Miscommunications are responsible for a multitude of healthcare mistakes every year. They not only result in readmissions but also loss of life. When the left hand doesn’t know what the right hand is doing, there are omissions, duplications and incorrect treatments and procedures. The issues can be large or small, but all could be prevented with clear communication.
There are many reasons for the breakdowns which I won’t attempt to get into here. But I will say, that using ethnography-type mystery shopping, we’ve been able to identify specific areas where communication breaks down.
One example was with a middle-aged woman recovering from a total joint replacement. The patient was very groggy and therefore unable to participate much in physical therapy and also slept through her “Coumadin” video. Coumadin is a blood thinner that helps prevent blood clots. One of the elements of the video recommends the patient on this drug limit the amount of green leafy vegetables which are high in vitamin K which works against the medication.
When the mystery shopper followed up with the patient after discharge she asked what she recalled about the information about the Coumadin video. She said, “I’m loading up on spinach.” Indicating she misunderstood key information. She also reported that she didn’t recall ever getting exercises to do at home.
Another event occurred with an elderly woman who was scheduled for surgery and was to be, “nothing by mouth.” A very sweet aid delivered a dinner tray to her even though the white board clearly said nothing by mouth. The woman’s daughter turned to our mystery shopper and said, “This is why I can never leave. The right hand doesn’t know what the left hand is doing.”
That says it all.