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Zorluk: OrtaInterprofessional Teamwork and Conflict Resolution

A 55-year-old man is undergoing an elective cholecystectomy under general anesthesia. During the procedure, the patient experiences sudden bradycardia with a heart rate of 38/min. The anesthesiologist verbally instructs the circulating nurse, "Give him half a milligram of atropine." The nurse immediately retrieves a medication vial, draws up the medication, administers it intravenously, and discards the empty vial. Five minutes later, the patient's heart rate increases to 130/min, and his blood pressure rises to 190/110 mm Hg. A review of the discarded vial reveals that 0.5 mg of epinephrine was administered instead of atropine. Which of the following interprofessional communication strategies would have most likely prevented this specific adverse event?

  1. A
    Application of the Two-Challenge Rule
  2. B
    Utilization of the SBAR (Situation-Background-Assessment-Recommendation) tool
  3. Implementation of closed-loop communicationCevap
  4. D
    Conducting a structured interdisciplinary huddle
  5. E
    Performing a prospective Failure Mode and Effects Analysis (FMEA)

Cevap

Implementation of closed-loop communication
The correct answer identifies that closed-loop communication is the most effective strategy for preventing errors during verbal medication orders. In this protocol, the sender initiates a message, the receiver accepts the message and repeats it back, and the sender confirms the message was received correctly. In this scenario, repeating the medication name back to the anesthesiologist would have immediately highlighted the discrepancy between atropine and epinephrine.

Adım Adım Çözüm

1
Analyze the clinical scenario and the mechanism of the error.
A verbal order for 'atropine' was given by the anesthesiologist, but 'epinephrine' was drawn up and administered by the nurse without verbal confirmation of what was heard or drawn.
Identifying the exact point of failure (transmission and reception of a verbal order) is necessary to determine the correct preventative strategy.
2
Evaluate the communication frameworks available for verbal orders in high-stakes environments.
Closed-loop communication specifically targets the accurate transmission of verbal information by requiring a 'call-out' and a 'check-back'.
Different tools serve different purposes (e.g., SBAR for handoffs, Two-Challenge for hierarchical conflicts).
3
Apply the chosen framework to the scenario to confirm its efficacy.
If the nurse had repeated, 'Drawing up 0.5 milligrams of epinephrine,' the anesthesiologist would have recognized the discrepancy and corrected it before administration.
Confirming the mechanism of action of the chosen communication strategy ensures it directly addresses the root cause of the specific error in the vignette.

Anahtar Kavram

Closed-loop communication is the standard safety protocol for verbal orders in high-acuity settings, requiring the receiver to repeat the message back to the sender for confirmation.

Alternatif Yöntem

When evaluating patient safety questions, categorize tools by their primary function: 'Verbal order accuracy' = closed-loop; 'Shift change/escalation' = SBAR/I-PASS; 'Conflict resolution/Hierarchy' = Two-Challenge/CUS; 'Retrospective review' = RCA; 'Prospective review' = FMEA.
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Interprofessional Teamwork and Conflict Resolution

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