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Nurses Dish On Communication Lapses That Harm Patients

Network technology giant Cisco Systems, Inc. invited nurses to offer focus group feedback on a recent study that showed that 92% of nurses believe that communications lapses adversely affect patient safety.  I joined five nurses in a cozy break out room at the HIMSS convention center and asked about their real-life experience with communications lapses in the hospital. Here are the highlights:

1. Technology Isn’t Perfect – although some hospitals have instituted bar code scanners and wireless computers to help to reduce errors, these devices often drop their connections. One nurse said that the devices actually slow down the process of distributing medications, and bypassing the system simply results in a loss of automated medication cross-checking. The devices don’t perform well in the case of an electrical surge, and nurses often waste time finding computers on wheels (affectionately known as “COWs”) that have a full battery.

2. Where’s The Patient? - the group of nurses all agreed that poor coordination of care inside the hospital can harm patients. Some nurses expressed frustration at having proceduralists and radiology teams remove the patients from their rooms without scheduling it with the nurses. They explained that nurses give out medications at specific times, and when the patients are taken to another part of the hospital without their knowledge, then they can’t plan to give them their medications appropriately. Missed doses or missed meals (for patients with diabetes for example) can result in dangerous hypoglycemic episodes, syncope, and various other harms.

3. Where’s The Pharmacist? – easy access to hospital pharmacists is critical for all clinical staff. One nurse relayed the shocking story of a med tech who was unable to get in touch with a hospital pharmacist to confirm I.V. zinc dosing in the NICU, and gave such an overdose that one of the premature babies died.

4. Where’s The Doctor? -during an audience poll at the Cisco booth, most nurses rated physicians as the hardest staff to get a hold of in the hospital setting. There is regular confusion about who’s on call, and there is often no direct line to call the physicians.

5. Where Are The Nurses Aides? – when it comes time to transfer patients (who are often very heavy) or move them in bed, nurses often have no way of finding peers to help them lift the patients safely. This results in wasted time searching for staff to assist, or even worse, can result in low back injury to the staff or patient falls.

6. Language Barriers - when patients are transitioned home from the hospital, they are often given complex instructions for self-care. These instructions are particularly hard to follow for patients whose native tongue is not English. Nurses see many re-admissions based on language-based miscommunications.

7. Decision Support Systems – one of the nurses suggested that a recent study showed that the number one source of clinical information for nurses was their peers. That means that nurses turn to other nurses for educational needs more often than they turn to a textbook or peer-reviewed source of information. Nurses would like to have better access to point-of-care decision support tools for their own educational benefit and the safety of patients.

8. Change of Shift – nurses identified shift changes as a primary source of communication errors. Technology that enables medication reconciliation is critical to safe continuation of inpatient treatment. One nurses said: “shift changes is when all the codes happen.”

And so I asked the nurses what their ideal technology would do for them to help address some of the communications problems that they’re currently having. This is what they’d like their technology to do:

1. All-In-One – nurses don’t want more devices to carry around. They want one simple device that can do everything.

2. Call a code – with one press of the button, the nurses would like the device to contact all staff who should participate in resusscitating a crashing patient.

3. Lab Values – nurses would like the device to alert them of all critical lab values on the patients under their care.

4. Clinical Prompts – nurses would like reminders of clinical tasks remaining for individual patients (e.g. check blood pressure on patient in bed 3)

5. Call and Locate Colleagues – the device should function as a full service cell phone with pre-programmed staff names/numbers and team paging lists

6. Locate Equipment -nurses would like to be able to track and locate wheelchairs, electronic blood pressure cuffs, and other equipment throughout the hospital.

7. Translate Verbal Orders To Written Orders – verbal orders are more prone to errors than written ones. An ideal device would have a voice recognition system in it that would translate physician orders to text.

Is there such a device on the market today? There are many different devices that have the capability to do some of above, but to my knowledge there is no device that can do it all yet. Companies like Cisco are working hard to provide integrated solutions for nurses – and the Nurse Connect phone is an important first step. What technologies would you recommend to nurses?

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More information about the phone (from press release):

Cisco Nurse Connect is a newly introduced solution that integrates nurse call applications, including Rauland-Borg’s Responder product lines, with Cisco Unified Wireless IP 7925G Phones to deliver nurse call alerts to mobile caregivers.

The Cisco 7925G Phone was specifically designed with the features necessary to support the unique safety and biohazard requirements of hospitals, including a battery that supports up to 13 hours of talk-time, ruggedized and hermetically sealed, and Bluetooth support for hands-free use.

The Nurse Connect Solution offers many benefits. For example, by reaching nurses on their mobile devices, the need to continually walk back to nursing stations or patient rooms is greatly reduced. Nurses can also have two-way communications with patients and send immediate requests to different levels of personnel after talking with the patient.


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