Poor practice and medical errors occur mainly because of failings in organisational culture and the non-technical skills that underpin good clinical practice, rather than a lack of knowledge or technical ability. This is even more apparent when we are caring for acutely unwell patients.

The non technical skills which dramatically impact on patient care are:

As health professionals we assume that we are generally very effective at communicating. After all we deal with people everyday and we have received training in how to communicate, so we should be very good?

Poor communication involving healthcare staff however is often a central factor in many patient safety incidents, and this includes patients who deteriorate. A Danish study analysed 84 incidents within hospital and concluded that over half were attributable, directly and indirectly, to verbal communication (Rabol et al 2011). Of the 25,000 - 30,000 preventable adverse events that led to permanent disability in Australia, 11% were due to communication issues, in contrast to 6% due to inadequate skill levels of practitioners (Zinn 1995).

NHS Improvement (2018) highlight that poor spoken communication is almost always one of the causal factors for patient safety incidents, either directly or indirectly. 6 areas for improvement are identified but it is acknowledged that poor communication is a complex issue and there is not always a simple solution.

1. The environment: clinicians often work under pressure with many interruptions and distractions.

2. Information exchange: ensuring the correct information is communicated effectively and understanding is checked.

3. Attitude and listening: where people feel respected and work collaboratively with others.

4. Aligning and responding: shared assumptions and behaviours between two parties when communicating and continuously responding to needs and expectations.

5. Creating the preconditions for effective communication within a team: creating a mutually respectful ethos within a team where everyone feels comfortable to share concerns about safety.

6. Communicating with specific groups: ensuring that extra time and care is given when communicating with certain groups of people, for example those with mental health problems or where English is not a first language.

What happens when communication is poor? Nurses and doctors may not realise the urgency of the situation and as a result important tests or investigations may get missed or there may be delays in the patient being reviewed or in receiving important treatment that could halt or slow deterioration.

One of the simplest ways to improve communication is good preparation.

• Ensure you know when the patient came in, the reason for admission, past medical history and their normal level of functioning.

• When communicating important information and requesting help or advice from senior colleagues it is sometimes easy to adopt a passive role or to become aggressive if challenged.

• You will be most effective by trying to be assertive. This means being direct, remaining calm and in control, having sufficient self esteem to state what you want from others.

• Some of us are naturally more assertive but we can all learn to be more assertive and being prepared and being sure about what we want the outcome of the conversation or phone call to be will both help make you sound more confident.

Here are two examples of effective communication about a deteriorating patient:

"Hello Dr Roberts, This is Staff Nurse Miller on Ward 7. I have just seen Mrs White, a 42 year old lady under the care of Dr Judd, admitted yesterday with cellulitis of her right leg. She is very unwell. Her NEWS2 score is 12. She is hypotensive BP 85 /62 (she is normally hypertensive), she is tachypnoeic with a Respiratory Rate 32 and her Oxygen Saturations are only 90% on 15 L oxygen. I think she has severe sepsis and I would like you to come and see her urgently please."

"Hello Mr Stewart (SpR), this is Robert Davies your F1 from Ward 8. I am very worried about one of the patients we saw on the ward round this morning. Mr Ellis, 57 year old man who is five days post op right hemicolectomy. He has been making a good post op recovery, but since we saw him on the ward round he is complaining of central chest pain. He has no previous history of IHD. He is cold, clammy and he is hypotensive 90/54 and tachycardic 132 bpm. His NEWS2 score is 12. His ECG shows ST depression in V3 -V6. I have given him some GTN, oxygen, taken some bloods and asked the RMO to review him. I have just prescribed diamorphine as the GTN was not effective, and I wondered about giving him some fluid? I would like you to come and review him if possible or advise me re his further management whilst the RMO arrives....."

The examples are clear and succinct, and help senior colleagues appreciate your concern and prioritise their workload.

SBAR

Situation: State your name and ward.

This is staff nurse / Dr ... on ward 8. I am calling about Mrs Jones ...

Background: State the admission diagnosis and date of admission. Relevant Medical History. A brief summary of treatment to date:

54 year old, previously fit and well. Admitted two days ago with abdo pain. Diagnosed as diverticulitis. Today very breathless - RR 30, Sa02 90% on 10L Oxygen ....

Assessment: State your assessment using ABCDE, Observations, fluid balance and NEWS2 score:

NEWS2 score is 7, she is tachypnoeic with resps of 32 and, hypotensive - systolic BP is 85mmHg (normally 140mmHg). I am not sure what is happening but her condition is deteriorating and I am very concerned ....

Recommendation: State what you would like to happen now.

I would like you to come and review her urgently please ....... I would like your approval of my course of action whilst you are on you way......

Patients are often moved between departments or wards and may encounter up to three different shifts of staff each day. It is essential that the handover between nurses, nurses and doctors, and doctor to doctor includes all the essential information. Gaps can predispose the patient to inappropriate treatment and potential harm. Lessons on how to improve handovers are being learned from other high risk industries such as the nuclear power or aviation industries.

The World Health Organisation (2007) recommends the following techniques:

• Use of standard communication frameworks (such as SBAR / RSVP)

• Streamlining and standardising the change of shift handover. (These may vary between wards and sometimes include information not directly relevant to the main risks to the patients' safety)

• Use of a technique called 'read back' - this is where the receiver of the information writes the information down and then reads it back to the provider to obtain confirmation that it was understood.

When a patient deteriorates, everyone is busy and it is easy to neglect the patients' need for information and involvement. Remember to try and reassure the patient and inform them of events in language they can understand – they need to know what you and the doctors are thinking (likely reasons for their deterioration) and what the plan of treatment is which will help them.

The patient's experience

Imagine how it must feel if you are a patient and your condition is deteriorating. You are seeing the anxious looks of staff as they check your observations. Below is a account from a real patient of how it feels to become acutely ill on a general ward and then be transferred to HDU...

My hospital stay was after an accident at home, when my husband was installing a new central heating system. I fell through a hole in our bedroom floor and ended up on my lounge floor. I wanted to give you a brief history as I feel it has a bearing on my physical recovery and mental state at the time. We had just buried our son's first daughter, our first grandchild, and at times when I was told I was lucky to be alive; it caused me a lot of confusion with my feelings. I was taken to hospital by ambulance and after several hours in A&E I was eventually admitted to a busy surgical ward, they took a long time to decide if I was a medical or surgical patient. My injuries consisted of most of my ribs were broken on my left hand side, a punctured lung, severe bruising on my right hand side, two unstable crush fractures (T7 and T8) and a blow to the back of my head. Once on the ward I was put in a bed opposite the nurses' station, which was for obvious reasons but was also very busy, brightly lit and noisy. I was very aware of being “on view” to everyone, staff visitors etc. I was having a struggle to take each breath, which was very painful, even though I have a very high pain threshold. As I deteriorated my chest was raising and falling alarmingly and now I think could not have been pleasant for other patients to see, I will never forget the noise it made. Even with my family by my side and the ward being busy I had an overwhelming feeling of being alone in this and in constant fear, I also found that the care can change with each shift, as different nurses had different views as to my care. On one occasion I was asked if I could use a bedpan!! The longer that time went on the more exhausted I became and felt awful, I just wanted to be able to breathe properly again.

To the staff everything is so normal but not to me, every time your blood pressure etc. changes it is added to your fear about what is happening to you. On day three I started to feel very ill my breathing was becoming more and more laboured and now they were looking an Intensive Care Unit (ICU) for me as no beds were available this was now increasing my fear. My deterioration was quite rapid from this time, the pain and exhaustion was becoming unbearable, I was also fully aware that people die in ICU. I was actually taken to theatre on the fourth day and incubated and kept there until and ICU bed was available. One was found on the other side of the country and was a 6 hour journey for my children every day. On arrival my husband was told I was very ill and they were concerned I was developing ARDS, but pulled through with the dedication of the nursing staff. My return to the general ward after ICU also confirms what I have said, I was six weeks flat on my back, had MRSA and a lot more problems.

12/03/19

08.00 Patient looks unwell. NEWS2 score 11. Breathless. Respiratory rate 32. Oxygen saturations 88% on 4 L oxygen. Blood pressure low 96/ 45. Dr James (Bp 409) called and asked to review urgently. Oxygen mask changed to Reservoir Bag at 15L. Critical Care Outreach contacted. A.N.Other Staff Nurse

12/03/19

08.20 Doctor James bleeped again as had not attended. Blood pressure now 94/47. Oxygen saturations 91% on 15L. A.N.Other Staff Nurse

12/03/19

09.10 Reviewed by Dr James. Given 500 ml Normal Saline via pressure bag.

Once the doctor has reviewed a deteriorating patient, a detailed monitoring plan should be written in the notes that includes parameters for acceptable vital signs and criteria for when the Doctor should be called to come back to see the patient. See the example below.

23/6/19

14.25 Continue hourly observations. Continue high flow oxygen at 15L. If systolic BP drops below 90 mmHg Systolic, and or urine output drops below 35mls / hr give further bolus of Normal Saline 250mls stat as prescribed and bleep me on 512. Dr Sandly 512

Problems getting help

Doctors may be unavailable for a number of reasons but it is vital that one of the medical team reviews a deteriorating patient. Initially it is acceptable for this to be a Junior Doctor (primary responder) but within a short time this must be a Senior Doctor (Secondary or Tertiary responder) particularly if the patient's condition is not improving. Do not waste valuable time bleeping repeatedly if there is no response. Try urgently bleeping via switchboard or try the wards where the individuals/ team normally work, theatres or clinic. If you are having trouble contacting a doctor or senior colleague- delegate the phone task to the Ward Clerk or Health Care Assistant and ask them to fetch you when the person you are contacting answers the bleep. Your time can be much more valuably spent with the patient until someone else contacts help further up the chain of response for you. If you cannot contact a junior doctor, try further up the chain of command - the SpR or the Consultant. Nurses and some doctors are often reluctant to contact the Consultant but if one of their patients is acutely ill they should be made aware so they can guide the patient's management and if necessary, make any decisions about escalation of care to ICU / HDU or resuscitation (DNAR). If you cannot contact any of the patient's own team then try the 'on call' Medical or Surgical SpR for that day / night or the on call consultant. If you are having problems getting a medical review for a deteriorating patient, then inform Critical Care Outreach / Hospital Out of Hours, your Matron or the Senior Nurse acting as the site manager if necessary.

Team communication

Within a team you may take on the role of a team leader or follower. As team leader it is critical that an open and safe environment is created where individuals with in the team feel able to speak up and voice concerns. Hierarchies where team members are not encouraged to participate or speak up are often cited as being responsible for failings in patient care.

As a follower you have a responsibility to be assertive and raise concerns. To be assertive you need to be polite and persistent until you get an answer. The common practice of speaking indirectly is fraught with risk.

It is important to treat others in your team with respect, kindness and civility. The NHS Patient Safety Strategy (NHS England and NHS Improvement, 2019) promotes workplace civility as it is known that the opposite, incivility (rudeness, lack of respect, subtle negative behaviours towards others), can have a significant impact on the safety of patient care. Watch the video below for more information.

Situation awareness

Situational awareness refers to the care team maintaining the ‘‘big picture'' and thinking ahead to plan and discuss contingencies. This ongoing dialogue, which keeps members of the team up to date with what is happening and how they will respond if the situation changes; it is a key factor in ensuring patient safety.

Picture you are caring for a patient who desaturates to 85%. In this initial situation you may sit the patient up, apply oxygen at 15 litres and continue to monitor and assess and the patient improves whilst awaiting a medical review. If the situation changes and the patient does not respond to the interventions you have made and continues to desaturate your situation may be very different, the patient may have a hypoxic arrest.

If being situationally aware you would have anticipated the patient could deteriorate further; because of this you thought about who and what you might need, hopefully senior help is on its way and emergency equipment is available.

Reporting failure to recognise and respond to deterioration

If you feel that an obvious deterioration has not been picked up or acted on appropriately then tell the Ward Manager or the patient's Consultant. An incident form should be completed. This is not about blaming anybody but is about learning from the incident so that we can find out why the incident happened and try to prevent similar episodes in the future. Completing an incident form means that the patient safety team and senior managers in the Trust can be alerted to common threads involved in incidents where patient deterioration isn't recognised or acted upon appropriately.

The video below illustrates the importance of incident reporting which can influence safety responses at a national level and contribute to National Patient Safety Alerts.

• ACT Academy and NHS Improvement (2018) Quality, Service Improvement and Redesign Tools: SBAR communication tool- situation, background, assessment, recommendation. Retrieved from https://improvement.nhs.uk/documents/2162/sbar-communication-tool.pdf

• Franklin, B.J. Ghandi, T.J. Bates, D.W. Huancahuari, N. Morris, C.A. Pearson, M. Bass, M.B. and Goralnick, E. (2020) Impact of multidisciplinary team huddles on patient safety: a systematic review and proposed taxonomy. BMJ Quality and Safety. 07 April 2020. doi: 10.1136/bmjqs-2019-009911 .

• General Medical Council (2019) Good Medical Practice. Manchester, GMC.

• NHS England (2019) Improving patient safety by introducing a daily Emergency Call Safety Huddle. Retrieved from https://www.england.nhs.uk/atlas_case_study/improving-patient-safety-by-introducing-a-daily-emergency-call-safety-huddle/

• NHS England and NHS Improvement (2019) The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients. NHS Improvement Publication Code: CG43/19. Publication approval reference: 000717. Retrieved from https://improvement.nhs.uk/documents/5472/190708_Patient_Safety_Strategy_for_website_v4.pdf

• NHS Improvement (2018) Spoken Communication and Patient Safety in the NHS. R&A 05/18. London, NHS Improvement.

• Nursing and Midwifery Council (2018) The Code. London, NMC.

• Rabol, L.I. Andersen, M.L. Ostergaard, D. Bjorn, B. Lilja, B. and Morgensen, T. (2011) Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals. BMJ Quality & Safety. March; 20(3): pp268-74. doi: 10.1136/bmjqs.2010.040238.

• World Health Organisation (2007) Communication During Patient Hand-Overs. Patient Safety Solutions Vol 1, Solution 3, May 2007.

• Zinn C, (1995) 14,000 preventable deaths in Australia. British Medical Journal 310: 1487

• Clinical Human Factors Group

• Royal College of Physicians - Acute care toolkit 1: Handover

• World Health Organisation - Patient Safety: Making health care safer.