Verbal Orders

I have been on airplanes a lot since I came to Baltimore for my first interview at GBMC this spring and a few times recently to see my family (my college-age children have summer jobs in Massachusetts). When I fly, I don't worry about my safety. This was not always the case.

I am old enough to remember when NBC had a correspondent, Robert Hagar, who only reported on airline crashes when they used to happen about 4 or 5 times a year in the US. Mr. Hagar retired and NBC eliminated the position (I think) because it is now a rare event that someone dies in a commercial airplane. What happened to make airline travel safer than it used to be?

There are many reasons why its safer to fly now than before but one big reason is that the Federal Aviation Administration has had pilots and air traffic controllers designing the communication system for safety. Pilots and air traffic controllers are humans....and humans make errors.

Even though both groups are very smart, have had many hours of training, and want all planes to land safely, in the past sometimes they would miscommunicate and cause catastrophes. Their communication system was reliable but not reliable enough. Very rarely, a pilot would hear "land on runway 1 Right" when the command was actually being given to a different airplane. The pilots and air traffic controllers realized that a system that was 99%+ reliable wasn't reliable enough if someone they loved was on the plane (see my first blog posting "What if it was your daughter?" http://ahealthydialogue.blogspot.com/2010/07/what-if-it-was-your-daughter.html).

All reliability means is "What should happen....happens and what should not happen.....doesn't. So, pilots and air traffic controllers now use a designed communication system called hear-back. The air traffic controller announces herself to the pilot and gives a command like "USAir 1006 ascend to 30,000 feet over" and the pilot announces himself and then repeats the command as he has heard it, like "Roger, USAir 1006 ascending to 30,000 feet, over". In this way, the air traffic controller "hears back" the precise instruction that she has given the pilot to assure that he has received the message correctly.

This week, I was with our wonderful planning team for the implementation of CPOE, Computerized Provider Order Entry. The team was discussing our on-going challenge of making sure that when a doctor gives a nurse or therapist a verbal order, that the order that the nurse "hears" is the order that the doctor intended to give. The computer system will give the physician the ability to directly put orders into the system from anywhere that he or she can get an internet connection. This will eliminate the handoff that exists in the paper world where a written order must be transcribed by a clerk. However, there will still be occasions like in an emergency, or when the physician is in the middle of a procedure, or when the physician is speaking with a nurse on the phone and is not near an internet connection, when verbal orders will be required. So the team was discussing our use of read-back where the nurse who has entered the order will read it back to the physician to assure that the correct care is delivered to the patient.

Medical care is a high risk endeavor just like commercial aviation. Its great to see us learning tools and techniques from another industry to make our care safer. If it was your daughter who was the patient, you would expect us to be doing this to protect her.

Collaborators in Care

This week, I had the great experience of having lunch with members of our Geriatrics/Palliative Care/Hospice team. Their work is inspiring to me as we figure out how to give outstanding care to very sick and often elderly patients in the last phase of their lives. You may know that our hospice company Gilchrist Hospice, recently had a Joint Commission survey and had no findings of deficiency! In my experience, surveyors always find some areas for improvement even if they are minor. Gilchrist got a perfect score. I am very proud of them.

Yesterday, I was given a tour of Sheppard Pratt Hospital http://www.sheppardpratt.org/ by the system's president, Dr. Steve Sharfstein. Dr. Sharfstein was very kind and he took me on a tour of the facility and educated me about the rich history of his hospital. I will spend more time on this blog in the future talking about care for our patients with mental illness, but it is a wonderful gift to have such a marvelous organization as our "sister hospital" and colleagues on the hill.