Communication breakdowns are a frequent risk management finding in claims. In a review of 113 closed claims, failure or delay in ordering diagnostic tests (17 percent), failure to establish a differential diagnosis (14 percent), and poor patient rapport (7 percent) contributed to undesirable outcomes. The following case discusses these issues.
The 38-year-old male, a known IV drug user, came to the emergency medicine department (EMD) complaining of pain in his left shoulder blade and back. At that time, he was diagnosed with a thoracic strain with spasms and given IM morphine and Phenergan. He was discharged home after reporting pain relief from the medication.
Shortly after midnight four days later, the patient returned to the EMD, complaining he couldn’t feel his legs and that there was blood in his urine. His wife described the patient as being confused. A physical exam revealed tenderness in the abdominal left lower quadrant and upper left side of his back. His temperature was 101°F. With catheterization, 1600 cc of urine was obtained. His laboratory tests showed a white blood count (WBC) of 21.9, glucose 170, and a positive toxicology screen for methamphetamines and heroin. A CT revealed renal calculus with mild bilateral hydronephrosis. He was admitted to the hospitalist at 5:30 AM. The working diagnoses were pyelonephritis, urinary retention, and urosepsis.
The hospitalist was informed of the patient’s admission about an hour after the patient was transferred to the nursing unit. Documentation showed that a note written at 8:00 AM included a limited history and examination. The patient was described as uncooperative (the patient said he did not like the hospitalist). There was noted leg weakness, back pain, and bladder distention, with a question of cauda equina syndrome or nerve root compression to be ruled out.
It should be noted that English was not the hospitalist’s primary language. At times the nurses noted that this communication barrier resulted in an inability to understand the physician and that it sometimes led to not calling the physician because it was frustrating and time consuming.
The history and physical (H&P) was dictated at 1:30 PM. The patient’s chief complaint was his inability to feel his legs. It was noted that the patient was a poor historian and uncooperative. He had been unable to walk since the prior day and had also experienced loss of bladder control. The left leg was worse than the right. He appeared sleepy, experienced nausea and vomiting, and his abdomen was tender in all four quadrants. The neurological examination was limited because the patient was uncooperative. There was some lower extremity paresthesia, but motor power could not be reliably examined. The hospitalist agreed with the admitting diagnosis of pyelonephritis but believed the patient had other issues, including possible acute neurologic insult. He ordered an MRI of the lumbosacral (LS) spine and a urology consult.
An MRI without contrast showed a minor disc herniation at L4-5 and degenerative changes at L5-S1. A urology consult was completed the next day. The urologist noted the patient had trouble walking the day before admission. He felt the hydronephrosis was not significant and could not explain the lower extremity weakness. He agreed with antibiotics and suggested further workup of the leg issue.
That evening the patient was found moaning and complaining of pain in the abdomen and legs. He was given IV Dilaudid. The hospitalist’s note, timed shortly after this, said that the patient refused to be treated, refused examination, and had requested another physician. The hospitalist noted that he was unable to examine the patient and had discussed the situation with the case manager, who would advise about assigning another physician.
By early the next morning, the patient stated his pain was out of control. He was medicated, and blood cultures at that time were returned with gram-positive cocci. The hospitalist was notified, and vancomycin was started.
That afternoon, the patient’s care was assumed by another hospitalist. The patient fell while being transported from the bed to the bathroom. He reported at that time that he had no sensation in his legs. A thoracic MRI, CT, and stat neurology consult were ordered.
An hour later, the neurology consult was completed. The MRI showed an epidural abscess with spinal cord compression from T3-T10. He was taken emergently to surgery for evacuation of the abscess.
Postoperatively, there was no motor function or sensation of the lower extremities, and the patient was having difficulty swallowing. A week later, the patient was discharged to a rehabilitation facility with a diagnosis of epidural abscess with a culture growing methicillin-sensitive Staphylococcus aureus (MSSA).
At the end of seven months, the patient remained confined to a wheelchair, showing some ability to stand with mechanical assistance and support. He had, however, developed contractures in the lower extremities.
The claimant alleged that the hospitalist failed to diagnose an epidural spinal abscess, resulting in spinal nerve damage.
The defense internist was supportive of the care provided by the hospitalist. Even though the patient had refused to work with the hospitalist and had requested another physician, the admitting diagnosis was appropriate, given the patient’s symptoms. The initial labs and medications were appropriate. There was nothing at that time to suggest the need for a neurology consult. The patient’s lower extremity weakness was explained by his history of back trauma and pyelonephritis. A complete neurology exam to verify lower leg weakness would have helped, but the patient refused to allow the hospitalist to examine him.
There was criticism that the emergency medicine (EM) physician had ignored the patient’s complaints of leg numbness and that a CT or MRI should have been ordered at that time. In addition, the hospitalist should have been called sooner. The thoracic MRI should have been done sooner, given the non-diagnostic LS. In addition, the hospitalist should have clearly outlined attempts to find another physician when the patient-physician relationship was deteriorating.
The hospitalist had a duty to perform a detailed neurological examination and chart its results. If the patient refused to be treated, the hospitalist should have ordered an immediate neurological consult. Because English was not the hospitalist’s primary language and he had a strong accent, some staff members noted that they had difficulty understanding him.
Patient Safety Recommendations
- Review or develop clear communication guidelines between providers. Once a decision is made to admit a patient to the hospitalist’s service, having guidelines between services will promote prompt and thorough communication of a patient’s condition. In the case outlined here, the EM physician would have contacted the hospitalist and provided the patient’s history and condition. Further testing could have been discussed—in particular, which steps would be taken to address the issue of leg weakness.
- Use communication guidelines and processes between nurses and physicians. Nursing communication is different from physician communication styles. To enhance efficient communication of a patient’s status, facilities often use SBAR (Situation Background Assessment Recommendation) or a similar standardized communication process. Such a process provides vital, clear, and relevant information about a patient’s condition.
- Promote a safe culture when communication is lacking. Nursing staff had difficulty understanding the hospitalist due to a language barrier. The communication barrier may have been a strong factor in the delay in relaying details of the patient’s condition (such as his ambulation and pain status). Unless nursing staff and other health care providers feel safe in expressing when they have difficulty understanding a provider, communication barriers and missing or absent communication will continue.
- Develop protocols for dealing with challenging patients and transfer of care. When the physician/patient interaction is impeded, either through language barriers or personality conflicts, processes need to be in place to transfer the patient’s care to another practitioner or address issues directly so other measures (such as a translator) can be considered. Additionally, when care is transferred, it should be done in a timely manner with verbal interaction between practitioners to ensure that vital information is communicated. In this case, had care been transferred in a timely manner (sooner than 12 hours), further testing would have been ordered and the degree of injury could have been mitigated or avoided.
By Laura A. Dixon, JD, RN, Director, Department of Patient Safety, Western Division.