Background:
We observed that clinical pages in our institution on both medical and surgical services do not always reach the primary inpatient provider. Because we use pagers to communicate critical, time-sensitive information, delayed or misdirected communication can adversely impact patient care.
Purpose:
Our goal was to quantify the frequency with which pages did not reach the intended providers and identify common causes of communication breakdown. This information could then guide systems-level changes to improve physician-nurse communication and thus patient safety.
Description:
We surveyed providers to investigate the scope, causes, and potential solutions to the problem of misdirected pages, including perceived adverse impacts on patient care. 495 physicians (residents and hospitalists) and 148 floor nurses responded to our survey. 96% of physicians reported receiving pages on patients for whom they were not caring. 37% stated this occurred on a weekly basis. The primary reasons reported for this error was incorrect pager coverage or incorrectly updated “Treatment Team” in the EMR. Incorrect pager coverage was primarily attributed to human error (forgetting to assign coverage), or a malfunction in the current touch-tone automating phone system utilized to sign out pagers. Nurses reported difficulties in contacting providers on a daily basis. 71% of nurses and 25% of physicians reported an adverse impact on patient care (including delayed medication, test, intervention and discharge) relating to miscommunication.
Conclusions:
Most providers and nurses have experienced misdirected pages, and while instances of perceived significant harm were rare, mild and moderate harm were common and caused delays in patient care. Our solutions included assigning the responsibility of updating the “Treatment Team” and pager assignment to a single person (senior resident on the team), as well as augmenting the current phone sign-out system with a website facilitating simultaneous coverage of multiple pagers with immediate visual confirmation. We collaborated with the Office of Clinical Affairs, Information Technology and Paging and Communication departments to implement the website, which is currently in the prototype stage. We plan to send a follow up survey 2 months after the website is implemented to assess the impact of our project.