SAFETY TIP # 2 - ASK EARLY IF YOU HAVE A QUESTION

SAFETY TIP # 2 - ASK EARLY IF YOU HAVE A QUESTION
ABOUT A TASK TO BE DONE LATER.
Why? Mistakes often occur because care team members lack clarity about
exactly what they are to do, or when they are to do it. Research has shown that
asking a question early (rather than asking the same question later) not only
reduces the risk of failure or injury, but also saves time and reduces the stress
that comes with ambiguity and uncertainty.
An example: An intern joined rounds late. At the end of rounds, the senior house
officer noted that it was time to remove the first of the two chest tubes in an
elderly patient. While everyone present nodded in agreement, the task was given
to the late intern, who did not know which tube was placed first and did not feel
comfortable asking after having nodded knowingly moments before. He
incorrectly assumed the patient was the one that he participated in rounds on.
Later, the intern went to carry out the task, and incorrectly removed what looked
like the older tube. Had he asked questions when first assigned the task, he
would not have removed the wrong chest tube from the wrong patient. This
caused the patient respiratory distress requiring placement of another chest tube.
Reference: Sexton, J.B. (2004). Golden Rules of Group Interaction in High Risk
Environments: Evidence based suggestions for improving performance. Book.
Gottlieb Daimler and Karl Benz Foundation and Swiss Re Centre for Global
Dialogue. Ladenburg & Rueschlikon.