Location: Surgery inpatient floor
Time: 6:00 a.m.
Surgery morning rounds began:
“Ms. A, your MRI shows you have colorectal cancer, so we plan to take you to the OR for surgery tomorrow. Alright, see you later,” said my surgery attending, who rushed out of Ms. A’s room right after he abruptly dropped this shocking news. Inside the room, Ms. A, a fragile, bony 75-year-old lady, was laying on her bed with her eyes full of fear and confusion. Her face immediately turned pale after she heard those words from my attending. She tried to open her mouth, but she was at a loss for words. Finally, she slowly raised her shaking arm and squeezed out a few incoherent sounds, “I … I don’t … understand.” However, my attending, along with the whole surgery team, had already left the room.
Location: Dictation room
Time: 12:30 p.m.
Rounds just adjourned:
A nurse ran into the surgery dictation room furiously, “Who is Ms. A’s doctor? Did you guys know she has depression, and today is the first time she’s heard she had cancer? She just attempted suicide by cutting her wrist in her room!”
Silence fell upon the team. “Well, I thought somebody had already told her,” said my attending while scrolling down numerous progress notes in the electronic record. “Aren’t GI, oncology and ID all on board for her case?”
As a third-year medical student who just started my first week of surgery, I was shocked by this incident. How could the entire surgery team not know Ms. A hadn’t been informed of her cancer status? Why did nobody mention her psychiatric history during rounds? Was it because it was not pertinent to surgery? In the setting of a multidisciplinary team approach to health care, who should we blame when a patient’s safety is in danger? Later on, I learned Ms. A was rescued and stabilized from her suicide attempt; but by improving the organization and communication of multidisciplinary teams, this incident could have been completely avoided.
The physicians involved in Ms. A’s care may have understood the necessity of delicately delivering the bad news and answering her questions. However, in the setting of the multidisciplinary team approach, the buck kept getting passed. The lack of coordination between the service teams led to a lack of delegation in delivering bad news. Consequently, this breakdown of communication between the health professionals and the patient put Ms. A’s life in danger. As hospitals gradually lean more toward specialty care, each service team primarily focuses on managing the medical problems in their own field. Hence, they tend to forget to look at the patient as a whole person. In Ms. A’s case, my surgery attending did not note her history of depression before he entered the room.
Ms. A’s incident made me realize the importance of improving the teamwork climate in not only this hospital, but hospitals nationwide. There are several possible interventions that can be implemented:
1) Daily goals of care and safety checklists: A daily goals worksheet with collaborative input from different service teams can be introduced to the bedside and the electronic record system. The checklist is helpful to update the daily status of medical management, and to avoid duplicated or omitted actions. This can help provide structure to the interdisciplinary care process and create a shared understanding of patients’ plans of care.
2) Structured Interdisciplinary Rounds (SIDR): It may be useful to organize members from different care professions to round at the same time in order to address shared clinical purpose and delegate direct care responsibilities among the specialties. Recent studies have shown SIDR resulted in significantly higher ratings of the quality of collaboration and teamwork climate, and a reduction in the rate of adverse effects.
3) Teamwork training: Conducting formalized team training that emphasizes the core components of successful teamwork on a regular basis can improve communication in a complex team environment.
Along with these interventions, hospitals should consider utilizing the Case Process Self-Evaluation Tool (CPSET) studied by Seys et al. to evaluate improvements in multidisciplinary teamwork. Developed in 2007, the CPSET evaluates five areas of patient care, including: patient-focused organization, coordination of the care process, collaboration with primary care, communication with patients and family, and follow-up of the care process. Seys et al. compiled a table of CPSET cutoff scores to rank the teams, identify differences between teams within the same hospital, and discuss how to improve the organization of care.
My experience from the tragic event of Ms. A. reaffirmed my belief that improving the priorities, communication and coordination in a complex multidisciplinary team environment is a necessity. When an adverse event like this occurs, it is our obligation as health care providers to identify the root of error and take actions to prevent it in the future. As the British Chief Medical Officer Sir Liam Donaldson said, “To err is human, to cover up is unforgivable, and to fail to learn is inexcusable.”