Mitchell, MD | Policy
    • Unveiling the hidden damage: the secretive world of medical boards

      Alan Lindemann, MD | Physician
    • An inspiring tribute to an exceptional radiologist who made a lasting impact

      Kim Downey, PT | Conditions
    • The hidden factor in physician burnout: How the climate crisis is contributing to the erosion of well-being

      Elizabeth Cerceo, MD | Physician
    • Proactive risk management: a game-changer in preventing physician burnout

      Howard Smith, MD | Physician
  • Recent Posts

    • Physician employment contracts: the key to fighting burnout and improving working conditions [PODCAST]

      The Podcast by KevinMD | Podcast
    • A tense family drama unfolds as a young daughter pursues unconventional career path

      Osmund Agbo, MD | Physician
    • Decoding the brain’s decision-making: insights for medical professions and strategies for success

      Harvey Castro, MD, MBA | Physician
    • Unmasking the truth: the shocking reality of the opioid epidemic and who’s really to blame

      Jay K. Joshi, MD | Physician
    • Discover your true north: Navigating life’s confusions and embracing your path to success

      Tyler Jorgensen, MD | Physician
    • A revolution in patient empowerment: Working together to save our medical system [PODCAST]

      The Podcast by KevinMD | Podcast

Subscribe to KevinMD and never miss a story!

Get free updates delivered free to your inbox.


Find jobs at
Careers by KevinMD.com

Search thousands of physician, PA, NP, and CRNA jobs now.

Learn more

Leave a Comment

Founded in 2004 by Kevin Pho, MD, KevinMD.com is the web’s leading platform where physicians, advanced practitioners, nurses, medical students, and patients share their insight and tell their stories.

Social

  • Like on Facebook
  • Follow on Twitter
  • Connect on Linkedin
  • Subscribe on Youtube
  • Instagram

CME Spotlights

From MedPage Today

Latest News

  • Insomnia Symptoms Tied to Stroke a Decade Later
  • Studies Question Role of CDK4/6 Inhibitors in First-Line Advanced Breast Cancer
  • Full-On Reversal of Cardiac Amyloidosis Possible With Antibodies
  • Spell Check-Up: Do You Have the Skills to Pass This Spelling Test?
  • For Some, Sex Is Better Sleep Aid Than Pill, Small Survey Finds

Meeting Coverage

  • Studies Question Role of CDK4/6 Inhibitors in First-Line Advanced Breast Cancer
  • For Some, Sex Is Better Sleep Aid Than Pill, Small Survey Finds
  • Skipping Radiotherapy 'Seems Safe' for PMBCL Patients in Remission
  • Promising Gene Therapy for Overactive Bladder
  • Shotgun Sequencing of Small Intestine Reveals Species Tied to GI Symptom Severity
  • Most Popular

  • Past Week

    • A physician’s typical day, as envisioned by a non-clinician health care MBA: a satire

      Jennifer Lycette, MD | Physician
    • Is chaos in health care leading us towards socialized medicine? How physician burnout is a catalyst.

      Howard Smith, MD | Physician
    • Revealing America’s expansion: the dark truth of Native American suffering and unjustified abuses

      Anonymous | Physician
    • The tragic story of Mr. G: a painful journey towards understanding suicide

      William Lynes, MD | Physician
    • The rising threat of lung cancer in Asian American female nonsmokers

      Alice S. Y. Lee, MD | Conditions
    • From Moscow Mule to the opioid crisis: Unveiling the tragic legacy and urgent solutions

      Osmund Agbo, MD | Meds
  • Past 6 Months

    • “Is your surgeon really skilled? The hidden threat to public safety in medicine.

      Gene Uzawa Dorio, MD | Physician
    • Breaking the cycle of racism in health care: a call for anti-racist action

      Tomi Mitchell, MD | Policy
    • Unveiling the hidden damage: the secretive world of medical boards

      Alan Lindemann, MD | Physician
    • An inspiring tribute to an exceptional radiologist who made a lasting impact

      Kim Downey, PT | Conditions
    • The hidden factor in physician burnout: How the climate crisis is contributing to the erosion of well-being

      Elizabeth Cerceo, MD | Physician
    • Proactive risk management: a game-changer in preventing physician burnout

      Howard Smith, MD | Physician
  • Recent Posts

    • Physician employment contracts: the key to fighting burnout and improving working conditions [PODCAST]

      The Podcast by KevinMD | Podcast
    • A tense family drama unfolds as a young daughter pursues unconventional career path

      Osmund Agbo, MD | Physician
    • Decoding the brain’s decision-making: insights for medical professions and strategies for success

      Harvey Castro, MD, MBA | Physician
    • Unmasking the truth: the shocking reality of the opioid epidemic and who’s really to blame

      Jay K. Joshi, MD | Physician
    • Discover your true north: Navigating life’s confusions and embracing your path to success

      Tyler Jorgensen, MD | Physician
    • A revolution in patient empowerment: Working together to save our medical system [PODCAST]

      The Podcast by KevinMD | Podcast

MedPage Today Professional

An Everyday Health Property Medpage Today
  • Terms of Use | Disclaimer
  • Privacy Policy
  • DMCA Policy
All Content © KevinMD, LLC
Site by Outthink Group

Leave a Comment

Comments are moderated before they are published. Please read the comment policy.

Loading Comments...