Impact of Communication on Human Medical Errors: A Case Study

This essay examines the critical role of communication in mitigating human medical errors, using the case of Vanessa as a focal point. The analysis delves into how poor communication, lack of clear policies, and inadequate documentation contributed to a series of preventable errors. The essay explores the application of communication strategies, such as SBAR, to improve information transfer between healthcare professionals, emphasizing the importance of accurate assessments, clear instructions, and adherence to established protocols. The study highlights the consequences of communication breakdowns, including medication errors, inadequate patient monitoring, and delayed interventions. It also discusses the findings of the inquiry into Vanessa's death and the subsequent changes implemented to improve clinical practice, including the need for clinical communication training and the establishment of clear policies and procedures. Ultimately, the essay underscores the significance of effective communication in fostering a culture of patient safety and reducing the likelihood of adverse events in healthcare settings.

Running header: COMMUNICATION AND HUMAN MEDICAL ERRORS 1
Communication and Human Medical Errors
Student’s Name
University

COMMUNICATION AND HUMAN MEDICAL ERRORS 2
Patient safety is one of the greatest concerns that every practitioner needs to adhere and
ensure that they meet the required standards thus preventing errors and reducing human harm.
Goncalves, Rocha, Anders, Kusahara, & Tomazoni (2016) suggest that medical errors result in
adverse effects of care that can be both harmful and less harmful to the patient. These include,
injury, incomplete diagnosis of disease, behaviour, infection or any other ailment that the patient
can contract due to practitioner errors. Rimal & Lapinski (2011) suggests that it has been
difficult measuring the frequency of medical errors since the mistakes and errors made vary from
simple to complicated situations. Sometimes the effects of the error can be realized earlier
through the effects of the error and sometimes this never happens in the case where the error is
less fatal thus the signs and symptoms show up later. In the Vanessa case the Deputy State
Coroner indicated that the case was different since the conceivable errors of omission were
detected but continued building up on top of each other. This indicated that there was a challenge
in putting proper mechanisms in place to reduce these errors. This essay analyses the case of
Vanessa focusing on the application of human communication strategies to reduce errors, which
had been detected in the case but continued being repeated.
According to Standard 4 of the Registered Nurse standards for practice, registered nurses
should accurately conduct comprehensive and systematic assessments through analyzing
information and data to communicate the outcomes of the situation with other practitioners for
proper mechanisms on mitigating the situation. Medical errors range from mistakes and
violations that affect patient outcome. Richter & Ford (2016) argues that communication allows
relaying and interpreting of information between physicians, caregivers and patients to provide
the best care and patient outcomes. Patient care is a team sport that relies on effective relaying of
information from one level to another. Since the care of patient is dependent on several efforts of

COMMUNICATION AND HUMAN MEDICAL ERRORS 3
different practitioners, then it means that communication is key in achieving quality outcomes.
The accident model suggests that failures in healthcare settings are a consequence of latent
failures that create conditions of work which lead to active failure. Dr. Little only discovered that
Vanesa was under her care after midday when the patient has been in the hospital for a while.
This lapse on communication between practitioners can impact the health of a patient and at the
same time delay medical intervention like in the case.
The role of communication in an organization is to reduce human failures through real-
time detection of errors and addressing them. Since care is a team process, then communication
plays an instrumental process throughout the patient’s entire healthcare process (Shitu, Hassan,
& Aung, 2018). This process allows transfer of information and knowledge from one point to
another. Communication is thus the heart of effective quality care through interaction of patients
and practitioners to meet the needs of the organization (Morello, Lowthian, Barker, Dunt &
Brand, 2013). Practitioners play different roles in the process of patient care which means that
they have to communicate with each other as they hand over the patient from one profession to
another. Jin, Choi, Kang, & Rhie (2017) argue that documentation allows practitioners to
communicate with each other allowing all those who are engage with the patient to understand
the nature of the situation. In the case study there was a documentation challenge which means
that the medication and care process that followed was not based on the diagnosis and analysis
results but personal interpretations of the situation.
Effective communication means improved care and reduced human factor errors. The
reason why errors in Vanessa’s situation kept piling is the absence of clear communication that
allows practitioners to share their experiences on patient care. Poor communication means that
the practitioners did not properly share information regarding the situation of the patient to

COMMUNICATION AND HUMAN MEDICAL ERRORS 4
understand the errors that have been made and how to address them to reduce their effects to the
patient (Amutio-Kareaga, Garcia-Campayo, Delgado, Hermosilla, & Martinez-Taboada,
2017).This means that as the patient was reassigned from one practitioner to another, there was
no proper information that can inform the approach and decisions to be made. When Dr.
Williams prescribed endone increase to 5-10mg after every three hours, the maximum dose was
not indicated to the nurse to limit the amount that the patient took. Further, Dr. Williams made
the wrong prescription yet he was not the one to do it rather the neurosurgical consultant was the
one to do it. This indicates a challenge in communication between entities in the facility which
impact the patient.
According to Berman & Chutka (2016) communication is a process of reducing medical
errors focusses on four themes of situation, background, assessment, and recommendation. This
process is called SBAR which was initially designed for application in acute setting due to its
ability to increase communication time thus improving the transfer of information, perception of
the safety culture and patient satisfaction as a result of clear clinical processes. Through clear
communication, practitioners can share patient details to develop strategies that can be put in
place to mitigate the situation (Mazurenko, Richter, Swanson-Kazley, & Ford, 2016). In this
scenario, clear and effective communication between practitioners could have resulted in
reduction of the errors through early identification and development of strategies for addressing
such errors. The relationship between Nurse Perrin, Dr. Williams, Nurse Becker, and Dr.
William is poor due to communication issues in the facility. There is a documentation challenge
where the practitioners were not documenting the observations and interventions thus creating
confusion and relaying little information to each other which compromised the quality of care for
the patient.

COMMUNICATION AND HUMAN MEDICAL ERRORS 5
Lafaa, Shay, & Winship (2017) suggest that effective communication can be used to
reduce medical errors that arise through miscommunication between caregivers during transfer
of patients as seen in the case of Vanessa. The handoff sign-out protocol allows practitioners to
assess patient situations during handover to determine areas that need to be addressed (Kuo &
Balakrishnan, 2013). This allows understanding of the challenges that the other practitioner faced
and putting strategies in place to address them. Through complete, accurate and timely sharing of
patient information, medical errors can be reduced to create increased care outcomes.
Throughout the case study, human errors developed as a result of poor communication
between practitioners and lack of proper organizational guidelines. The role of policies in an
organization is to communicate the approaches that practitioners need to take like documentation
of clinical notes during observation to allow another practitioner to use the same notes for
reference (Amutio-Kareaga, Garcia-Campayo, Delgado, Hermosilla, & Martinez-Taboada,
2017). Further, the doctor did not give clear instructions to the nurse on the care to be given to
Vanessa after every required duration to monitor the changes in the patient like doing GCS scan
incase the situation became worse. From Westmead (2007) the following were findings from the
inquiry into Vanessa’s death. There was poor communication between different practitioners that
were working on the patient.
The prescriptions of the drugs given were not based on pharmaceutical standards like the
maximum dose and the level of allergies.
Dr. Ismail was to work under supervision to demonstrate satisfactory performance which never
happened.

COMMUNICATION AND HUMAN MEDICAL ERRORS 6
Dr. Ismail violated the ethical code of prescription by not communicating to the nurses on proper
dispensing of oxycodone and failing to document the instructions.
The observations on the patient were not documented at all times.
Vanesa died of respiratory arrest form depressant effect of opiate medication which was
avoidable.
After the death of Vanessa, the Coroner asked for a holistic inquiry into the hospital and
identify the errors and the reasons why the errors were repeating themselves and leading to tragic
situations like the case of Vanesa (Westmead, 2007). This led to a professional and standards
committee inquiry which is constitutionally mandated to hold an inquiry regarding the conduct in
which a patient was handled by the Dr. in charge. The standards committee found professional
issues in the work of Ismail and recommended the need for her to undergo clinical
communication training to improve her competencies and be more professional in the field of
practice. The fact that she had been placed on clinical supervision means that she needed proper
training to on clinical processes to improve her abilities.
Other changes that took place in the hospital were institution of proper policies for
guiding practitioners during clinical processes. One notable challenge that the facility witnessed
in the case of Vanessa was lack of proper policies and procedures that practitioners need to
follow. For example, documentation of clinical observations and medicines administered to
patients can be critical in achieving the intended clinical outcomes. By instituting policies, then
practitioners will be accountable to the clinical actions that they engage in. Further, management
was required to offer training to all practitioners to equip them with clinical skills for response
and handling different clinical outcomes. The fact that the death of Vanessa was as a result of

COMMUNICATION AND HUMAN MEDICAL ERRORS 7
several errors that were repeated from one level to another means that the hospital system lacked
a proper framework for managing patients. The errors revolved mostly around the role that the
RN plays in managing the condition of the patient and reporting deterioration.
Freitas, Preto, & Nascimento (2017) argue that nurses are care givers thus spend more
time with the patient than any other practitioner. By working with patients, nurses are required to
monitor the progress and the way patients respond to medication or other therapeutic processes
and share the information with physicians, doctors or any other concerned professionals.
Registered nurses are supposed to use observation strategies to asses the clinical deterioration or
improvements in the patient. Mok, Wang, & Liaw (2015) argue that nurses can monitor vital
signs like shortness of breath, failing to respond to simple commands like calling their names and
signs of increased pain to determine if the patient is improving or not. Further, Salmon & Young
(2017) adds that doctors need to give specific instructions to the registered nurse on the expected
responses and thus any signs that is against the expected signs means the patient is deteriorating
and thus the need to report the matter.
According to Westmead (2007), the following are contributing factors that led to
Vanessa’s death which could have been avoided.
Poor patient analysis diagnoses, documentation and record keeping of the patient’s progress to
inform clinical decision making.
Failure to follow Dr. Little’s chart and administration of Dilantin.
Failure to communicate allergic concerns raised by Vanesa mother to other practitioners.
Failure by Dr. Ismail to identify that the patient was chattered for Panadeine Forte for referral.
Failure by Dr. Ismail to consult Dr. Little on the level of dosage increase in analgesia.

COMMUNICATION AND HUMAN MEDICAL ERRORS 8
Failure to conduct neurological examination after every three hours as required.
Failure by of the nurse to consult with the doctor on the events that occurred from 1 am on
8/11/05.
The death of Vanessa led to an investigation on the facility and Dr. Ismail’s conduct
about the death of the patient. Since the Coroner found so many errors that were repeated by the
practitioners that led to the death of the patient. The investigation was supposed to address the
circumstances that led to the death of the Vanessa since her death could have been avoided. By
the fact that she died from complications related to drug overdose rather than the injury that she
had, it means that somebody was supposed to take responsibility at one point in time.
The investigation on Dr. Ismail was based on the fact that she had been placed under clinical
supervision where she was to work with the assistance of other practitioners to minimize medical
errors. It means that her clinical duties were limited and she did not have the right to administer
specialized medications unless under the assistance of another practitioner.
Reprimanding of Dr. Ismail and an order for her to complete the clinical communication
program for general practitioners from a cognitive institute to improve clinical communication
abilities (Profesional Standards Committee Inquiry, 2009).
Implementation of policies for managing closed head injuries to ensure that such errors do not
occur in future.
Introduction of new organizational policies that guide different responsibilities that practitioners
need to take when handling patients.

COMMUNICATION AND HUMAN MEDICAL ERRORS 9
Educating of staff on proper documentation and management of patients to ensure that patient
information is properly captured to inform clinical decision making.
Develop record auditing strategies to ensure the level of documentation within the organization
and how the established standards are being made.
Educate staff on use of electronic tools like radiological analysis of data to increase clinical
decision making.
From the case study, it is evident that human failures of poor communication between
practitioners caused the death. The death was avoidable since Vanessa died of respiratory arrest
due to the depressant effect of opiate overdose. Despite having an allergic history of Dilantin, the
concerns raised by her mother were not communicated to Dr. Little for advice. On the other
hand, the dosage level of analgesia was not communicated to the nurses to determine the
maximum amount that should be administered to the patient to avoid any side effects. What is
seen in the case is a set of human errors that came as a result of poor communication between the
practitioners who were handling the patient. The process was a team activity that required proper
documentation and taking of clinical notes to allow every practitioner to understand medical
interventions receives by the patient. However, this was the opposite since all the practitioners
failed to document serious medical issues that the patient was facing thus leading to a series of
mistakes that led to Vanessa’s death. From the analysis, she did not die from the injury that she
had sustained but rather an overdose from a series human medical errors. The case of Vanessa
should have mitigated or she had a better chance of surviving if there was clear communication
among the practitioners.

COMMUNICATION AND HUMAN MEDICAL ERRORS 10
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