Patient Safety Advisory Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 1 (March 2005) Produced by ECRI & ISMP under contract to the Pennsylvania Patient Safety Authority Multiple Messages, Multiple Tasks A recent PA-PSRS report concerned a patient ad- mitted with head trauma who was evaluated with a CT scan, then monitored. He showed signs of worsen- The clinical staff involved in this occurrence already understood the importance of transmitting changes noted in obviously urgent studies, of writing down what ing, prompting a repeat CT. The radiologist noted a is said, of shortening the information chain, of making change warranting treatment and called the ICU to the information accessible, and of being transparent to inform the surgeon who was responsible for the pa- the family. tient. The ICU nurse transcribed the reading and called the surgeon in the OR, reaching the anesthetist. The In commentary, we also note that this report indicates anesthetist conveyed the reading to the surgeon, who the hazards of multi-tasking. The surgeon attempted to was doing an emergency operation. The surgeon process critical information while doing another impor- found the message confusing. tant task. Under these conditions, the probability of error is known to increase.1 Multi-tasking cognitive He explained to the circulating nurse how to retrieve tasks is not an indicator of efficiency. In this case, indi- the CT on the PACS system in the OR. The nurse dis- viduals were being called upon to do too much at once. played the first early morning film instead of the second Safety experts warn against trying to solve safety prob- late morning film. The surgeon, thinking he was view- lems solely by being more careful, or working harder, ing the second film, read it as unchanged, requiring no or being more efficient. Experts who have studied further treatment. After leaving the OR hours later, the highly reliable systems mention reserves and reorgani- surgeon discovered the error and instituted the indi- zation: the ability to bring more resources to the prob- cated treatment, but belatedly. The family was notified lem.2 Others describe this as capacity. If the system of the problem. The hospital’s assessment found the has adequate capacity, it is not necessary for a nurse root cause to be ineffective communication. Policies assisting a surgeon to become a radiology file clerk or were changed to ensure direct physician-to-physician for the surgeon in the middle of an operation to conversation. make a decision about another patient. The hospital is to be commended for a thorough inves- Notes tigation and identification of the importance of effective 1. Schacter DL. The seven sins of memory: how the mind for- communication. Two components of communication gets and remembers. Houghton Mifflin (NY); 2001. are salient to this report. One is that the fewer interme- 2. Roberts KH, Yu K, Van Stralen D. Patient safety as an or- diaries, the less the chance for misunderstanding. The ganizational systems issue: lessons from a variety of indus- second, less obvious point, is that the less the interme- tries. In Youngberg BJ, Hatlie MJ, eds. The patient safety diary understands about the content, context, and im- handbook. Sudbury MA: Jones & Bartlett; 2004:169-86. plications of the message, the greater the chance of misrepresentation. This article is reprinted from the PA-PSRS Patient Safety Advisory, Vol. 2, No. 1—March 2005. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI & ISMP under contract to the Authority as part of the Pennsylvania Patient Safety Reporting System (PA-PSRS). Copyright 2005 by the Patient Safety Authority. This publication may be re- printed and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. To see other articles or issues of the Advisory, visit our web site at www.psa.state.pa.us. Click on “Advisories” in the left-hand menu bar. ©2005 Pennsylvania Patient Safety Authority Page 1 Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 1 (March 2005) An Independent Agency of the Commonwealth of Pennsylvania The Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI, as contractor for the PA-PSRS program, is issuing this newsletter to advise medical facilities of immediate changes that can be instituted to reduce serious events and incidents. For more information about the PA- PSRS program or the Patient Safety Authority, see the Authority’s website at www.psa.state.pa.us. ECRI is an independent, nonprofit health services research agency dedicated to improving the safety, efficacy and cost-effectiveness of healthcare. ECRI’s focus is healthcare technology, healthcare risk and quality management and healthcare environmental management. ECRI provides information services and technical assistance to more than 5,000 hospitals, healthcare organizations, ministries of health, government and planning agencies, and other organizations worldwide. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP's efforts are built on a non-punitive approach and systems-based solutions. Page 2 ©2005 Pennsylvania Patient Safety Authority