Untangling Charlotte's Web
Patricia Iyer MSN RN LNCC CLNI and Barbara Levin BSN RN ONC LNCC
University of Pennsylvania, 4th Annual Patient Safety Conference
Philadelphia, PA
March 30, 2007

Background: "Every day tens if not hundreds of thousands of errors occur in the healthcare system," according to the Institute of Medicine, and "some cause disastrous effects." Errors are costly to patients, hospitals and insurance companies. Patient safety is fundamental to quality nursing and health care as stated in the ICN position statement on Patient Safety. A collaborative approach towards patient safety involves all members of the healthcare team. Communication issues are the leading contributing factors resulting in patient injury. This poster will focus on how communication factors lead to a variety of patient injuries. There are a multitude of facets which will be addressed and include inexperience, generational, cultural and communication styles.

Objective: The learner will receive specific guidance on the use of communication to avoid unexpected events.

Content: This poster will utilize a case study where the breakdown in communication resulted in a sentinel event and cardiac arrest. This extraordinary program will affect every attendee. Medical records, photos, and videos will be shared detailing this unexpected and near fatal event. The information will also focus on the root/cause analysis and the new programs designed/implemented in the facility as the lessons were learned. Topics discussed in this program include communication – telephone and verbal orders, reporting of critical lab values, patient advocacy and chain of command.

Conclusion: The viewer will learn what an institution did with a root cause analysis to incorporate new policies and procedures and an education program to safeguard lives.