Patient Safety — Interprofessional Collaboration
Expert committees of the Chief Coroner’s Office call for better teamwork after reviewing circumstances of two deaths.
- A hospital nurse questions a nursing colleague as to why a patient with significant hypokalemia has not received a further order for IV potassium and asks whether oral potassium should be administered on the patient’s arrival to the inpatient unit. The nurse is told that the doctor would have ordered it if it was needed.
- A community pharmacist is concerned with the high-risk medications ordered by a family physician for an elderly patient. He communicates his concerns about their potential interactions with the patient’s current medications to the physician by fax. The prescribing physician directs that all medications be continued as prescribed, with no modifications.
These two instances of health-care professionals being shut down and ignored by other-health-care providers were noted in recent reviews of two deaths undertaken by expert committees of the Chief Coroner’s Office. Both reports suggest that improved interprofessional collaboration could have played a role in preventing the deaths of the patients.
The cause of death in the first case was believed to be hypertensive heart disease and advanced coronary atherosclerosis. However, the pathologist noted that the significant hypokalemia noted on admission might have precipitated an arrhythmia that led to the woman’s death.
The Patient Safety Review Committee (PSRC) looked into the circumstances of the death and noted that the case should serve as a reminder of the importance of communication amongst nurses and between nurses and physicians. Nurses, the Committee suggested, should feel comfortable raising questions about orders, or the absence of orders, if they feel that a patient is at risk.
To that end, the Committee recommended that hospitals support staff through the establishment of collaborative models of care. “This will encourage nurses to question orders if they feel they are incomplete or in any way put their patient at risk,” stated the report.
The second case, which was reviewed by the Coroner’s Geriatric and Long-Term Case Review Committee, focused on the death of an 86-year-old woman who died from gastro-intestinal hemorrhage, due to dabigatran therapy and coagulopathy.
At the time of dispensing of verapamil and dabigatran, the pharmacist reviewed the new medications as well as the patient’s medication history. The pharmacist noted a concern for both the prescription for dabigatran and for verapamil and communicated them to the family physician.
Notwithstanding the pharmacist’s advice, the family physician directed that the medications be dispensed, as originally prescribed.
Shortly after beginning her new medications, the patient’s family noted a significant decline in her health. She suffered a gastrointestinal bleed, hypotension, bradycardia with junctional rhythm and acute renal failure leading to her death.
In its report, the Committee reminded physicians that community pharmacists are an important part of the health care team. “Alerts from the pharmacist related to high risk medications should be carefully considered,” it stated.
The College, for its part, has made system collaboration one of our priorities in our new strategic plan. Key to the success of that priority is the College’s ongoing promotion of interprofessional collaboration.
In order to better meet patient needs, health care has evolved such that the delivery of care no longer takes place through exclusive domains of practice but rather through multidisciplinary teams, said Dr. Saroo Sharda, a CPSO medical advisor and anesthesiologist.
For several years, Dr. Sharda, whose Master’s Degree and Medical Education Fellowship focused on interprofessional teamwork, has been using a simulated environments to coach multidisciplinary health-care teams to work together as they practised the management of rare but important emergency situations.
“Most interprofessional issues do not stem from technical or knowledge deficiency but rather from communication breakdown,” noted Dr. Sharda. “Changing the culture of medicine from one that expects physicians to have all the answers all of the time, to one which encourages openness, transparency and the ability to ask of others ‘Am I missing anything here?’ requires all team members to feel valued and safe,” she said.