Health Services Administration class work Please read through and make sure you fully understand the Material. There is a separate folder with the assignment and instructions attached. Thank you
Running head: COMMUNICATION FAILURE IN HEALTHCARE SETTING 0
Case Study 2: Communication Failure in Healthcare Setting
Name
Professor
Due Date: March 7, 2021
Case Study: Communication Failure in Healthcare Setting
Three Communication Failures in Communication
Dr. Levitzky, a Family pediatrician had provided recommendation about Rory condition after critically examining the child information that was to be used by the NYU Langone doctors to make accurate diagnoses and treatment. The information was not used nor viewed as important when deciding on Rory's care. The reason why the information was not viewed or relied on was because the hospital records did not reflect any communication with Dr. Levitzky, on her finding of Rory (Dwyer, 2013). The doctors made a clinical decision of discharging Rory believing that the fluid made him better even when vital signs had indicated that Rory was seriously ill.
The hospital laboratory established that Rory was producing vast quantities of cells that combat bacterial infection. The lab result reported neutrophils and bands, white blood cells that suggest a bacterial infection. This information was not presented to Ms. Stauntons or action taken by the hospital to reach out to Ms. Staunton to know the child current situation and at most requests Ms. Stauntons to present the child back to the hospital for treatment.
Dr. Levitzky said that she did not know about lab test done to the child meaning that she was not informed about lab tests or asked about the tests conducted on the child (Dwyer, 2013). This is a clear indication of a communication breakdown between physicians associated with NYU Langone's.
The consequence of lack of communication for the patient and Healthcare organization
Lack of communication from NYU Langone to Rory's family contributed to the loss of Rory’s life because Ms. Staunton did not know what to do after getting discharge notice for home supportive care.
If there was effective communication about the lab finding, Ms. Stauntons could have pressured the doctor do further diagnoses or transferred the child to another healthcare setting where Rory could receive quality care. Poor communication resulted in misdiagnosis and mistakes that led the emergency doctor to discharge Rory without waiting for the lab results to make an accurate clinical decision on whether to discharge Rory or not. After the lab result was out the hospital did not get in touch with the patient even after noticing that Rory was in danger. The communication breakdown led to delays in providing essential treatment which negatively affected the patient outcome resulting in death.
Experience with healthcare setting communication breakdown
I experienced a communication breakdown in a local healthcare facility where we sought healthcare services. My cousin who was 40 years old was rushed to the emergency department at Patan Hospital with a complaint of weakness in the right of the body, and fever. The physician came and reexamine the patient and instructed a nurse to give a certain injection to stabilize the patient. A nurse was to give an injection as prescribed by a physician; the lab technician was to undertake a blood test afterward. In this case, a nurse delayed in giving an injection and after 30 minutes a lab technician entered the ward and conducts a blood test, a procedure that was to be undertaken after nurse had injected the patient with the drug prescribed by the doctors.
After lab personnel had taken the test, a nurse entered the ward, injected the patient as prescribed. The doctors after receiving the lab result further recommended a similar injection to the patient, and another nurse was instructed to give the injection. I saw a nurse entering the ward I had to stop her and let her know the status of the patient; where he reported that after the patient was given the first injection the test indicated that he was still unstable.
I intervene by informing the nurse that the patient was given the first injection after the lab test was conducted. Originally, the lab test was supposed to be undertaken after the first injection. This scenario shows a communication breakdown between physicians, lab personnel, and nurses and this could result in medical error through overdose.
I felt that the nurses were not careful and the patient was not safe in that hospital, if the physician gave instruction without following up to know whether the patient was given the first medication as instructed. The nurse looked a bit tired and unmotivated. The reason I was able to coordinate the communication is because I was sitting outside the ward and I could see and seek information on what was happening and even bothered to know the status of the patient after each healthcare personnel enter or move out of the ward.
References
Dwyer, J. (2013, July 11). An Infection Unnoticed Turns Unstoppable. New York Time: Retrieved from https://www.nytimes.com/2012/07/12/nyregion/in-rory-stauntons-fight-for-his-life-signs-that-went-unheeded.html
Feedback from Professor: You articulated extremely well the failures in communication that contributed to the most negative outcome for Rory, and his family. From the details provided in the article it seems clear that this could have been preventable.
Thank you for sharing the very negative experience your aunt and family experienced. Yes, while unfortunate it must be recognized that health care providers do not always “do their best” in communicating with Patients. This is very frustrating and very harmful to Patients. As health care professionals we always need to be vigilante for and intervene in all of possible instances of miscommunication. This should be is part of a service-oriented mentality and patient focused approach to our work.
