Patient safety through conversation. Doctor's orders as suggestions | Blogs | CMO Blog

In high performing health care organizations, two features stand out as success factors. The first is reliable standardized processes; the second is a culture focused on relationships. The primary relationship is with the patient and family while at the same time the provider-team relationships also define safe practices. To be truly patient centered, there are a set of inclusive behaviors that communicate to our patients that we care about what matters to them, especially when they are most vulnerable. Interestingly, how we – as providers – treat each other also has a strong influence on safe care, and it is noticed by patients who then feel even more confident and satisfied.

In my favorite medical journal, the New York Times, an oncology nurse writes about how the doctor / nurse hierarchy in a culture that tolerates anger and disrespectful behavior, causes patient safety risks. She uses the example of a doctor’s

"Doctor's orders: Could there be a clearer word defining the relationship?"
-- Theresa Brown, Healing the Hospital Hierarchy

orders. Could there be a clearer word defining the relationship? She refers to the physician attitude about orders as the ‘poof factor.’ When a doctor writes an order, he or she thinks “poof!” It just gets done.

Most physicians don’t think of feedback or questions about an order as important dialogue to ensure the best care. Often such questions are treated as annoyances. In highly functioning teams, orders are written after or during multidisciplinary rounds where a comprehensive care plan is developed together, in front of the patient, with input from nurses (Have you considered how that treatment can be continued at home? Is there a simpler regimen that she can follow?); pharmacists (Did you know that drug costs $8 a day? I can find you another drug for $1 a day); care managers (Will she need home care to assure this plan gets done?); and the patient (Gee, I don’t think I understand what you are proposing. Can you go over the plan later when my husband is here so we both can ask questions?). I worked in a hospital with a magnet nursing designation where nurses participated in almost all care plans. As the chief of surgery said all the time, “around here doctors orders are viewed as suggestions!”

The Institute for Safe Medication Practice has published an interesting set of phrases that should alert providers and those who receive doctors' orders of a safety risk. These are not the cautions I am used to reading about: disruptive behaviors ‘putting down’ those who question orders, but rather innocent phrases like: “the dose is from the patient’s old chart,” or “we always give it that way” or “the patient says that’s how they take it at home.”

The ISMP proposes a process for resolving medication order conflicts with steps such as nurses involving the pharmacy with medication order concerns before calling the ordering physician to engage the knowledge of the pharmacy staff in any question.

Relationships: this is the business we are in. Remembering that our behaviors define those relationships makes care better and safer.