Paging the Doctor: Sorry, Wrong Number

Miscommunication is a form of waste, since it can drag out a process or lead to improper outcomes.

And in hospitals, apparently it is a significant form of waste, according to the Health Blog of The Wall Street Journal, which reported on a study in the Archives of Internal Medicine.

A review at two Canadian teaching hospitals reveals that in a two-month period, 14% of all pages were sent to the wrong physician—meaning to a resident who was scheduled to be off-duty or out of the hospital—and 47% of those were urgent messages. Extrapolating, that’s about 2,000 misdirected pages per year per hospital that require an immediate response, but don’t get one, the study found.

In one example cited in the study, an incorrect pager number was posted on a whiteboard.

The study did not look at how patients were ultimately affected by the delays caused by the paging mistakes. I hope someone does investigate that part of it.

From a lean standpoint, how can this problem be addressed? While I don’t usually push technology as a solution, that may help. There may be some kind of IT system that sends pages at the push of a button, with the numbers already programmed in.

But this probably is not just about incorrect numbers. There may also have been misinformation about which doctor was on duty.

Is it a question of standard work? Probably. Of eliminating handoffs? Perhaps. What are your suggestions?


Dean Bliss said...

Standard work? Less handoffs? Error proofing? Yes, yes, and yes. I've seen examples of all three. The big issue, though, is helping nurses, clerks, and others recognize that there is a problem to solve, and that we have ways to address the situation. Once we get there, the solutions can be developed and maintained. Easier said than done, but certainly doable.

Mark Graban said...

Before proposing solutions, best to understand the problem. Why was the whiteboard incorrect, for example?

Was there not a good process for updates? Unclear ownership of that responsibility??

Peter P Patterson, MD MBA said...

I've been a physician for 40 years, though happily only a few of them in academic medical centers (grin).

A significant underlying issue is segmentation of on-call rotations across the multiple subspecialties in an academic medical center. Now combine this with the trading of on-call days/shifts and it can become hideously complex. No published schedule can keep up. The default organizational culture of specialty silos also adds to the problem. Eliminate handoffs -- yeah, right.

The academic medical center I retired from a few years ago had an operating rule that whoever was carrying a pager for a particular service was on-call for that service. This had the practical advantage of people being very conscious of turning over call at the right time and if the operating rule was strictly followed, you answered the page even if you were not technically on-call any longer but still (sadly) had the pager on your belt.

All this explanatory hoo-hah aside, the problem can be addressed and solved if the appropriate academic chiefs can be trained to solve problems rather than "study" problems and publish journal articles. This is what the healthcare lean transformation culture is all about, though as Dean Bliss rightly points out above, it cannot begin until there is recognition that a problem exists.
/Dr. Pete