know the plan, share the plan, review the risks: a method of structured communication for the...
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Authors: Mary Salisbury, RN, MSN, andSusan M. Hohenhaus, MA, RN, FAEN, Wellsboro, Pa
Cognitive Errors
Teamwork and Cognitive Error
Know the Plan, Share the Plan, Review the Risks in Action
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C L I N I C A L N U R S E S F O R U MKnow the Plan, Sh
the Risks: A Method of S
for the EmergeMary Salisbury is President, The Cedar Institute, Inc., N. Kingstown, RI.
Susan M. Hohenhaus is President, Hohenhaus & Associates, Inc,Wellsboro, Pa.
For correspondence, write: Susan M. Hohenhaus, MA, RN, FAEN,6 Willard Terrace, Wellsboro, PA 16901; E-mail: shohenha@ptd.net.
J Emerg Nurs 2008;34:46-8.
0099-1767/$34.00
Copyright n 2008 by the Emergency Nurses Association.doi: 10.1016/j.jen.2007.11.008
46cannot state the names or ages of her children, and is
intolerant of light. Her blood pressure is 140/90 mm/Hg;
her temperature is 98.28F; her pulse is 88 beats perMrs J, suffering from a headache of intolerable
proportions, arrives at a level I trauma center
with the worst headache of my life. The
triage nurse is worried about a subarachnoid hemorrhage
(SAH) and immediately assigns a bed. Mrs J is evaluated
by a veteran ED physician-nurse-technician team, who noted
the following information:
Situation. The patient is a 53-year-old female
secretary, the mother of 5, who was driven from work
by a friend. She presents with a 4-hour history, sudden
onset, crushing, worst headache of my life.
Background. The patient denies trauma or another
precipitating event. Her head and neck pain is reported as
10 on a scale of 10, unrelieved by acetaminophen 6 inthe past 16 hours.
Assessment. The patient is curled in a side-lying
position on a stretcher, her coat over her head, her eyes
closed. She arouses with difficulty in response to her name,
is slow to answer, is confused regarding time and place,
e the Plan, Review
uctured Communication
y Care Settingminute; her respirations are 22 breaths per minute and
shallow; arterial oxyhemoglobin saturation is 92% on
room air.
Recommendation. Perform a work up to rule
out SAH.
Mrs J is sent for a computed tomography scan without
contrast. Despite the working diagnosis and the lack of a
fever, the ED attending physician has a gut instinct that
Mrs J has meningitis and orders a retake temperature.
No additional discussion occurs between the nurse and
the attending physician, who is called to another case. A
JOURNAL OF EMERGENCY NURSING 34:1 February 2008
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sions and is an example of how humans use simplifying
develop contingency plans to mitigate or negate f lawed rea-
C l i n i ca l Nu rse s Fo r um / S a l i s b u r y a n d Hoh e nh a u sstrategies and rules of thumb to ease the burden of de-
cision making in complex circumstances. Often the way to
proceed is time compressed and unclear because of the
ambiguity created by information overload.8 To ensure
outcomes, the time-stressed professional relies on experi-
ence to facilitate the subconscious mental procedures for
processing information.8 Research specific to ED triage
decision making indicates that triage decisions are non-
analytic and based on intuition and experience.9 The an-
choring or bias that occurs during times of rapid fire triage
may later be corrected as data are gathered and analyzed
during the ongoing ED assessment and care. However,nursing assistant retakes the patients temperature and
notes it in the chart but is pulled to transport another
patient to radiology before she sees the nurse. Mrs Js care
is picked up by another physician who performs a quick
review of the chart and notes Mrs Js retake temperature of
103.88F. Unable to determine if antibiotics were started,the relieving physician seeks out Mrs. Js treating team.
However, this physician is met by another critical patient
and is consumed by this case before further investigation
into Mrs Js case can occur. Ultimately, meningitis is
confirmed with delayed administration of antibiotics.
COGNITIVE ERRORS
Errors, slips, and lapses occur all around us in emergency
care. Medical errors are human errors that often involve
cognitive activities and the inadequate processing of infor-
mation.1-3 When information is inadequate, as in Mrs Js
case, medical plans of care will be under-informed, leading
to faulty thinking, f lawed decisions, and/or errors of exe-
cution.4 An under-informed plan or a plan unknown to the
team may mean every action taken thereafter could be an
incorrect action. Recent research cites cognitive errors
how we think and what we decideto be the foundation
of most ED diagnostic errors.5-7 Cognitive errors are dis-
tinct from procedural errors and inextricably linked to the
conditions of ED care.
Anchoring, or bias, is one type of cognitive error. Bias
describes the common tendency to rely too heavily upon
one pattern or piece of information when making deci-February 2008 34:1soning or decision making.
In a team-trained setting, Mrs Js physician would have
stated the plan and the risks: This might not be a SAH,
but, with worst headache of her life and no fever, we have
to continue to rule out the SAH. If, however, a fever de-
velops, we should think about meningitis, and I need to
know immediately so we can start antibiotics. The team
briefing should be conducted with all pertinent members
of the team, including the nursing assistant, who, in Mrs Jswithout knowing the plan and updating the plan, the
anchor, once set, will result in a predictable drift toward
the bias with the potential to err.8 Precisely because
anchoring is common and specific to triage, caution must
be exercised when care is delivered under conditions of fast-
moving, incomplete, time-compressed information and
communication and when tasks are delivered in high-stress,
high-stakes arenas where volume and turnover are high.
TEAMWORK AND COGNITIVE ERROR
Engaging in formal, evidence-based, team training educates
caregivers to recognize unfolding error and provides the
skills and practice necessary to exercise the team tools and
strategies critical to trapping, managing, and/or mitigating
error and its impact.10 In operation, staff take specific ac-
tions to form or join a team where they use structured
communication to plan and problem solve; to balance
workload; and to manage and monitor care for a popula-
tion of patients over time, while performing regular event
debriefings as an ongoing mechanism for improving team
performance and care.
Knowing the plan improves outcomes.10 In one study,
after implementing an ICU Patient Daily Goals form,
the percentage of staff who knew the plan increased from
10% to 95%, and ICU length of stay was reduced by half
(2.2 to 1.1 days).11
ED teams meeting to know the plan also may improve
outcomes by conducting interdisciplinary rounds and
sharing information using the structured communication
tool of Know the Plan; Share the Plan; Review the Risks.
Verbalization of the plan alerts the team to potential risks
or bias and provides new information or the opportunity toJOURNAL OF EMERGENCY NURSING 47
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fication area and shares the plan for evaluation for D. After
C l i n i ca l Nu r ses Fo rum / S a l i s b u r y a n d Hohe n ha u sthe evaluation, D is found to have acute and chronic sub-
dural hematomas and is scheduled for surgical intervention.
Biasin this case, that the patient smells of alcohol
is well known to EMS and the emergency department, and
that he always goes to detox was at work as well. How-
ever, a brief team discussion that included the correct team
members, the charge nurse, the ED physician, and the care
team, ref lected that the team knows the plan and reviewscase, was the team member who ultimately had the key
piece of clinical information. In addition, the authors
suggest that planning briefings be conducted with use of
standardized critical communication techniques such as
the Situation-Background-Assessment-Recommendation
(SBAR) method used to describe Mrs Js condition at any
patient hand-off.
KNOW THE PLAN, SHARE THE PLAN, REVIEW THE RISKS
IN ACTION
At 11 AM at a community hospital, the charge nurse takes a
call from an incoming EMS agency regarding D, a long-
time alcoholic well known to the department. Today, how-
ever, D is found down in the bushes, and after initial care
by the EMS professionals, is transported to the emergency
department awake, confused, and uncooperative. Prior to
arrival, the charge nurse pulls the treatment team together
to discuss the plan for Ds care, and using an SBAR format,
describes the plan:
Situation. Patient D is en route to the emergency
department via EMS after being found down.
Background. D has a history of alcohol abuse and is
well known to the emergency department (no assumptions
are made that the team is aware of Ds history).
Assessment. Ds behavior is different than usual, and
trauma cannot be ruled out.
Recommendation. Direct EMS is to bring D to the
resuscitation room.
The charge nurse then briefs the triage team using the
same information. As EMS enters, they note that the triage
area is overwhelmed and they move to the detoxification
area, as they have countless times in the past with D. The
triage nurse observes EMS wheeling D toward the detoxi-48 Jthe Plan, Review the Risks is a good place to start to better
manage or mitigate the potential for error in the emer-
gency department.
REFERENCES
1. Zhang J, Patel V, Johnson T. Medical error: is the solution med-ical or cognitive? J Am Med Inform Assoc 2002;9(6 Suppl 1):s75s77.
2. Kohn L, Corrigan J, Donaldson M. To err is human: buildinga safer health system. Washington: Committee on Quality ofHealth Care in America, Institute of Medicine, NationalAcademy Press; 1999.
3. Reason JT. Human error. New York: Cambridge UniversityPress; 1990.
4. Reason JT. Managing the risks of organizational accidents.Aldershot, England: Ashgate; 1997.
5. Redelmeier DA. Improving patient care. The cognitive psychol-ogy of missed diagnosis. Ann Intern Med 2005;142:115-20.
6. Croskerry P. The importance of cognitive errors in diagnosisand strategies to minimize them. Acad Med 2003;78:775-80.
7. Croskerry P. Cognitive forcing strategies in clinical decisionmaking. Ann Emerg Med 2003;41:121-2.
8. Tversky A, Kahneman D. Judgment under uncertainty: heu-ristics and biases. Science 1974;185:1124-31.
9. Patel VL, Zhang J. Human error in naturalistic medical environ-ments: medical triage in the ED. Available at: http://cognitive.asu.edu/research/humanerror.php. Accessed December 12, 2007.
10. Agency for Healthcare Research and Quality. TeamSTEPPS:strategies and tools to enhance performance and patient safety(2006). Available at: http:www.ahrq.gov/qual/teamstepps/. AccessedJune 15, 2007.
11. Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T,Haraden C. Improving communication in the ICU using dailygoals. J Crit Care 2003;18:71-5.
Clinical questions from nurses are welcome, as are names andaddresses of clinicians who are interested in answering questions.Submit to:
Susan McDaniel Hohenhaus, RN, MA, FAEN6 Willard Terrace, Wellsboro, PA 16901
570 724-1715 . shohenha@ptd.netthe risks prior to the patients arrival. In addition, sharing
the information with others who could affect the decision-
making process, such as the triage nurse, was critical to
timely and correct intervention for the patient. If the plan
is known at the time of communication, it also can be shared
with the transport team prior to the patients arrival.
Formal, structured communication tools are essential
to safe and effective emergency care. Know the Plan, ShareOURNAL OF EMERGENCY NURSING 34:1 February 2008
Know the Plan, Share the Plan, Review the Risks: A Method of Structured Communication for the Emergency Care SettingCognitive ErrorsTeamwork and Cognitive ErrorKnow the Plan, Share the Plan, Review the Risks in ActionReferences
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