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The nurses and patient care attendants were unbelievably nice. So was the man who delivered the food, the woman who mopped the floors and the special duty attendant who kept a close eye on the patient. They could not have been more pleasant.

communication gapThey all introduced themselves, explained their role in caring for the patient and when thanked, replied almost universally, “It is our pleasure.” Most even washed their hands.

The bulletin board in the hallway extolling the virtues of joint governance in nursing practice, the morale boosting slogans and employee stars in promoting customer satisfaction, was also impressive.

Less so was the ongoing medication dosage error and the admitted miscommunication between the attending physician and this exceedingly polite care team. The atmosphere of the care was good but if you were paying attention, you could see the communication gaps. The nurses and PCAs were not consistently talking to one another. The physician said he was not told about certain developments even though the nurses said they called. Then there was the reference to not knowing if they talked to the physician or a nurse practitioner. All these miscommunications could have been avoided if they had a proper channel for internal communication. The availability of digital signage for hospitals should have been utilized properly. Such digital signage can share information and effectively enhance staff communication on patient status, staff scheduling, and other important matters.

Luckily, other than experiencing some periods of extreme disorientation and some aggressive behavior, the patient apparently did not suffer any lasting harm from these little mistakes. The team’s “misunderstanding of the doctor’s order” probably did not extend his length of stay and certainly will not register even the slightest blip on patient satisfaction scores.

If they realize (admit) the error, it probably will go unreported. No one in the bowels of this hospital’s quality assurance apparatus will even know that it happened. In the grand scheme of things, given the thousands of medications administered to other patients over the couple days he was there, this situation clearly did not rise to the level of a tiny dot on a pinhead. No harm, no foul.

And that is one reason why healthcare is in the mess it is in when you talk about patient safety and, ultimately, preventable hospital deaths.

The good news is that this hospital is spending hundreds of millions of dollars implementing a state-of-the-art electronic health record, a Cadillac system apparently designed to replace several existing legacy programs.

That will probably solve these problems and ensure that the mistakes, big and small, are “kept to a minimum” which, by the way, is a dubious measure for performance in excellence and safety.

I do believe, however, if the patient had been a relative of one of the nurses, someone would have questioned the dosage or asked the physician to clarify his “vague instructions.”

But he wasn’t.

Being polite with a service oriented demeanor is not going to change the fundamental process of care flaws. When you treat the patient as just a patient, another butt in the bed in a hospital operating at full capacity, these little mistakes, and far too many bigger ones, will continue to occur. This seems analogous with a belief that teaching students to pass the standardized tests is the same as providing them with a good education.