For the past 18 years, I’ve helped healthcare systems solve strategic and technical challenges, with the goal of improving workflows and outcomes for their staff and patients. As a professional, I understand the importance of achieving strategic initiatives and generating ROI, but as a father, I’m passionate about designing and implementing healthcare solutions that keep patients safe.
My youngest daughter Lily was born with a chromosome disorder known as 1p36 Deletion Syndrome (pronounced one P three six), which is a genetic condition where a band is missing (deleted) from the tip of the short arm of chromosome 1. This results in moderate to severe intellectual disabilities, delayed growth, hypotonia, seizures, limited speech ability and distinct facial features. Lily is non-verbal, has a gastrostomy tube, has a secondary diagnosis of Autism, and is our beautiful angel. While my wife and I are not clinicians, we are lifetime care providers and advocates for our daughter.
During one hospitalization when Lily was 3 years old, my wife and I noticed she seemed to be experiencing a negative side effect from a new medication. We pointed this out to the nurse, who immediately paged the physician. We then waited an hour, with no response. The nurse paged the doctor a second time, and after 45 minutes, the doctor called in to the Unit Secretary. Unfortunately, by that time the nurse was busy with another patient, and the Unit Secretary was unable to reach her. After another hour passed, the doctor came to Lily’s room while the nurse was not present. We discussed the side effect, and the doctor agreed to discontinue the medication. We wrote the notes from our conversation on the whiteboard in Lily’s room, and the doctor indicated that he would enter the discontinue (DC) order into the electronic medical record (EMR).
An hour later, a different nurse entered the room with the same medication. We referred to the notes on the whiteboard and informed the nurse that the medication had been discontinued. Neither the nurse nor the Pharmacist had received any communication about a DC order, so the nurse tried to call the doctor again. After 45 minutes, the nurse verbally confirmed with the doctor that the DC order had been entered into the EMR, though no communication had been delivered to the care team. In total, it took 3 ½ hours from the time we first noticed the negative side effect to when the care team was informed of the discontinue order!
My family’s experience is just one example of how communication failures impact patient outcomes. In fact, The Joint Commission ranks communication third on its list of the 10 most frequently identified root causes of sentinel events.
Had the hospital that treated Lily used Voalte smartphones, here’s how the workflow could have been streamlined:
- The parents speak with the nurse.
- The nurse sends a secure text message to the doctor with details about the patient, medication and adverse effects.
- The doctor calls back the nurse directly from the text message thread to have a voice conversation, or simply replies via text that he or she will discontinue the medication in the EMR.
- The doctor or nurse sends a group text message to the care team that the medication will be discontinued in the EMR, and/or a DC order notification is sent automatically from the EMR as an alert to all care team members of the DC order in the EMR.
It’s easy to imagine that this communication could take as little as three minutes, compared to more than three hours.
I am passionate about keeping patients – especially children – safe. I truly believe Voalte can help meet your organization’s communication goals and improve patient safety in the process.
Jason Friedman is Area Sales Manager at Voalte.